Skip to main content

Abstracts from the ICBM 2012 Meeting



Kaufmann P. G.1, Powell L. H.2, Freedland K. E.3

1National Heart, Lung and Blood Institute, Bethesda, MD, USA

2Rush University Medical Center, Chicago, IL, USA

3Washington University, St. Louis, MO, USA

Randomized controlled trials are the gold standard for evaluating efficacy and effectiveness of interventions in biomedical clinical research. Their implementation in behavioral medicine poses specific challenges that warrant careful consideration.

This workshop is designed to provide a basic overview of the most salient principles that underlie the conduct of valid randomized behavioral clinical trials. Material will include a discussion of equipoise and blinding, efficacy and effectiveness, pragmatic trials, large simple trials, multisite trials, relationship of pilot studies to outcomes in the main trial, a consideration of Phases of trials, applicability of “Good Clinical Practices” as promulgated by regulatory agencies, issues in analysis including intent-to-treat, responder, and per-protocol analyses, primary and secondary endpoints, ancillary studies, and the structure and function of data and safety monitoring committees.

CORRESPONDING AUTHOR: Peter G. Kaufmann, PhD, National Heart, Lung and Blood Institute, USA;



Schwarzer R.

Freie Universität Berlin, Psychologie, Berlin, Germany

The purpose is to introduce health psychologists to some principles that have been found relevant in the study of health behaviour change.

Topics are, for example, the distinction between stage and continuum models, the path analytic design of popular health behaviour models, the role of behavioural intentions and of distal and proximal factors that influence outcomes such as physical activity, dental hygiene, smoking cessation, sun safety and dietary behaviours.

Participants will understand constructs such as self-efficacy, outcome expectancies, health-specific optimism, planning, and action control. Examples of the measurement of such constructs will be given.

Particular attention will be given to mediators and moderators. We will discuss the rationale for mediation and moderation and will also practice the computation of such models, providing examples in SPSS. Participants will be informed about the above topics and will become capable of specifying and examining models of health behaviour change.

We will use a flexible instructional format that includes brief presentations, small-group collaboration, and plenary discussions.

This workshop would be suitable for graduate and post-graduate students as well as for investigators who are new to this field of research.

CORRESPONDING AUTHOR: Prof. Dr. Ralf Schwarzer, Freie Universität Berlin, Germany;,



Meade C. M.

Senior Member and Professor, Population Science, Health Outcomes & Behavior

Moffitt Cancer Center, Department of Oncologic Sciences, University of South Florida, Tampa, FL, USA

Meeting the challenge of a strong research agenda in behavioral medicine requires an understanding and consideration of culture and literacy in intervention development, and entails a high degree of interdisciplinary collaboration to effectively incorporate such components into meaningful research outcomes.

This pre-conference tutorial workshop highlights a series of systematic steps and strategies for creating audiovisual materials (printed, electronic, multimedia, etc), which are part of interventions aimed to impact health disparities. This workshop calls attention to a learner-centered mindset for creating materials that are dynamic, salient, and responsive to audience language and literacy demands.

The facilitator draws on current literature and her extensive communications and media background to outline steps that underscore key components important to this process: 1) interdisciplinary collaboration; 2) learner involvement and engagement; 3) use of iterative planning steps; 4) conduct of formative research; 5) incorporation of elements of design, and 6) ongoing refinement procedures.

To illustrate this process, Dr. Meade shares examples from ongoing studies including how an existing English-language stress management training intervention (DVD/booklet), was “transcreated” for use in another study involving Spanish-speaking Latinas about to begin chemotherapy. Commonly-faced logistical and practical aspects of this process, including budget considerations, will also be delved into as part of this workshop.

The appropriate audience for the workshop includes students, junior investigators, and those at any career level who intend to include audiovisual materials as part of their studies. A number of helpful resources and worksheets will be made available to support skill development.

Objectives: Highlight how culture and literacy inform the development of audiovisual materials. Apply a learner-centered mindset to the development of educational interventions. Explain the steps to transcreate an intervention for a new audience. Discuss challenges and practical considerations when advancing a concept to final product.

Format: Combines didactic presentations, group discussions and in–class exercises.

CORRESPONDING AUTHOR: Cathy D. Meade, PhD, RN, FAAN , Moffitt Cancer Center, USA;



Llabre M.M.

University of Miami, Miami, FL, USA

Structural equation modeling (SEM) is a broad and flexible methodology for analyzing data whose structure may be specified in the form of linear models.

There are two components to the general model: the measurement model and the structural model. When both components are applied, SEM allows the estimation of effects and the testing of hypothesized causal relations free from measurement error.

One important application of SEM is the analysis of growth models. In latent growth models (LGM), the two components of SEM may be mapped onto data from repeated measures designs to address questions about change over time.

This workshop will introduce the basic concepts of SEM and LGM and illustrate the potential these models bring to different areas in behavioral medicine research. Particular emphasis will be given to the analysis of LGM in longitudinal studies and cardiovascular reactivity.

The concepts will be illustrated with several examples including a measurement model of medication adherence, estimation with data missing by design, and examining predictors of cardiovascular reactivity and recovery from different stressors. The emphasis will be on the specification of the models and the interpretation of results.

CORRESPONDING AUTHOR: Maria M. Llabre, PhD, University of Miami, USA;



Kaufmann P. G.1, Powell L. H.2, Freedland K. E.3

1National Heart, Lung and Blood Institute, Bethesda, MD, USA

2Rush University Medical Center, Chicago, IL, USA

3Washington University, St. Louis, MO, USA

This advanced workshop on Randomized Behavioral Clinical Trials will present in-depth features of intervention development, the critical aspects of control groups, and the important influence that the selection of clinically significant primary outcome measures can have on the interpretation of results.

The presentation will address features of interventions that govern design, optimization, and early testing of behavioral interventions and how confounding can be avoided using methods to foster retention and follow-up.

Features of various control group options that are consistent with existing knowledge and clinical practice will be discussed in the context of the objectives of a clinical trial.

Selection of outcome measures will include discussion of multiple targets of interventions, multiple expressions of symptoms, and criteria for combining outcome measures.

The session will draw on existing clinical trials literature in behavioral medicine and related fields. While the session will assume a degree of familiarity with clinical trials, the presentations and discussion from the floor should be of interest to individuals over a wide range of experience in clinical research.

CORRESPONDING AUTHOR: Peter G. Kaufmann, PhD, National Heart, Lung and Blood Institute, USA;



Leanne Morrison, Laura Dennison, Lucy Yardley

University of Southampton, Southampton, UK

This is an introductory level workshop intended for any researcher or health professional interested in creating, delivering, and evaluating health behaviour change interventions using digital technologies (e.g. Internet, Smartphones).

The workshop will: a) discuss the role of digital technologies in the delivery of health behaviour interventions and address issues relevant to their development, delivery, and evaluation, and b) introduce and demonstrate open source software (the LifeGuide) that has enabled a growing community of researchers and health professionals to create, share, and evaluate their own digital interventions.

Digital technologies are a popular means of delivering health behaviour interventions since they have the potential to increase the reach of an intervention and provide ‘tailored’ advice based on the specific needs and characteristics of the user, at a time and place convenient to them. However, the development of digital interventions is often restricted by the need to programme each intervention individually – once programmed they cannot be easily modified. The LifeGuide is open source software that allows researchers and health professionals with no programming skills or resources to flexibly create, modify, deliver, and evaluate their own digital interventions. This workshop will introduce the LifeGuide software, present examples of the diverse range of features and components of digital interventions that can be created using the LifeGuide, and explain how the LifeGuide can be used to trial and evaluate interventions. We will provide an interactive demonstration of the LifeGuide software and describe what it is like to use LifeGuide from the researcher’s perspective. The future of digital interventions will also be discussed, including demonstration of how we can capitalise on Smartphone technology and virtual social networks to support behaviour change. The workshop will end with an opportunity for participants to ask questions and discuss the issues raised throughout the workshop.

CORRESPONDING AUTHOR: Leanne Morrison, University of Southampton, UKlm;



Wayne F. Velicer1, Bettina Hoeppner1

1Cancer Prevention Research Center, University of Rhode Island, USA

2Department of Psychiatry, Center for Addictive Behaviors, Harvard Medical School, USA

Idiographic methods focus on the time-dependent variation within a single individual or unit (intra-subject variability) in contrast to methods which focus on group-level relationships (inter-subject variability). Idiographic methods are widely used in other disciplines, such as engineering, business, and economics but only recently are being employed in the behavioral sciences. This method is an alternative to the dominant scientific approach in the behavioral sciences, the nomothetic approach, which focuses on group level analysis.

An inter-individual analysis may yield different results than an intra-individual analysis. Equivalent results will occur only if the two conditions specified by the Ergodic Theorems are met: (1) Each individual trajectory has to obey the same dynamic laws, and (2) Each individual trajectory must have equal mean levels and serial dependencies. These theorems appear unlikely to be met in practice but we have seldom had data adequate to test them. Available examples do not provide support for these conditions.

In addition, idiographic methods have several advantages. First, idiographic methods can address different research questions and may provide more insight into the data. Second, idiographic methods can be used in applied settings, such as businesses, schools, clinics and hospitals. More traditional between-subject research designs may not be appropriate, or, in some instances, impossible to implement in such settings. Third, idiographic methods have important advantages for investigating patterns of change across time. Some questions that can be investigated in this context include whether intervention effects are temporary or permanent, whether the intervention produces the same pattern of change for each person or unit. Fourth, idiographic methods can be used to determine the generating function for the behavior of interest. Fifth, idiographic methods can address the relationship between variables over time.

In this presentation, four different examples from behavioral medicine will be used to illustrate the types of problems that can be studied using idiographic methods, including a nicotine harm reduction study, a study of the patterns of adherence in a sleep apnea, an intervention study which identifies different patterns of arousal in children with autism, and the use of time series analysis to evaluate the effects of a Hepatitis C intervention for persons with HIV.

The studies illustrate how idiographic methods can provide a method of addressing unique and important research questions. In addition, the workshop will provide the opportunity for participants to analyze some of the data from the examples presented.

CORRESPONDING AUTHOR: Wayne F. Velicer, University of Rhode Island, USA;



Arnetz B. B.

Wayne State University, Detroit, MI, USA and Uppsala University, Uppsala, Sweden

A major limitation to today’s approach to link psychosocial stressors to biological disease processes and effective prevention is the lack of feasible technologies that allows for ecological momentary assessments of psychosocial stress and physiological responses and feed-back such data for instant analysis.

Today, such technologies are only available in the laboratory settings, severely limiting its ecologic validity. In recent years there has been a remarkable development in the area of wireless sensor technologies that allows for body area network that is connected to a remote server using smart phones.

We have developed and field tested for feasibility a body area network that allows for the instant and real-life assessment of cardiovascular responses as a person go about their daily life.

A remote smart web-based server triggers messages to the person’s Smartphone when cardiovascular data indicates increased biological stress. The smart web server is programmed with algorithms that allows for the process to be automated.

The workshop will discuss recent development in means to assess psychosocial and physiological stress using bodily sensors and smart phones. Furthermore, a simple and cheap system that is readily deployable in stress research and behavioral interventions will be discussed.

The workshop does not require any prior knowledge in body area networks.

The workshop will use non-technical and down-to-earth language.

CORRESPONDING AUTHOR: Prof. Bengt B. Arnetz, Wayne State University, USA;


August 29, 2012

ICBM 2012 Satellite Forum

09.00 – 16.00


Chaired by: Brian Oldenburg (Chair, International Collaborative Studies Committee), Carina Chan (Chair, ISBM Early Career Network - INSPIRE) and Vish Viswanath (Chair, Organizational Liaison Committee)

Historically, researchers and policy makers have focused most of their attention on developing and testing empirically supported interventions. Much less attention has been paid to what is needed to implement and sustain these in a range of real-world settings. Many empirically supported interventions are less effective and/or fail to reach their target audiences when implemented within existing service structures and systems, and few are sustained over the long term. Clearly, if effective public health programs are not widely adopted and implemented, their potential to improve people’s health is significantly impaired. This challenge is exacerbated by the different values and perspectives that exist between practitioners, program implementers, policy makers and researchers. Practitioners often find evidence-based interventions difficult to conduct in community settings especially when there is such limited information about how to adapt programs to the local context. Furthermore, public health decision-makers and program implementers are often reluctant to consider ‘new’ interventions when effectiveness has not been demonstrated in their particular setting or country. By contrast, researchers are usually more concerned with the internal validity of their programs rather than generalizability and external validity.

Effective dissemination, implementation and translation for public health and behavioral medicine interventions require the triangulation of evidence from formal trials with case studies, expert opinion, network analysis, systems thinking, as well as assessments of the local context. These combine information about scale, resources and structuring, with the practical experiences of the end-users. This combination of evidence from different fields and perspectives is essential. These steps requires methods, study design and approaches which most researchers are not formally trained in.

CORRESPONDING AUTHOR: Dr Carina Chan, Chair, ISBM Early Career Network – INSPIRE, Monash University, Jeffrey Cheah School of Medicine and Health Sciences , Petaling Jaya , Malaysia;

Poster Session A



Covaliu B.1, Mocean F.1, Del Olivo del valle Gómez M.2

1 University of Medicine and Pharmacy Iuliu Hatieganu, Department of Public Health, Cluj-Napoca, Romania

2 Universidad de Oviedo, Department of Public Health, Oviedo, Spain

Purpose: Assessing preferences of medical professionals (physicians, resident physicians, nurses) on the countries that they wish to practice their profession.

Material and methods: The study included 8116 people (100%) from Romania, Hungary and Bulgaria that have participated during March 4th- April 10th, 2011 in career fairs specialized for the medical sector. Of these, 1248 (%) were medical doctors - specialists, 1426 (%) - resident physicians, 3297 – students in medical sciences, 409 – dentists, 410 pharmacists, 822 (%) – nurses and 504 with another profession in the medical field.

Results: were collected using a questionnaire, in which subjects expressed their willingness to work in different health systems in Europe. Data were statistically processed using Microsoft Excel.

Results: Out of 3557 health professionals in Romania, 3531 (99.27%) want to find a different job than the current one and 26 (0.73%) of them were not looking for a job. Among those who sought a job, 537 (15.09%) want to work in Romania and are ready to work in other countries as well, 120 (3.37%) - want to work exclusively in Romania, 236 (6.63%) want to work exclusively in France, 176 (4.94%) want to work exclusively in Germany, 360 (10.12%) want to work exclusively in England, and 1869 (52.54%) are ready to work in several medical systems, while 259 (7.28%) did not answer this question. Similar results were found in Bulgaria and Hungary, reported to the size of the population.

Conclusions: The study demonstrated a great availability of health professionals to relocate and practice in a country other than their own.

Keywords: labor migration, specialized medical professionals, health systems, the EU, medical system.

CORRESPONDING AUTHOR: Covaliu Bogdan, UMF Iuliu Hatieganu, Cluj-Napoca;



Oh CH., Saito E.

Tokyo Metropolitan University Graduate School of Human Health Sciences, Department of Nursing Sciences, Tokyo, Japan

Purpose: The present study aimed to clarify the level of acculturation of registered elderly Koreans living in an urban area of Japan and their use of health services. Acculturation has been shown to be associated with significant changes in health behavior, health, and morbidity among ethnic minority groups. Koreans are the second largest registered minority group in Japan, after Chinese (2011). It is thought that many Koreans deal with health conditions on their own due to their unstable living environment and poor socioeconomic status. Similar to the Japanese population, the number of elderly Koreans is increasing. However, to date, no research in the field of nursing has investigated registered elderly Koreans.

Methods: Data were collected using the embedded descriptive case study design reported by Yin (2008). In 2011, semi-structured interviews were conducted on 10 registered elderly Koreans (7 women, 3 men) living in an urban area of Japan. For data analysis, a pattern matching technique was used, in which several pieces of information from one or more cases are related to a theoretical proposition. We employed the definition of acculturation used by Berry (2010).

Result: Six participants were first-generation residents of Japan and 3 were second-generation residents. All participants had contributed to the long term insurance system, but 8 participants had left the pension plan and did not receive pension payments. The participants were found to have two levels of acculturation. The first level was “integration”, in which they used health services effectively, but maintained some degree of cultural identity and customs, while at the same time seeking, as a member of an ethno-cultural group, to participate as an integral part of the larger social network. The second level was “separation”, in which they used health services as needed, but emphasized the importance of holding onto their original culture, while at the same time hoping to avoid interaction with the larger social network.

Conclusion: We found that the degree of the use of health services differed according to the participants’ level of acculturation. Therefore, it is important for public health nurse to consider the registered foreigner's acculturation level when approaching them.

Keywords: Acculturation, Minority health

CORRESPONDING AUTHOR: Oh Chu Hyang, Tokyo Metropolitan University;



Gariepy G.1, Schmitz N.2

1 McGill University, Epidemiology and Biostatistics, Montreal, Canada

2 Douglas Mental Health University Institute, McGill University, Research, Montreal, Canada

Background: Depression and distress are frequent in people with diabetes and can have detrimental effects on disease prognosis and outcomes. The place where people live is thought to affect mental health above and beyond the characteristics of individuals. The neighborhood environment could be particularly important to people with diabetes, who rely more on their local area for resources and support. Yet, no study has examined the associations between social and physical characteristics of neighborhoods and mental health in the diabetic population.

Objective: To investigate if neighborhood characteristics are associated with depression and diabetes distress in adults with type 2 diabetes.

Methods: We used data from a community sample of 600 adults with type 2 diabetes from Quebec, Canada. We collected information on perceived neighborhood environment from a telephone interview. We conducted a factorial analysis to combine the neighborhood questionnaire items into meaningful constructs. We assessed depressive symptoms from the Patient Health Questionnaire and diabetes-specific distress from the Diabetes Distress Scale. We performed logistic regressions, adjusting for socioeconomic, lifestyle and health variables.

Results: Factorial analysis uncovered 3 important neighborhood constructs: order (social and physical order; 13 items), culture (social and cultural environment; 10 items) and access (land use and access to services and facilities; 9 items), with higher score indicating better neighborhood qualities. All 3 constructs were significantly associated with high depressive symptoms; order and culture were associated with high distress [high depressive symptoms adjusted OR (AOR) 0.8 (95% confidence interval 0.7-0.9), 0.8 (0.6-0.9) and 0.8 (0.7-1.0) and high distress AOR 0.8 (0.7-0.9), 0.8 (0.7-0.9) and 0.9 (0.8-1.1), for order, culture and access scores, respectively].

Conclusion: Neighborhood characteristics are associated with high depressive symptoms and diabetes distress in people with type 2 diabetes. Clinicians should consider the neighbourhood environment of their diabetic patients when assessing and addressing mental health. Public health interventions to improve the neighborhood environment may help protect the mental health of people with diabetes.

Keywords: depression, mental health, diabetes, environment, physical environment

CORRESPONDING AUTHOR: Gariepy Genevieve, McGill University, Montreal;



Lua PL., Talib NS., Neni WS., Abdul Latif AZ.

University Sultan Zainal Abidin, Centre For Clinical & Quality of Life Studies , Kuala Terengganu, Malaysia

Orang Asli represents the indigenous minority people of Peninsular Malaysia. It is believed that even until today, they are still lagging behind in terms of disease perceptions, health education and healthcare facilities. Consequently, their awareness, knowledge and attitudes (AKA) towards chronic diseases (e.g. epilepsy) and health-related quality of life (HRQoL) status are still not well understood. Our study aimed to assess the general level of epilepsy AKA and HRQoL status in a cross-sectional sample of Orang Asli from Sungai Berua village, Terengganu, Malaysia. Descriptive and non-parametric statistics were employed for data analysis (SPSS 16). The Malay AKA Epilepsy and WHOQOL-BREF were administered consecutively. Only 22 out of 30 available respondents (response rate = 73.3%) consented participation (median age = 25.5 years; female = 90.9%; married = 90.9%; housewife = 68.2%; education ≤ primary school = 86.4%; monthly income ≤ MYR 500/USD 158.5 = 100%). Across all respondents, their AKA (median = 82.5; range 0 - 170.0) and HRQoL status (median = 13.6; range 8.9 - 17.0) seemed moderate. Interestingly, they possessed better Knowledge on epilepsy (median = 40.0, range 20.0 - 55.0) compared to Awareness (median = 20.0, range 0 - 50.0) and Attitude (median = 20.0, range 0 - 40.0). Among all the HRQoL domains, Social Relationship was reported as the most favourable (median = 16.0, range 4.0 – 20.0) while Environmental issues emerged the least favourable (median = 12.0, range 8.0 - 15.5). In conclusion, both disease perceptions and HRQoL issues among Orang Asli still require attention particularly in aspects concerning Awareness, Attitude and Environment. Essentially, tailored health education strategies are vital for improvement.

Keywords: epilepsy, health beliefs, low-income and minority groups, quality of life

CORRESPONDING AUTHOR: Lua Pei Lin, University Sultan Zainal Abidin;



Fradkin C., Wallander J.

University of California, Psychology, Merced, USA

Past research has documented racial/ethnic disparities in obesity among adolescents that place non-Hispanic African American and Hispanic youth at higher risk than their non-Hispanic white counterparts. While many of these studies attribute differences in weight status to socioeconomic factors, there is a dearth of information that examines risk for adolescent obesity within income and educational strata. This research examined whether racial/ethnic disparities in obesity risk in adolescents can be attributed to family socioeconomic factors.

A multi-site study enrolled 4,186 children from one of the three major racial/ethnic groups in the U.S. (Hispanic = 38%, African American = 36%, White = 26%). Measurements of body mass index (BMI) were taken in 5th and 7th grades. Parents provided demographic information on the household.

Complex sampling analysis revealed marked disparities in obesity among racial/ethnic minority children. When stratified by household income level, obesity rates of the least obese non-Hispanic African American and Hispanic 5th graders exceeded those of the most obese non-Hispanic white 5th graders, independent of household income level. Likewise, obesity rates of the least obese Hispanic 7th graders exceeded those of the most obese non-Hispanic white 7th graders, independent of household income level. When stratified by caregiver education level, obesity rates of the least obese non-Hispanic African American 5th and 7th graders exceeded those of the most obese non-Hispanic white children 5th and 7th graders respectively, independent of caregiver education level.

These findings suggest that there are striking racial/ethnic disparities in adolescent obesity that exist independently of household income and education, and provide basis for further exploration of the relationship between family socioeconomic factors and obesity in children.

Keywords: obesity, adolescents, socio-economic status, disparities

CORRESPONDING AUTHOR: Fradkin Chris, University of California, Merced;



Katzenstein M., Fruchter Y., Ganz D., Marquez C., Veres S., Suchday S.

Yeshiva University, Clinical Psychology (Health Emphasis), New York, USA

Introduction: The current study investigated the relationship between perceived stress and subjective social status, within urban youth in India, a country which has experienced vast changes due to increase in income, emphasis on education, and industrialization. It is hypothesized that decreased subjective social standing will predict increased perceived stress. In addition, the effects of Westernization on perceived stress were examined.

Methods: Sample consisted of 398 college students, 66% female, with a mean age of 18.6 (SD = 1.13) enrolled at St. Xavier’s College in Mumbai, in 2003 and 2005. Perceived stress was assessed using the Perceived Stress Scale, a 10-item scale that asks participants to rate recent stressful experiences. Subjective social standing was measured using The MacArthur Scale of Subjective Social Status ladder for community and national comparisons. Westernization was measured using The Westernization and Acculturated Distress (WAD) scale, a 49-item scale that asks participants to rate distress related to cultural westernization.

Results: Mean score on Perceived Stress was 18.3 (SD = 7.02). Mean score on the totaled ladders was 13.5 (SD = 2.62), and mean score on the WAD was 157.6 (SD = 19.7). The correlation (r = -.326) between perceived stress and subjective social standing was significant (p < .001), indicating that the lower someone subjectively placed themselves in the community, the higher their perceived stress. In fact, subjective social standing, was shown to be an independent predictors of perceived stress (β = -.88, p < .001). There was a significant correlation between the WAD and perceived stress (r = .290, p < .001), indicating that increased negative effects of westernization are related to higher self-reported stress.

Conclusion: Results demonstrate that subjective social standing and Westernization has a significant impact of perceived stress within a sample of urban Indian youth. These results have implications for negative health outcomes and the continued understanding of the effects of globalization.

Keywords: acculturation, adolescents, social stress, social support

CORRESPONDING AUTHOR: Ganz Debora, Ferkauf Graduate School;



Lacey R.1, McMunn A.1, Sacker A.2

1 University College London, Department of Epidemiology and Public Health, London, United Kingdom

2 University of Essex, Institute of Social Science Research, Colchester, United Kingdom

Background: Substantial changes in the work and family lives of men and women are well-documented, but their relationship with health and wellbeing remains unclear. As a first step towards assessing the health impact of social change in women’s and men’s work-family life courses, participation in paid and unpaid domestic work, and family forms are characterised using longitudinal typologies from British birth cohort studies. Socioeconomic, gender and cohort differences in these typologies are examined.

Objectives and methods: This study characterises cohort differences in women’s and men’s participation in paid work, unpaid domestic work and family forms in Britain using longitudinal typologies. Socioeconomic differences in these typologies across cohorts are also examined. Participants of three British birth cohort studies are included: the National Study of Health and Development (NSHD) born in 1946, the National Child Development Study (NCDS) born in 1958, the 1970 British Cohort Study (BCS70). Work-family typologies will be constructed using longitudinal data on employment status and hours worked, marital and partnership status (including cohabitation) and the number and ages of children (in and out of the household) from each adult data sweep. Information on responsibility for household chores and childcare were collected at ages 33 and 42 in the NCDS and ages 30 and 34 in the BCS70. Reflecting the dramatic changes in this area, this information was not collected in the NSHD. Socioeconomic position is measured using educational qualifications, household income and occupational class in childhood and adulthood. Optimal matching analysis will be used to assess observed individual work-family histories in relation to their distance from pre-determined ideal-type sequences.

Results: It is hypothesized that results will show increasing individual diversity, and decreasing gender differences, in work-family life courses across cohorts. It is hypothesized that decreases in gender differences will be greater in socioeconomically advantaged households.

Keywords: Family, Gender, Health




Konkoly Thege B, Székely A, Pilling J., Kopp M.

Semmelweis University, Institute of Behavioural Sciences, Budapest, Hungary

The relationship between religiosity and health has been investigated in the western world for decades. However, very little data are available from the post-communist region of Europe, where religion was suppressed both at the individual and institutional levels for decades. The aim of the present study was to lessen this gap.

In 2002 in the frame of a national representative study of the population above 18 years of age 12,643 persons (Mage = 47.6 yrs; SD = 17.9yrs; 44.8% male) were interviewed in Hungary thirteen years after the regime change. The relationship of mental and physical health indicators with religious worship and personal importance of religion - controlling for gender, age, and education - were analyzed using logistic regression and general linear model procedures. In 2002 in the total adult population 25% percent of the respondents considered themselves as non-believers, 18% did not practice their religion, 27% were believers in their own way, 17% practiced rarely, and 13% regularly practiced their religion in their own church. Our results showed that being religious and the higher personal importance of religion were largely associated with better mental health (e.g., better well-being and more meaning in life) and more favorable physical health status (better self-rated health, less health-damaging behaviors, less days on sick leave). Persons being religious in their own way, tended to show more unfavourable results across several variables when compared to those practicing religion regularly in a religious community or even to those considering themselves as non-religious.

We can conclude that after an anti-religious totalitarian political system practicing religion remained a very significant health protecting factor in the Hungarian population.

Keywords: religious worship, importance of religion, physical health, mental health, Central- Eastern Europe

CORRESPONDING AUTHOR: János Pilling, Semmelweis University,Budapest;



Dahlui M., Wong YL., Choo WY.

University Malaya, SPM, Faculty of Medicine, Kuala Lumpur, Malaysia

Female genital mutilation/FC causes serious and irreversible damage to the physical, psychological and sexual health of many women and girls. FGM/FC is one of the most devastating human rights violations against female infants, adolescent girls, and women who are incapable of giving consent due to age or coercion. The increasing trend of trained health providers (HP) carrying out FGM/FC is maintaining high prevalence of FGM/FC despite these negative consequences. WHO has thus been advocating for the prohibition of medicalization of FGM/FC. In Malaysia, FC is practised among Muslims. Malaysia has ratified WHO resolution to eliminate FGM/FC. This paper presents findings of a study to determine the extent of FC being conducted by trained HP, latter’s perceptions/beliefs, FC procedures, and impact on FC prevalence. Mixed methods were used: a cross sectional survey of 307 HP (269 trained and 38 traditional HP) and in-depth interviews with selected sample on perceptions/beliefs about FC. All FC practitioners were Malay Muslim and female, viz. 56 general practitioners (GP) in private clinics and 32 traditional midwives (TM). FC procedures involved braising and minute cutting of the prepuce (tip of clitoris). Both GP and TM used small knives and scissors but only GP applied sterilization. No adverse effects or long term complications were reported. HP cited reasons given by clients for performing FC as religious obligation, to control female’s sexual desire and hygienic purposes. Malay Muslim FC practitioners agreed that FC for Muslim females is an honourable Islamic practice and it probably has a role in controlling female sexual desire. Majority believed that FC should be done although more TM than GP perceived so. Medicalization of FC is thus apparent in Malaysia although comparatively FC is a minor procedure with no adverse side effects. Yet, medicalization of FC constitutes a misuse of professional medical role and may wrongly legitimize FC as medically safe/beneficial. As there is no such medical benefit, medicalization of FC should be abandoned to facilitate elimination of FC practice.

Keywords: religion, beliefs, female circumcision, medicalization, Malaysia

CORRESPONDING AUTHOR: Wong Yut Lin, University Malaya, Kuala Lumpur;



Kojima R.

Ritsumeikan University; Doctoral Course of Sociology, Kyoto, Japan

There is an accumulation of research focusing on changes in marital relationships. Their findings can be used for analyzing changes associated with becoming parents. Shoji (2006) focused on coping with marital conflicts and reported that contemplation and reinterpretation of the self and the spouse, as well as the reason for the conflict happens when coping in a compromising manner. The present author (2005) conducted an interview survey with six couples that had their first child during the prenatal to postnatal period in 2000. Results indicated that couples that experienced marital conflicts coinciding with pregnancy and childbirth had deepened mutual understanding as a result of help from midwives, to encouraging them to compromise and to cope. However, given that domestic violence (hereafter DV) is sometimes caused by prenatal to postnatal marital conflicts, it is necessary to examine the experiences of such couples. Nevertheless, DV offenders are in a process of conflict, and thus, their stories are not easily delivered. Moreover, telling the stories sometimes results in psychological problems such as flashbacks. Therefore, this study was based on stories gathered from counselors who support DV offenders. The purpose of this study was to understand and identify the types of perinatal stage marital conflicts that result in DV, as well as the role of support providers.

Keywords: family, gender

CORRESPONDING AUTHOR: KOJIMA Rieko, Ritsumeikan University, Kyoto;



Khan N.1, Flach C.2, Kausar R.3, Howard L.2

1 University of the Punjab, Centre for Clinical Psychology, Lahore, Pakistan

2 King's College London, Department of Public Health, London, United Kingdom

3 University of the Punjab, Applied Psychology, Lahore, Pakistan

There is strong evidence of an association between gynaecological morbidity and somatic complaints and emotional distress. Women with Vaginal Discharge are reported to experience more psychological distress compared to general population. The current study aimed to assess psychological distress in women reported with vaginal discharge and those reporting with other gynaecological problems in Lahore, Pakistan. It was hypothesized that women presenting with vaginal discharge are likely to experience more psychological distress as compared to those presenting without vaginal discharge. Women presenting with and without vaginal discharge were recruited from the gynecology clinics of both private and public sector hospitals of Lahore, Pakistan. A total of 425 women were contacted and 377 (89%) consented to participate in the study. An in-depth interview and General Health Questionnaire was used to assess psychological distress in women reporting with gynaecological problems. Several gender disadvantage variables showed significant association with CMDs: marriage at young age, pregnancy during adolescence, husband verbal abuse and physical abuse, concern about husband habit, low level of social integration, low level of autonomy in decision making, and lack of family support were associated with Common Mental Disorders (CMDs).

Keywords: vaginal discharge, common mental disorders (CMDs)

CORRESPONDING AUTHOR: Khan Nashi, University of the Punjab, Lahore;



Guedes M., Canavarro M.C.

University of Coimbra, Faculty of Psychology and Educational Sciences, Coimbra, Portugal

The postponement of first child birth has been a growing trend in economically developed countries (OCDE, 2011). However, researchers have described this reproductive decision as commonly uninformed, regarding the impact of age on fertility, risks for maternal, fetal and infant health and assisted reproduction technologies’ treatments (Cooke, Mills, & Lavender, 2010). Among women, a lower level of knowledge on specific reproductive risks has been frequently related to higher symptoms of anxiety during pregnancy (Lampinem, Vehvilaïnen-Julkunen, & Kankkunen, 2009). Nevertheless, little is known about their partners’ level of knowledge and its impact on couples’ emotional adjustment to pregnancy.

This exploratory study aimed to assess knowledge on specific reproductive risks of primipara women who experienced pregnancy in advanced maternal age (35 years and older), comparatively to their partners. Moreover, it aimed to evaluate the impact of this level of knowledge on couples’ emotional adjustment during the third trimester of pregnancy.

The sample was constituted by 42 couples, who were recruited in the Genetic and Human Reproductive Service of the Hospitais da Universidade de Coimbra, EPE. Both couples´ members completed the Knowledge on specific reproductive risks scale (Tough et al., 2006) during prenatal diagnosis routines, as well as the Brief Symptom Inventory-18 (Derogatis, 2001; Canavarro, Nazaré, & Fonseca, 2008) during the third trimester of pregnancy.

Both couples' members showed a low level of knowledge on specific reproductive risks related to advanced maternal age. However, men revealed a marginally higher level of knowledge comparatively to women (Pillai's Trace = 0.22, F(1, 41) = 2.59, p = .05), especially regarding the impact of age in fertility and risks for maternal health (F (1, 41) = 6.67, p = .01). Men’s higher level of knowledge was associated with higher levels of psychopathological symptomatology among men (F (2, 30) = 4.36, p = .03) and women (F (2, 30) = 25.41, p < .001), explaining respectively 52% and 86% of the variance.

These results tend to emphasize the preventive role of health professionals to promote informed reproductive decisions. They also seem to highlight the importance of couple-centered interventions focused on reproductive risks, life styles and reproductive health, in order to enhance couples’ perception of control and facilitate emotional adjustment to pregnancy in advanced maternal age.

Keywords: pregnancy; advanced maternal age; knowledge on specific reproductive risks; couple-focused; mental health; prevention

CORRESPONDING AUTHOR: Guedes Maryse, University of Coimbra (Portugal);



Guedes M., Canavarro M. C.

University of Coimbra, Faculty of Psychology and Educational Sciences, Coimbra, Portugal

Postponement of first child birth has been a growing trend in economically developed countries (OCDE, 2011). This decision has been commonly described as a result of women’s perceptions of psychological readiness and professional, financial and marital stability (Cooke, Mills, & Lavender, 2012). Nevertheless, little is known about the previous reproductive health of primipara women aged of 35 or over and its impact on couples’ adjustment to pregnancy.

This exploratory study aimed to characterize the previous reproductive health of primipara women who experienced pregnancy in advanced maternal age (35 years or over). It also aimed to evaluate its impact on couples’ emotional adjustment during the third trimester of pregnancy.

The sample was constituted by 42 couples, who were recruited in the Genetic and Human Reproductive Service of the Hospitais da Universidade de Coimbra, EPE. Both couples´ members completed a brief reproductive health questionnaire during the prenatal diagnosis routines as well as the Brief Symptom Inventory-18 (Derogatis, 2001; Canavarro, Nazaré, & Fonseca, 2008) during the third trimester of pregnancy.

Most couples (61.3%) did not previously experience reproductive health problems. However, 16.1% of the couples experienced reproductive health problems in advanced maternal age, mainly related to obstetrical complications (miscarriage or ectopic pregnancy) in a previous pregnancies (14.9%); 4.8% of these couples had difficulties to conceive but only 3.2% underwent medical treatments. Moreover, 22.6% of the couples suffered reproductive health problems previously to advanced maternal age, mainly related to difficulties to conceive (19.4%); most (17.7%) of them underwent medical treatments. Women showed higher levels of psychopathological symptomatology comparatively to men (Pillai’s Trace = 0.26, F(1, 30), p = .03). Among women, previous reproductive health problems were related to marginally higher levels of psychopathological symptomatology; conversely, men who did not experience previous reproductive health problems reported marginally higher levels of psychopathological symptomatology (Pillai’s Trace = 0.20, F(1, 30), p = .08).

These results tend to emphasize the preventive role of health professionals to promote informed reproductive decisions. They also highlight the importance of couple-centered interventions that assess reproductive trajectories, in order to better understand emotional adjustment to pregnancy in advanced maternal age and to prepare clinical interventions focused on couples’ specific needs.

Keywords: reproductive health; pregnancy; advanced maternal age; couple-focused; mental health; prevention

CORRESPONDING AUTHOR: Guedes Maryse, University of Coimbra (Portugal);



Wong YL.1, Low WY.2, Tong WT.2, Choong SP.3, Jegasothy R.4

1 University of Malaya, SPM &Centre for Population Health, Faculty of Medicine, Kuala Lumpur, Malaysia

2 University of Malaya, Faculty of Medicine, Kuala Lumpur, Malaysia

3 Klinik Rakyat, Family Planning Centre, Penang, Malaysia

4 Hospital KL, O & G, Kuala Lumpur, Malaysia

Despite provision of contraception services for the past 40 years, contraceptive prevalence is stagnating at 51%, unmet need is 25% and unintended pregnancies among young unmarried women is rising in Malaysia. Abortion surveillance and database is lacking although there was liberalization of abortion law in 1989. This paper presents findings of a qualitative study on women’s abortion experiences to assess fulfilment of their rights and access to reproductive health. In-depth interviews were conducted with purposive sample of 31 abortion seekers of diverse ethnicity. Women’s age ranged from 21-43 years. Majority were married and working but earning low income. Pregnancies averaged at 4, each woman had an average of 2 children, and 2 abortions. Financial difficulties in raising children were main reason to abort though they perceived that abortion is religiously unacceptable. Other reasons included inability to cope with yet another baby as the last child was too young; had completed family; or could not have a child out of wedlock. Many were unsure of the abortion law but tended to perceive that it is illegal. Majority had difficulty accessing abortion information and services because of its clandestine nature as abortion is perceived to be illegal. They reported that public hospital staffs were judgemental, labeling abortion as ‘wrong’ and ‘sinful’. Many women practised contraception but confined to ‘non-modern’ methods such as withdrawal and “calendar” method. Fear of side effects, lack of spousal cooperation, and misinformation about contraception were cited as reasons for non-adherence and contraception failures. Insights from women’s experiences point to the following. Abortion though permitted by law but when restricted or rendered inaccessible violates women’s right to sexual reproductive health. Cultural bias and ignorance of abortion must be eliminated so that Malaysian women can access safe, open and affordable abortion services. Contraception promotion must be comprehensive and effective to address the stagnated contraceptive prevalence and to prevent unintended pregnancies.

Keywords: gender, women's health, abortion, cultural bias, Malaysia

CORRESPONDING AUTHOR: Wong Yut Lin, University Malaya, Kuala Lumpur;



Grubic M., Bogdanic A., Dumic M.

University Hospital Centre Zagreb, Pediatrics, Zagreb, Croatia

Congenital adrenal hyperplasia (CAH) is a genetic disorder characterized by a deficiency in the hormones cortisol and aldosterone and an over-production of the hormone androgen, which is present at birth and affects sexual development. This is the reason patients with CAH are often used within studies exploring effects of hormones on human behavior. Behavioral studies have shown that children and adults with CAH, especially girls and women, differ in behavior and interests from unaffected same-sex individuals.

Aim of this study was to examine the influence of androgen exposure on gender related behaviour (GRB) in children by establishing the differences in GRB between children with different types of CAH and healthy children. Behaviours that we examined were: type of play (active, athletic, rough and tumble, quiet) and aggressiveness (using Play Activity Questionnaire; Finnegan et al. and Aggressiveness and Prosocial Behaviour Scale for Children; Vlahović-Štetić, Žužul).

Participants were 53 girls and 24 boys (aged between 4 and 17 years) with CAH and 77 healthy controls (matched by age and gender).

We compared three groups of CAH patients classified by disease severity: salt wasting, simple virilizing and non-classical variant, among themselves and with healthy controls (matched by age and gender).

Our expectations that girls with CAH will differ from control group in examined aspects of gender-related behavior and show more masculine behavior in comparison with non-CAH groups have been confirmed.

Girls with CAH are more often involved in games normally preferred by boys, are more active, less involved in quiet games and show increased aggression when compared with non-CAH girls. Behavior masculinization is more pronounced in severe forms of CAH and girls with non-classical form of disorder do not differ in gender-related behavior from comparable control group.

We found no difference in examined behaviors between boys with CAH and comparable control group.

Our findings support a contribution of sex steroids to differences in gender-related behaviour and aggressiveness among girls with different types of CAH and healthy peers.

Keywords: gender related behaviour, sex steroids, congenital adrenal hyperplasia, children




Pimenta F., Leal I., Maroco J., Rosa B.

Instituto Superior Psicologia Aplicada, Psychology and Health Research Unit (UIPES), Lisbon, Portugal

Objective: It has been evidenced that menopause has a significant and independent effect on the increase of the body’s fat mass in peri-menopausal women (e.g., Ho, Wu, Chan, & Sham, 2010). This study explores in which period middle-aged women started to present excessive weight, and investigates the variation of body weight around the time of the menopausal transition.

Method: This is a cross-sectional research and encompasses a community sample of 497 Portuguese women in peri- and post-menopause. Menopausal statuses were determined with STRAW criteria (Soules et al., 2001). A questionnaire to explore weight history (current weight, height, weight before the beginning of menstrual changes, beginning of excessive weight in participants with obesity and overweight) was built for this study.

Results: The vast majority of women (69%) gained weight from pre-menopause to current menopausal status (peri- or post-menopause), 13% lost weight and 18% maintained their weight. Women who had gained weight and were in peri-menopause had a mean increase of 5.6 kg (SD = 3.863), comparing with the weight they had before menstrual changes had started; participants in post-menopause gained a mean of 7.5 kg (SD = 6.185). The chi-square test (for independence) showed that the weight variation (loss, maintenance and gain) was not independent of menopausal status (χ 2(2) = 18.907; p < .001).

Of the 497 participants, 206 were overweight (BMI > 25kg/m2) or were obese (BMI > 30kg/m2). Of these women, 87 (42%) identified menopause has the moment where excessive weight began and 55 – 27% - allocated it in early adulthood.

Conclusions: This study evidences that, in this community sample of middle-aged Portuguese women, most participants gain weight from pre- to peri-/post-menopause. Additionally, a considerable percentage of women state that excessive weight starts during menopause. Given the difficulty of the weight loss process and the negative impact of overweight/obesity on health, prevention of weight gain in pre-menopause is recommended.

Keywords: weight control; gender; health; weight changes; menopause

CORRESPONDING AUTHOR: Pimenta Filipa, ISPA - Instituto Universitário;



Pimenta F., Leal I., Maroco J.

Instituto Superior Psicologia Aplicada, Psychology and Health Research Unit (UIPES), Lisbon, Portugal

Objective: Weight gain during midlife is frequent in women. This study explores the predictors of weight gain in women in peri- and post-menopause.

Method: This is a cross-sectional study, encompassing a community sample of 497 women in peri- and post-menopause who provided information about weight before the menopausal transition and current weight. Structural equation modeling was used to investigate a causal model of weight increase. The studied variables included socio-demographic characteristics (age, marital status, parity, professional status, educational level and household annual income), physical and psychological health and menopausal status, lifestyle (alcohol and coffee intake, smoking and physical exercise), body shape concerns, depression, stress and life events.

Menopausal status was determined according to STRAW criteria (Soules et al., 2001). Body shape concerns were measured with the Body Shape Questionnaire (Cooper et al., 1987). Depression and stress were assessed with the Depression, Anxiety and Stress Scales (Lovibond & Lovibond, 1995; Pais-Ribeiro et al., 2004). Moreover, the Life Events Survey was used to evaluate the impact of life events on weight gain (Sarason et al., 1978; Silva et al., 2003). All instruments used were validated for Portuguese.

Results: The significant predictors of weight gain were educational level (β = -.146; p = .017), physical exercise (β = -.111; p = .021), having a recent psychological problem (β = .191; p < .001), transition from peri- to post-menopause (β = .147; p = .013) and body shape concerns (β = .313; p < .001).

Conclusions: Given the difficulty associated to the weight loss process and the negative impact of overweight/obesity on health and wellbeing, prevention of weight gain in pre-menopause is recommended. This study emphasises several risk factors for weight increase around the menopause period; as a result, risk groups should be given considerable attention taking into account the characteristics which account for a significant prediction of weight gain.

Keywords: weight control; women's health; weight gain; predictors; structural equation modeling

CORRESPONDING AUTHOR: Pimenta Filipa, ISPA - Instituto Universitário;



Santos-Rita J.1, Patrao I.2

1 Higher School of Health Technology of Lisbon – Lisbon Polytechnic Institute, Lisbon, Psychology, Lisbon, Portugal

2 Instituto Superior Psicologia Aplicada, Psychology and Health Research Unit (UIPES), Lisbon, Portugal

Due to social changes in the last decades, the educational challenges involve new skills and new requirements from teachers. Research in the occupational health field has shown that teachers are considered one of the most vulnerable professional groups to occupational stress and burnout. The persistence of tasks associated with the traditional female role puts into greater balance between daily wellbeing and work-life conflict. Several studies pointed to a negative association between work-life conflict and health, namely in the individual perception of health and wellbeing, in all professions. On the other hand, teachers’ educational practices are a critical skill area, thus they should be trained and supported in order to develop successful strategies to promote positive relationships. It seems that there are mutual influences between personal and professional contexts that can contribute to teachers’ adjustment and wellbeing, and even more demanding tasks for female teachers.

In order to better understand this aspect, we performed a cross-sectional study to assess the relationship between emotional adjustment, occupational stress and educational practices used by female teachers. A sample of 505 Portuguese female teachers, of elementary, middle and high public schools filled the Cuestionario Burnout Profesorado – Revisado – CBP-R (Moreno-Jiménez, Hernandez & Guitierrez, 2000, European Portuguese version Patrão, Santos-Rita & Maroco, 2011), the Depression and Anxiety Scale EADS-21 (Lovibond &Lovibond, 1995, European Portuguese version Pais-Ribeiro, Honrado & Leal, 2004) and the Educational Practices and Relationship Management Questionnaire for Teachers (Santos-Rita & Patrão, 2009).

The results indicate high levels of burnout, experienced by teachers suffering from high levels of depression and/or anxiety. Educational practices revealed to be inadequate, emphasizing a decreased wellbeing and less satisfactory relationships with colleagues, students and families. It will be important to develop intervention programs to promote individual and organizational skills, focusing on health behavioral change and healthy lifestyles, adopting an integrated comprehensive approach, though Occupational Health Medicine.

Keywords: stress, occupational health, women's health




Jarašiūnaitė G.1, Riklikienė O.2, Miškinis K.3

1 Vytautas Magnus university, Department of Psychology, Kaunas, Lithuania

2 Lithuanian University of Health Sciences, Department of Nursing, Kaunas, Lithuania

3 National Health Insurance Fund under the MoH, Strategy Department, Vilnius, Lithuania

Research studies show the difference between gender and health related behaviour. It is said that man engage in more risky and health adverse behaviours, while woman engage in more preventive behaviours, as well as more treatment seeking and self-care for illness (Verbrugge 1985; Gochman, 1997, Williams, 2003). Some of the findings support the gender role self-concept related with masculinity and weaker gender perceptions on health related behaviour (Waldron, 1988; George, Östlin, 2002; Fleming et al, 2000; Williams, 2003). Other studies indicate factors related with health literacy. It is said that men are less knowledgeable about health in general, specific diseases and their risk factors then woman (Courtenay, 2000); less able or likely to access, interpret and apply information to maintain and improve health (Galdas et al, 2005) and exhibit low levels of health literacy even about male-specific health issues (Singleton, 2008).

According to Lithuanian statistics on 2005, more women were vaccinated from influenza; blood pressure was also measured more often to women than men. After being diagnosed with higher blood pressure women (43.8%) were more likely to change their lifestyle than men (30.9%), equally more woman (88.7%) than man (76.6%) used medications in case to lower their blood pressure.

On 2011 representative survey of 1068 Lithuanian residents (495 men and 573 women, aged 18 and above)about health care system in Lithuania also revealed several important aspects about gender related differences in predicting health related behaviour. Women knew about 5 preventive programmes financed by national compulsory health insurance system better than men who kept preventive programs as waste of time. There were significant gender related differences in responsibility for personal health between men and women; knowledge about generic and branded medicines, and about compulsory health insurance policy was also better in women.

Keywords: gender, health behaviors

CORRESPONDING AUTHOR: Jarašiūnaitė Gabija, Vytautas Magnus University;



Von Humboldt S., Leal I.

Instituto Superior Psicologia Aplicada, Research Unit in Psychology and Health, Lisbon, Portugal

Aims: There has been little attention in the research literature on adjustment to aging. This research aims at examining the relationships between older adults’ adjustment and aging.

Methods: The measures used to in the study were selected to assess the reliability and validity of one new instrument, Adjustment to Aging Schedule (ATAS-33). Measures were completed using a variety of culturally appropriate methods, including mail-outs, self-administration and interviews. For the purposes of this study, the Health Survey Questionnaire (SF-6D), one measure of cognitive functioning - the Mini-Mental State Examination (MMSE) and demographics, were included. All variables had less than 1% missing values and there complete data were available for 709 older adults (mean age 82.4, SD = 6.45, (range 74-102)) from eight different nationalities. Exploratory factor analyses were run for data reduction and for exploring theoretical structure. Controlling for age, gender and country of origin, we assessed the level of adjustment of elderly people, and its effect on aging.

Results: The sampling adequacy was confirmed by the Kaiser-Meyer-Olkin test (KMO = 0.775) and the total variance explained by this eight-factor structure is 75.09%. Adjustment to aging appears to be a catalyst to attitudinal markers of maturity and internal development which in turn impact quality of life and aging, across cultures. All estimates were statistically significant (p < .01).

Conclusions: This cross-cultural study illuminates links among adjustment and aging in older age, warranting further study across cultures among frailer populations over time. Recommendations for future research on older adults' adjustment and clinical practice are also presented.

Keywords: aging; geriatrics; health promotion; older adults; research methods

CORRESPONDING AUTHOR: von Humboldt Sofia, ISPA, Lisbon;



Von Humboldt S., Leal I.

Instituto Superior Psicologia Aplicada, Research Unit in Psychology and Health, Lisbon, Portugal

Aims: To analyze the determinants of adjustment to aging (AtA) and subjective age (SA) identified by older adults and to investigate the differences of latent constructs that can work as major determinants in AtA and SA in an older Portuguese and Romanian population.

Methods: Measures were completed, including demographics and interviews. Complete data were available for 38 older adults aged between 74-90 years (M = 80.6; SD = 5.4), from Portugal and Romenia. Data was subjected to content analysis. Representation of the associations and latent constructs were analyzed by a Multiple Correspondence Analysis (MCA).

Results: The most prevalent response of the interviewed participants for determinants to AtA was ‘health status, physical and intellectual functioning’ (18.1%). ‘With apprehension’ and ‘good enough’ (both 27.0%) were identified as the most frequent SA responses. Findings showed a model for each nationality. AtA and SA for Portuguese elderly were explained by a three-factor model: ‘regardful’, ‘engaged’ and ‘conciliated’. A three-dimension model formed by ‘perseverant’, ‘congruent’ and ‘enjoyers’ was indicated as a best-fit solution for Romanian elderly.

Conclusions: AtA and SA are strongly explained by increased likelihood of specific constructs in its definition. AtA is related to SA in older adults in both countries, although in different degree.

Keywords: aging; geriatrics; health; older adults; quality of life

CORRESPONDING AUTHOR: von Humboldt Sofia, ISPA, Lisbon;



Von Humboldt S., Leal I.

Instituto Superior Psicologia Aplicada, Research Unit in Psychology and Health, Lisbon, Portugal

Aims: The increase of older adults in the population has emphasized the need for consideration of what it takes to live this phase of life with a sense of quality and satisfaction. This research aims at evaluating how person-centered therapy (‘PCT’) facilitates the degree of self-esteem and congruence of older adults.

Methods: Information was gathered by a research tool composed of three parts: (a) a demographic questionnaire and (b) the Self-Esteem Scale (‘SES’) and (c) one measure of cognitive functioning - the Mini-Mental State Examination (MMSE). The research sample comprised 40 elderly people between the ages of 65-93, from both genders, who completed eight sessions of PCT. All variables had less than 1% missing values.

Results: After the therapeutic process, results indicated an increase of the participants’ degree of self-esteem. It was verified a positive effect of PCT on older adults’ self-esteem, which was achieved by an increase of their congruence level.

Conclusions: Interventions with older adults may benefit from clearly understanding self-esteem as an important component for promoting successful aging and reducing health disparities. Recommendations for future research on older adults’ PCT impact on self-esteem, as well as suggestions for PCT with older adults are also presented.

Keywords: aging; geriatrics; health; health promotion; older adults

CORRESPONDING AUTHOR: von Humboldt Sofia, ISPA, Lisbon;



Okvat HA.1, Okun MA.2, Davis MC.2, Zautra AJ.2, Knopf RC.3

1 VA Boston Healthcare System, Behavioral Medicine, Boston, USA

2 Arizona State University, Department of Psychology, Tempe, AZ, USA

3 Arizona State University, Osher Lifelong Learning Institute, School of Community Resources and Development, Phoenix, USA

Healthy aging has been conceptualized as staying cognitively, physically, and socially active. As the population of older adults and the percentage of people living in urban areas are both increasing, it is important to find ways to promote city-dwelling, older adults’ cognitive vitality, physical activity, and social integration. Based on empirical review of the benefits of gardening, community gardening was conceptualized as a parsimonious intervention to promote all three aspects of healthy aging.

The present study was a pilot study to examine the feasibility of conducting a randomized, controlled trial of community gardening and to provide an initial assessment of a new intervention—“Mindful Community Gardening,” or mindfulness training in the context of gardening. In addition, this study examined through quantitative and qualitative methods whether community gardening, with or without mindfulness training, enhanced various endpoints associated with subjective well-being.

Fifty community-dwelling adults between the ages of 55 and 79 were randomly assigned to one of three groups: Traditional Community Gardening (TCG), Mindful Community Gardening (MCG), or Wait-List Control. The TCG and MCG arms each consisted of two groups of 7 to 10 participants meeting weekly for nine weeks. TCG involved typical gardening activities undertaken collaboratively. MCG involved the same, but with the addition of guided development of non-judgmental, present-focused awareness.

It was found that it is feasible to conduct randomized, controlled trials of community gardening with urban older adults. There was a statistically significant increase in two different aspects of mindfulness for the TCG and the MCG arms. The interventions did not measurably impact other quantitative outcomes in this small, high functioning, pilot sample. Qualitative analysis of interview data from 12 participants in the TCG and MCG groups revealed that participants in both groups perceived multiple benefits from their involvement in this community intervention, including improved mood, relaxation, increased physical activity, social support, and generativity. Lessons from this pilot study are reviewed for future research and practice using similar interventions to promote healthy aging.

Keywords: aging, community intervention, health promotion, mindfulness, mood, older adults, quality of life, resilience, social support

CORRESPONDING AUTHOR: Okvat Heather, VA Boston Healthcare System;



Saito E.1, Kaneko C.2, Ueki S.3, Yasumura S.2

1 Tokyo Metropolitan University, Department of Nursing Sciences, Tokyo, Japan

2 Fukushima Medical University, Faculty of Medicine, Fukushima, Japan

3 Tohoku Bunka Gakuen University, Faculty of Health and Social Services, Sendai, Japan

Purpose: In recent years, major changes in living arrangements have occurred in Japan. For example, from 1985 to 2005, the number of elderly people living alone increased from 1.18 million people to 3.87 million people. This tendency is continuing and according to estimated figures, the total number of elderly people living alone will reach 7.17 million in 2030. The purpose of this population-based cohort study was to compare the risk for certification of long-term care need in elderly people living alone with the risk among elderly people living with a spouse only.

Methods: Subjects were 185 elderly people (aged 70 years and older) living alone or living with their spouse who participated in a health examination in a rural area of Japan in 2004. The number of elderly people who received certification of long-term care need was observed over a 5-year period.

Results: Among the 185 subjects, there were 32 new certifications (17.3%) during the observation period. The number of certifications of long-term care need among subjects aged 80 years and older was significantly higher than that among subjects aged 79 years and younger. The number of certifications of long-term care need among men was not significantly different from the number among women. Over the 5-year period, significantly more elderly people living alone received certification (14/54, 25.9%) than elderly people living with a spouse only (18/131, 13.7%) (p = 0.04). According to Cox regression analysis adjusted for age, there was no statistically significant difference in the number of certifications of long-term care need between elderly people living alone and living with a spouse only (95% confidence interval, 0.6 to 2.6; p = 0.58).

Conclusion: The problems faced by elderly people are the result of not only aging and physical independence, but also living arrangements and social activities. Therefore, a diverse range of lifestyles must be examined. Furthermore, there is a need for variation in services based on difference in living arrangements.

Keywords: aging, family, longitudinal research

CORRESPONDING AUTHOR: Saito Emiko, Tokyo Metropolitan University;



Costa C.

Instituto Superior Psicologia Aplicada, Psychology and Health Research Unit (UIPES), Lisbon, Portugal

Aims: The aging process requires the individual’s adaptation to resulting losses and changes. In old age, individuals might search for existential meaning, through religion. Moreover, there is a need to collect empirical data to understand the contribution of religion in the adaptation of elderly to aging. This study aims at examining the relevance of religion for the elderly and at analyzing how different religions may be relevant to the quality of life (QoL) of elderly people.

Methods: The sample comprised 118 participants over 74 years old, from eight different nationalities, including Portuguese, German, English and Romanian; with no psychiatric disorders. For the purposes of this study, the Assessment of Gains in Health Scale (SF-6D), one measure of cognitive functioning - the Mini-Mental State Examination (MMSE) and demographics, were included.

Results: Findings indicated that QoL score was higher for taoist participants ( = 5.3), followed by protestants ( = 4.9), when compared to participants without religious beliefs ( = 4.1). German participants indicated a higher QdV score ( = 5.3) whilst Romanian showed the lowest QdV score ( = 3.9). There was no association found between QoL and religion or nationality.

Conclusions: This study makes a valuable contribution for the incorporation of religion as an intervenient in QoL in old age, enlightening its contribution to healthy aging and behavioral strategies. Recommendations for future research on older adults’ QoLand clinical practice are also presented.

Keywords: Behavioral Strategies; Elderly, Health Promotion, Quality of Life, Religion




Costa C.

Instituto Superior Psicologia Aplicada, Psychology and Health Research Unit (UIPES), Lisbon, Portugal

Aims: One of the motivations of human existence is linked to the search for meaning and value in life. In advanced age, elderly are affected by the end of life and death. These matters can be addressed through religion. Moreover, religion and spirituality are related to the physical and psychological well-being of elderly people. This study aims at assessing the association of religion to quality of life (QoL) and at analyzing the effects of religion on the six dimensions of quality of life: (i) Physical Functioning; (ii) Role Limitations; (iii) Social Functioning; (iv) Pain; (v) Mental Health and (vi) Vitality.

Methods: The sample comprised 118 people over 74 years, from eight different nationalities, with no psychiatric disorders. For the purposes of this study, the Assessment of Gains in Health Scale (SF-6D), one measure of cognitive functioning - the Mini-Mental State Examination (MMSE) and demographics, were included.

Results: Findings indicated that taoist participants showed the highest score for social function score ( = 6.0), whilst protestants showed the highest score for role limitations ( = 5.8). There were no association between religion and QoL.

Conclusions: Religion has proved to be a cross-cultural catalyst for personal investment, internal development and maturity. This study contributed to enlightening the relevance of religion to older adults’ QoL. Recommendations for future research and behavioral approaches on older adults’ QoLand clinical practice are also presented.

Keywords: Behavioral Approach, Elderly, Health Promotion, Quality of Life, Religion




Tanaka M.1, Tayama J.2, Arimura T.3

1 Hirosaki University, Department of School Health Science, Faculty of Education, Hirosaki, Japan

2 Nagasaki University, Center for Health & Community Medicine, Nagasaki, Japan

3 Kyushu University, Department of Psychosomatic Medicine, Fukuoka, Japan

Background: There have been many previous studies about body dysmorphic concern (BDC) in adolescent samples. However, little is known about BDC in middle and old ages. The purpose of this study was to investigate the developmental changes of BDC in Japanese population.

Methods: We conducted a cross-sectional web-based survey. Samples were collected from the database of Macromill INC in Japan. This database has over one million registrants who were individual respectively. Participants agreed to this survey were 2060 individuals (male = 1030, female = 1030) ranging from 20 to 69 years of age. They filled out the questions about their demographic features and the Japanese version of Body Image Concern Inventory (J-BICI). J-BICI has three subscales and assesses the behavioral and cognitive aspects of BDC. These subscales were as follows; Safety Behavior for one’s own appearance flaws (SB), Avoidant Behavior from one’s own appearance flaws (AB), and Negative Evaluation for one’s own appearance (NE). The same number of participants were assigned to the age (20s, 30s, 40s, 50s, and 60s) and sex (male and female) conditions. To examine the effects of age, sex, and age-sex interaction on BDC, we performed two-way analysis of variance (ANOVA) with the scores of J-BICI subscales and total as dependent variables.

Results: The results showed that there was significant main effect of age (F 4,2050 = 58.28; p < .001), sex (F 1,2050 = 456.04; p < .001) and interaction (F 4,2050 = 6.32; p < .001) on the score of SB. The simple main effect of age was significant in the sex condition (p < .001). The simple main effect of sex was also significant in the age condition (p < .001). On the score of AB, there was significant main effect of age (F 4,2050 = 30.29; p < .001) and sex (F 1,2050 = 33.58; p < .001). There was also significant main effect of age (F 4,2050 = 60.00; p < .001) and sex (F 1,2050 = 235.25; p < .001) on the score of NE. However, there was no significant interaction in both AB (F 4,2050 = 1.38; p = .238) and NE (F 4,2050 = 1.51; p = .196). In addition, there was significant main effect of age (F4,2050 = 66.47; p < .001), sex (F 1,2050 = 281.45; p < .001), and interaction (F 4,2050 = 2.81; p < .05) on the total score of J-BICI. Both the simple main effect of age in the sex condition and the simple main effect of sex in the age condition were significant (p < .001). Post hoc analysis revealed that there were tendencies that BDC in young ages (20s and 30s) were higher than middle and old ones (40s, 50s and 60s) in both male and female and that BDC in female were higher than male in all ages.

Conclusion: These findings suggested that it might be possible that the conditions of being young ages and female were the risk factors for high BDC in Japanese populations. In the future, we need to clarify the age-specific body areas of excessive dysmorphic concern.

Keywords: Aging, Culture, Internet, Mental health

CORRESPONDING AUTHOR: Masanori Tanaka, Hirosaki University, Japan;



Westerlund H.1, Chungkham HS.1, Kivimäki M.2, Head J.2

1 Stockholm University, Stress Research Institute, Stockholm, Sweden

2 University College London, Department of Epidemiology and Public Health, London, United Kingdom

Background: Medically-certified sickness absence is a marker of increased risk for disability pension and pre-mature mortality, but the extent to which sickness absence predicts future health functioning remains unclear.

Objectives: To examine if sickness absence is related to limitations in physical health functioning over the long-term.

Methods: Sickness absence records of 5,070 civil servants participating in the Whitehall II study were collected for a 3-year period preceding a questionnaire survey in 1991-1993. Surveys on functioning were repeated every 2-3 years up to 2007-2009. Presence of longstanding illness at baseline was assessed by a survey question about diagnosed diseases. Growth curve models of the trajectories of SF-36 physical health functioning were fitted using mixed modelling over the 18-year period for older and younger men and women separately.

Results: On average, physical functioning deteriorated over time, especially after the age of 70. Physical health functioning was substantially lower in the participants who had taken two or more medically certified (>7 days) sickness absences during the 3-year period compared with those who hade taken none, and this was seen in both younger and older women and men. This difference remained virtually unchanged during the whole 18-year follow-up, and was comparable to the difference between participants with and without longstanding illness. Participants who had taken one medically-certified absence had a somewhat lower physical functioning throughout the follow-up compared with those who had taken none.

Conclusion: Lower physical health functioning among employees who take medically-certified sickness absence persists over a long time period. This could contribute the link between sickness absence, future ill-health, disability pension, and mortality. In addition, the results indicate that repeated medically-certified sickness absence, which is often readily available in medical and company records, is a viable marker for the identification of individuals at high risk of long-term poor health functioning.

Keywords: aging health

CORRESPONDING AUTHOR: Westerlund Hugo, Stockholm University, Stockholm;



Li J.1, Jarczok MN.1, Loerbroks A.1, Schoellgen I.1, Siegrist J.2, Bosch JA.3, Mauss D.4, Fischer JE.1

1 Heidelberg University, Mannheim Institute of Public Health, Social and Preventive Medicine, Mannheim, Germany

2 University of Duesseldorf, Department of Medical Sociology, Duesseldorf, Germany

3 University of Amsterdam, Department of Clinical Psychology, Amsterdam, The Netherlands

4 Allianz Germany, Department of Occupational Medicine, Munich, Germany

Objectives: The relationship between work stress and cardiovascular disease is well-established. However, it is not clear whether psychosocial stress in workplace is related to diabetes or not. The aim of the study was to examine the association of work stress with diabetes and pre-diabetes in a sample of German industrial workers.

Methods: In this cross-sectional occupational study (N = 2674, 77% male), work stress was measured by the effort-reward imbalance questionnaire, diabetes and pre-diabetes were diagnosed by glycated hemoglobin A1c criterion or fasting plasma glucose criterion supplemented by self-reports.

Results: The overall prevalence rates of diabetes and pre-diabetes were 3.5% and 42.2%, respectively. After adjusting for numerous potential confounding factors, effort-reward imbalance at work was associated with diabetes (OR 1.30 (95%CI 1.08-1.56)) and pre-diabetes (OR 1.26 (95%CI 1.04-1.52)) in men, whereas the effects in women were somewhat less strong and did not reach statistical significance.

Conclusions: The findings indicate that work stress in terms of effort-reward imbalance is associated with diabetes and pre-diabetes in German industrial male workers. If supported by prospective evidence, results point to a new approach towards primary prevention of diabetes.

Keywords: Worksite health; Stress; Diabetes

CORRESPONDING AUTHOR: Li Jian, Heidelberg University, Germany;



Costa JC., Santos IM., Almeida HA., Silva CS.

University of Aveiro, Department of Education, Aveiro, Portugal

Executive functioning (EF) refers to the set of neurocognitive processes that facilitate novel problem solving, modification of behavior in response to environmental changes, planning and generating strategies for complex actions. All these skills are important to purposeful and goal-directed behavior as determinants dimensions in the work ability process. So, this raise the possibility that the integrity of these cognitive abilities could have a significant impact in subject’s working performance (work ability), as well as they can be a determinant factor in his career success. In this sense, the aim of this study was to analyse the impact of the deterioration of planning and abstract reasoning’s in work ability. With a sample of 71 nurses (mean age 39 years, 21% male and 79% female), it was administered the Portuguese version of Work Ability Index, the Halstead Category Test (HCT) (a well-established neuropsychological measure that assess multiple domains of non-verbal abstract reasoning) and the Tower of Hanoi (TH), (a well-established neuropsychological measure that assess the abilities of problem-solving and planning). Considering the analysis of the results, we found that the work ability index showed a significant negative correlation with the measure of preservation of HCT (r = .-345, p < 0.01) and the total number errors (r = .-2,90, p < 0,05). Concerning the TH, the work ability index showed a significant negative correlation regarding the timing of completion of the test (r = .-2,55 p < 0.05). This way, these results may suggest that the decline of executive cognitive functions, namely the ability to planning, problem-solving and abstract reasoning exert a detrimental effect in work ability. Our data emphasize the importance of developing and implementing programs and preventive strategies for health promotion in working setting, encompassing the subcomponents of executive cognitive functions, in order to contribute to a better development of the work ability.

Keywords: Work ability, Executive function, Abstract Reasoning

CORRESPONDING AUTHOR: Costa Jorge, University of Aveiro;



Milosevic M.

University of Zagreb, School of Medicine, Andrija Stampar School of Public Health, Croatia, Department of Occupational and Environmental Medicine, Zagreb, Croatia

Aim: To examine predictors of work ability and quality of life among emergency medicine employees in Croatia.

Background: An important personnel management challenge is to explore factors that stimulate or hinder the development of individual work ability and quality of life throughout a career.

Methods: The study was performed from May 2010 to July 2010 in the Zagreb Institute of Emergency Medicine with 425 employees: 252 (59.3%) medical staff (91 EP’s, 158 nurses/medical technicians and 3 laboratory engineers/technicians) and 173 (40.7%) non-medical: 122 drivers, 14 vehicle technicians, 2 tailors and 23 administrators. The self-administered questionnaire was used: assessed their work ability and their quality of life (QoL). Work ability was measured by the Work Ability Index (WAI) developed by the FIOH, and QoL by the Quality of Life questionnaire (WHOQL-BREF) developed by the WHO. 125 people (39 emergency physicians, 38 nurses/medical technicians and 48 drivers) returned completed questionnaires, giving a response rate of around 30%.

Results: Binary logistic regression assessed the impact of various factors on the likelihood that participants had a poor WAI score (WAI < 37) and included 16 independent variables (occupation, gender, WHOQOL-BREF domains, occupational stress factors, work experience and marriage). The full model containing all predictors was statistically significant (N = 125, X2 = 81.3 p < 0,001) indicating that the model was able to identify participants who had a poor work ability. The model as a whole explained between 47.8% (Cox and Snell R2) and 73.8% (Nagelkerke R2) of the variance in work ability status and correctly classified 92.0% of cases. The participants who had a lower score in the physical domain were 1.64 (1/0.78) times more likely to have a poor WAI and participants who had more professional and intellectual demands were 1.09 times more likely to have a poor WAI, when all other factors were controlled for in the model.

Conclusions: Similar studies have found the opposite effect: with high intellectual demands stimulating the employee to perform better. Thus, better work organisation and swifter implementation of the new EM residency programme is needed.

Keywords: emergency medicine, quality of life, work ability, work organization

CORRESPONDING AUTHOR: Mustajbegovic Jadranka, University of Zagreb, Zagreb;



Grilo AM., Gomes AI.

Instituto Politécnico do Lisboa, Department of Social Sciences and Humanities, Lisbon, Portugal

Introduction: Helpful physiotherapists do not simply dispense services, but provide them in a manner that reflects patient’s needs and understanding of his disease or disability (Darragh, Almquist & Krook, 2000). In fact, communication with the patient should occupy a prominent place in rehabilitation, but some results indicate that physiotherapists encounter many challenging conversations during their everyday work (Gard, Gyllensten, Salford & Ekdahl, 2000). Yet, health schools curriculum offers few means to prepare them for difficult situations. The aim of this work is to identify students’ and physiotherapists’ anxiety levels in difficult communications situations.

Methods: The study involved 60 2nd year students and 60 4th year students of physiotherapy from School of Health Technology in Portugal and 60 Portuguese physiotherapists. Data were collected through videotaped different scenarios representing problematic situations within the physiotherapist-patient interaction. These situations were related to specific assertive communication themes, like handling emotional expression, making requests, answering questions/requests, giving criticism and receiving criticism. Subjects have to answer in direct speech to the simulated patient in the video and then filled out a six-point Likert scale, focused on the students` and the physicians` perception of their anxiety.

Results: The results shows that there are significant differences between the perception of anxiety levels of the three groups in each of the six assertive themes. It tends to be higher in the groups of students (2nd and 4th years) than in the group of professionals. Thus, 2nd year students are those with higher levels of anxiety and the group of physiotherapists seems to have lower scores. Comparing the levels of perceived anxiety triggered by the different assertive themes, it appears that answer the question/ request is the one that triggers higher for the three groups of subjects, followed by the themes of emotionality, i.e, emotional expression in deficit and excessive emotional expression.

Discussion: These results should be considered in designing training programs for communication skills in pre-and post-graduate educational request.

Keywords: Anxiety, Rehabilitation, Emotions

CORRESPONDING AUTHOR: Grilo Ana, Instituto Politecnico. Lisbon;



Urakawa K.1, Yokoyama K.2, Hagi N.3

1 Mie University, Department of Stress Science, Graduate School of Medicine, Tsu, Mie, Japan

2 Juntendo University, Faculty of Medicine, Department of Epidemiology and Environmental Medicine, Tokyo, Japan

3 Yokkaichi Nursing and Medical Care University, Department of Psychiaric Nursing, Yokkaichi, Mie, Japan

According to the Japanese Nursing Association (1997), the ethical dilemmas that nurses encountered in their daily nursing practice included problems related to relationships with physicians, providing information to patients, problems between nurses, and imbalances in the abilities of nurses and the difficulty of their duties. However, there have been few studies evaluating ethical dilemmas in psychiatric nursing area.

In the study presented here, we investigated ethical dilemma faced by Japanese psychiatric nurses in two mental hospitals in Mie prefecture, by means of a postal questionnaire survey. The questionnaire included the item “conflict due to the relationship between nurses and physicians,” in addition to items regarding the four areas of clinical ethics developed by Jonsen et al. (treatment, self-determination, quality of life, and circumstances of the patients). A total of 284 nurses were asked to anonymously report the presence or absence of a dilemma for the above five items, and to give a detailed explanation by free comments. Eighteen-three nurses completed the form (29.2% of recovery). Survey period was February and March, 2004.

Forty-three nurses (51.8%) reported that they had a dilemma, whereas 22 (24.1%) had no dilemma; the remaining 11 nurses said “I do not know.” Thirty-eight nurses (45.8%) answered they had a sense of value and belief, while 31 (37.3%) answered they did not have; 14 (16.9%) did not answer. A sense of value and belief was significantly associated with the occurrence of dilemmas (p < 0.001, chi-square test). A qualitative analysis of free comments showed that ethical dilemmas were roughly divided into the following four categories: 1) compulsory care for patients, 2) circumstances in which family did not cooperate with them, 3) care in which individual patient’s need was ignored, and 4) care which had no consistency. These findings help to clarify the current states of difficulty of providing team nursing at psychiatric words in accordance with ethical problems.

Keywords: Ethical issues, Psychiatric nurses, Sense of value and belief, Self-determination

CORRESPONDING AUTHOR: Urakawa Kayoko, Mie University;



Holendro CH.1, Leineweber C.1, Tishelman C.2, Westerlund H.1, Lindqvist R.2

1 Stockholm University, Stress Research Institute, Stockholm, Sweden

2 Karolinska Institutet, Department of Learning, Informatics, Management and Ethics, Stockholm, Sweden

The present shortage of registered nurses (RNs) in many European countries is expected to continue and worsen, which poses a substantial threat to the maintenance of healthcare in this region. In Sweden, nursing staff is one of the occupational groups with the highest rates of long-term sickness absence. One way of dealing with the RN shortage is to keep staff healthy and willing to continue to work. This paper empirically examines whether the nurse practice environment is associated with experienced work-family conflict, a known risk factor for turnover and sickness absence. A multilevel model was fit with RN at the 1st, and department at the 2ndlevel using cross-sectional RN survey data from the Swedish portion of a 15-nation project (7982 women and 568 men from 369 hospital departments). We found that 6% of the variability in work-family conflict was on the department level, with 83% of the variability explainable by the nurse practice environment measured by aggregated ratings of: staffing adequacy, RNs involvement in hospital affairs, relationship with physicians, nursing quality of care, and leadership & support for nurses. Higher proportion of RNs in total nursing staff supporting nursing personal, staffing adequacy and involvement in hospital affairs were all significantly related to lower work-family conflict. Age, sex, length of work experience, and RNs’ self-reported job satisfaction accounted for 9% of the individual-level variance in the final parsimonious model. These results suggest that organizational factors related to the practice environment have significant impact on the risk of work-family conflict among RNs.

Keywords: work-family conflict, work environment factors, registered nurses, multilevel

CORRESPONDING AUTHOR: Chungkham Holendro Singh, Stress Research Institute;



Simães C.1, McIntyre T.2, McIntyre S.3, Silva M.4

1 University of Minho, School of Nursing, Braga, Portugal

2 University of Houston, Texas Institute for Measurement, Evaluation and Statistics (TIMES) & Department of Psychology, Houston, USA

3 University of Houston-Clear Lake, School of Human Sciences & Humanities, Houston, USA

4 University of Minho, School of Psychology, Braga, Portugal

Work-related stress among health professionals has been identified as an important health problem around the world, including Portugal. This study sought to test the variables of the Effort-Reward Imbalance model (ERI) as predictors of stress responses and organizational outcomes amongst Portuguese nurses. The role of overcommitment for work place health is also considered. The sample consists of 310 female hospital-based nurses, from the northern region of Portugal (Age: M = 33.83; SD = 8.70). Measures were a Socio-demographic and Professional Questionnaire, and the Portuguese versions of the Effort Reward Imbalance Inventory (ERI), to assess job effort and reward, effort-reward imbalance ratio and overcommitment; the General Health Questionnaire (GHQ-12) and the Brief Personal Survey-Revised (BPS-R), to measure stress responses; and the Organizational Climate Questionnaire (QuACO) to measure job attitudes regarding organizational climate. A subgroup of 59 nurses was also assessed using biological indicators of stress, i.e. salivary cortisol levels at the time of awakening (e.g. Ct(+0), Ct(+30), CAR, TMCR). Data from GHQ-12 revealed clinical levels of psychological distress in 75.8% of the total sample (2/3 cut off). The ERI model produced significant independent effects for both nurses’ stress responses (e.g. psychological distress, pressure overload) and job attitudes (e.g. global satisfaction with meetings and work environment). Overcommitment emerged as a significant moderator of the relationship between perceived occupational stress and nurses’ stress responses (e.g. pressure overload). It was also an important predictor of salivary cortisol measures: Ct(+0) (ß = .28) and TMCR (ß = .26). The total variance explained by all predictors and hierarchical tested models ranged from 3.5% to 29.0%. Results highlight the incidence of psychological distress in Portuguese nurses and point to the relevance of the ERI model variables in explaining stress responses and job attitudes in this context. Findings can guide intervention development to improve occupational health for women in the nursing profession.

Keywords: Occupational Stress, Hospital Nurses, ERI model

CORRESPONDING AUTHOR: Simães Clara, University of Minho, Braga;



Norlund S.1, Fjellman-Wiklund A.2, Nordin M.1, Stenlund T.2, Ahlgren C.2

1 Umeå University, Department of Public Health and Clinical Medicine, Umeå, Sweden

2 Umeå University, Department of Community Medicine and Rehabilitation, Umeå, Sweden

Objectives: The aim of this study was to explore experiences and thoughts in the process of returning to work in employed patients with Exhaustion Disorder, with focus on engagement and support.

Methods: Twelve patients with Exhaustion Disorder (burnout) who had been referred to a Stress Rehabilitation Clinic were interviewed. Grounded Theory was used as the qualitative method.

Results: A core category, regaining the ability to work, was developed. Alongside, two categories, internal resources and the external support system, were described as being important in the process. The internal resources were expressed through three key features (sub-categories), perceived validation, insights and adaptive coping skills. The external support system was diverse and described by the sub-categories practical/structural and/or emotional support. Four external actors were identified; the workplace, health care, the Social Insurance Agency, and the union. The supervisor was described as the most important external actor.

Conclusions: Internal and external resources are intertwined in the process of regaining the ability to work. The internal resources and external support can directly increase the probability to regain the ability to work. Moreover, these resources can affect each other and thus indirectly have an effect on the process.

Keywords: social support, coping, rehabilitation

CORRESPONDING AUTHOR: Sofia Norlund, Umeå University, Umeå;



Shimada K.1, Shimazu A.1, Bakker AB.2, Demerouti E.3, Kawakami N.1

1 University of Tokyo, Mental Health, Tokyo, Japan

2 Erasmus University, Work and Organizational Psychology, Rotterdam, The Netherlands

3 Eindhoven University of Technology, Industrial Engineering & Innovation Sciences Human Performance Management Group, Eindhoven, The Netherlands

Introduction: Contemporary society has greater numbers of dual-earner couples and the need to keep balance between work and family roles is becoming an important issue. As existing studies in the field of occupational health mainly focus on negative side of spillover between work and family roles, there are few studies that examined the positive side of spillover. Moreover, few studies have investigated the long-term effects of work-family spillover. The purpose of the present study is to examine the effects of multiple types of work-family spillover on psychological distress using longitudinal data.

Methods: Out of 2,992 dual-earner parents with preschool children in Tokyo, who answered the baseline survey (T1), 1,638 agreed to participate in the one-year follow-up (T2). Valid responses were obtained by 928parents (416 males, 512 females; follow-up rate: 60.8%). Multiple regression analyses on T2 psychological distress were conducted by gender, whereby predictor variables (T1) such as, demographics, psychological distress, job demands/resources, family demands/resources, four dimensional work-family spillovers (work-to-family negative spillover, work-to-family positive spillover, family-to-work negative spillover, family-to-work positive spillover), were entered into the equation.

Results: Work-to-family negative spillover and psychological distress (T1) had positive impacts on psychological distress at T2 for males. Neither family-to-work negative spillover nor bidirectional positive spillovers had significant impacts for males. For females, family demands and psychological distress (T1) had positive impacts on the outcome, whereas family autonomy had a negative impact. However, neither negative nor positive spillovers had significant impacts for females.

Discussion: Among spillovers, only work-to-family negative spillover had significant positive impacts on psychological distress for males. Among females, none of four spillovers had impacts on psychological distress. Results reveal that factors having long-term impacts on psychological distress vary according to gender, which is to say, in order to improve psychological health, knowledge and skills to manage the interference of work with family are important for males and that those to reduce family demands and increase family autonomy are important for females.

Keywords: Health outcomes, Mental health, Public Health, Gender

CORRESPONDING AUTHOR: Shimada Kyoko, University of Tokyo, Tokyo;



Mase J., Ota A., Inoue K., Iida T., Ono Y.

Fujita Health university, Public Health, Toyoake, Japan

Objectives: Karasek’s Job Content Questionnaire (JCQ) is a self-administered instrument and has served as a de facto standard to assess psychosocial work environment according to the Demand-Control-Support (DCS) model. Meanwhile, the Demand-Control-Support Questionnaire (DCSQ) is used mainly in Scandinavian countries. The DCSQ uses frequency response format instead of agree-disagree with risk of acquiescence. We translated it into Japanese, i.e., the Japanese-translated version of the DCSQ (J-DCSQ), and investigated its reliability and validity.

Methods: The subjects were volunteer 212 women workers in 18 nursery schools in Japan. Psychological demands (PD: calculated with 5 items), decision latitude (DL: 6 items), and social support (SS: 6 items) were assessed with the J-DCSQ. One-week test-retest reliability and internal consistency were estimated by means of intra-class correlation coefficient (ICC), weighted kappa and Cronbach’s alpha, respectively. Concurrent validity was evaluated with Spearman’s correlation coefficient for which the Japanese-version JCQ (J-JCQ) was used as the reference. Factorial validity was evaluated with factor analysis.

Results: ICCs were 0.81, 0.82, and 0.80 for PD, DL, and SS, respectively. Weighted kappa were from 0.58 to 0.75. Correspondingly, Cronbach’s coefficient alphas (the mean inter-intra correlation) and Spearman’s correlation coefficients were 0.64 (0.27), 0.63 (0.22), 0.86 (0.50) and 0.74, 0.60, 0.59 for PD, DL, SS. Factor analysis suggested an uncorrelated 3-factor construction. The first factor included the complete set of SS items. The second factor was consisted of a combination of 3 PD and 2 DL items. The third factor was consisted of 2 DL items. The factor loadings of other 2 PD and 2 DL items were under 0.4.

Conclusions: The J-DCSQ exhibited as equivalent reliability as the J-JCQ. The present findings suggested adequate concurrent validity of the J-DCSQ. Factor analysis did not present factor structure of the J-DCSQ as theoretically hypothesized. Previous studies also reported similar factor structure of the J-JCQ as three subscales, PD, DL and SS. Further studies are needed to its validity. The J-DCSQ would become an alternative to J-JCQ with the risk of acquiescence.

Keywords: Stress, Occupational Health

CORRESPONDING AUTHOR: MASE Junji, Fujita Health University;




Tsutsumi A.1, Inoue A.2, Kurioka S.3, Miyaki K.4, Takahashi M.5, Shimazu A.6, Kosugi Y.7, Enta K.8, Eguchi H.9, Kawakami N.6

1 Kitasato University School of Medicine, Department of Public Health, Kanagawa, Japan

2 University of Occupational and Environmental Health, Department of Mental Health, Fukuoka, Japan

3 University of Occupational and Environmental Health, Department of Health Policy and Management, Fukuoka, Japan

4 National Center for Global Health and Medicine, Department of Clinical Research and Informatics, Tokyo, Japan

5 National Institute of Occupational Safety and Health, Health Administration and Psychosocial Factor Research Group, Kanagawa, Japan

6 The University of Tokyo Graduate School of Medicine, Department of Mental Health, Tokyo, Japan

7 Kosugi Health Management Office, -, Toyama, Japan

8 Health Care Center, Central Japan Railway Company, Shizuoka, Japan

9 Shinshu University School of Medicine, Department of Preventive Medicine and Public Health, Matsumoto, Japan

Aim: The analysis aims to describe the baseline characteristics of the study population of an ongoing five-wave panel study of Japanese workers to elucidate mechanisms underlying the social disparity in health.

Method: We analyzed 9848 workers aged 18-69 from 12 enterprises registered until the end of 2011. Job strain, effort-reward imbalance, organizational justice, social capital, work engagement, and psychological distress were evaluated, and stress-related biomarkers including IL-6, CRP, homocysteine, DHEA and cortisol were measured, in addition to conventional cardiovascular risk factors. Social class were categorized in terms of 3 relevant socioeconomic indices—occupation: manager, professional or technician and others including clerk, service, laborer, or non-classifiable; education: up to high school and college or more; income: up to \5000000 (annual household) and \5000000 or more. Morbidities were defined based on questionnaire and health examinations. We did sex-specific analyses adjusted for age.

Results: In men, upscale workers work longer than downscales, at all socioeconomic indices. Adverse psychosocial job characteristics, smoking and sedentary lifestyle were prevalent among downscales. Hypertension, dyslipidemia and current alcohol drinking were prevalent among less-educated men. However, diabetes, dyslipidemia and alcohol drinking were prevalent among higher-income men. IL-6 was higher among lower-income men. DHEA levels were higher among less-educated but higher-income men.

Same as men, upscale women of any indices work longer. Smoking and sedentary lifestyle were prevalent among downscales and less-educated workers were hypertensive. Women with lower occupational and educational classes were more obese than the respective counterparts. Dyslipidemia was prevalent among lower occupational class. Homocysteine levels were higher among downscale women. However, upscale women were more effort-reward imbalanced and higher occupational class women were psychologically distressed.

Conclusion: Morbidities including psychosocial job characteristics were unevenly distributed across socioeconomic strata among Japanese workers. Some unfavorable profiles were associated with upscale and the associations were different by socioeconomic indices and genders.

Keywords: Cardiovascular disease, Gender, Socio-economic status, Stress, Worksite health

CORRESPONDING AUTHOR: Tsutsumi Akizumi, UOEH, Japan;



Karlson B.1, Larsson MR.1, Österberg K.2

1 Lund University, Psychology, Lund, Sweden

2 Lund University, -, Lund, Sweden

Introduction: Police work involves stressors specific to police work and to general organizational aspects of work. Some of the latter has previously been identified as risk factors for burnout, particularly to increased degree of the burnout sub-dimension cynicism. Cynicism has in turn been related to a positive attitude to the use of force to solve problems. In the present study the relationships between psychosocial work dimensions, exposure to threat and violence, burnout, and attitudes towards the use of force to solve problems were studied.

Methods: 509 patrolling policemen having worked as police officers 0-41 (Md = 4) years, participated in the study (50% response rate). They responded to a questionnaire measuring demographic variables, general psychosocial work dimensions (work load, control, community, reward, justice, and value conflicts) by Areas of Work Life Survey, exposure to threat or violence the last year, burnout by Maslach Burnout Inventory, and attitudes towards the use of force. Attitude was analysed as dependent variable with the other were block-wise entered into a regression analysis as predictor variables.

Results: In relation to an external reference group from the general population the police group reported lower degree of emotional exhaustion and cynicism and a higher sense of professional efficacy. They scored somewhat poorer than the reference group on the work dimensions of control, organizational justice and value conflict. In the regression analysis 17.2% of the variance (adjusted R 2) in the attitude variable was explained. All blocks of variables contributed significantly to R 2 change. The variables particularly contributing in the final model were: short tenure as police officer, a high work load, having been exposed to violence the last year, and higher degree of cynicism.

Conclusions: In spite of an overall favourably reported psychosocial work environment, and good well-being, high work load as well as cynicism was related to positive attitudes towards the use of force, which is in line with previous studies from other countries. In addition, exposure to violence and a relative short experience as police officer contributed to positive attitudes towards the use of force.

Keywords: attitudes, stress, risk factors

CORRESPONDING AUTHOR: Karlson Björn, Lund University, Lund;



Melamed B G.1, Skip R.2

1 University of Hawaii, Department of Psychology, Honolulu, Hawaii, USA 2 University of Southern California, Department of Psychiatry and Mental Health, Santa Barbara, USA

Results of treatment of PTSD in soldiers who served in Iraq and Afghanistan will compare Virtual Reality and Prolonged Exposure therapies. In war, we face issues related to: Behavioral health issues; Traumatic brain injury; PTSD: Infectious disease: Toxic exposures: Nutritional changes: Medication side effects; Alcohol and drug abuses. In addition relationship to psychological consequences to survival issues and loss due to Home Violence as seen in family members immediately after World Trade Center disaster and 4 years later. The data revealed that PTSD was much lower than Depression. Depression did abate over time in families with dead relatives, however, family members were 60% likely to still show Clinical Depression. Alcoholism was related to race (African Americans) showed a greater tendency to drink after the event. Data on 99 subjects followed for 4 years found that those with lower Hope Scores and tendency to use Avoidance Coping led to more depression remaining at this time. There was greater similarity in responses to Hurricane Katrina to those who vicariously experienced World Trade Center, especially by repeated TV re-exposure. New research on US war veterans is needed to look at long term resilience and relationships between coping styles, PTSD and recovery from depression.

Keywords: violence, PTSD, war, World Trade Center, Hurricane Katrina

CORRESPONDING AUTHOR: Melamed Barbara, University of Hawaii;



Melamed B G.

University of Hawaii, Department of Psychology, Honolulu, USA

The National Academy of Science (IOM) concluded that current research on the treatment of PTSD in U.S. veterans is inadequate to answer questions about interventions, settings, and lengths of treatment that are applicable. Peterson, et al. (Special Issue, 2011) and Otis et al. Special Issue, 2011) and the two articles on Virtual Reality and Telehealth (Rizzo et al., 2011; Stetz, et al 2011) provide empirical evidence for the efficacy of PE and Cognitive Processing. In PE patients are educated about the development and treatment of PTSD, are taught slow breathing techniques to promote relaxation, and practice imaginal and in vivo exposure to promote habituation to the feared trauma memory. CPT relies more on cognitive restructuring and emphasis on the individual creating impact statements about the trauma. Although PTSD patients typically avoid thoughts and situations that are reminders of the trauma, PE and CPT requires confrontation of trauma memories by having patients repeatedly tell the trauma story (imaginal/narrative exposure) and confront feared situations associated with the trauma (in vivo exposure) (Foa, et al., 2007). Yet the studies presented and those being conducted in the theater of war, suggest that once the war fighter is exposed and taught cognitive strategies in as few as 4–11 sessions they may re-enter the battlefield with more efficient functioning, a better chance of survival and less likelihood of developing PTSD. Once we understand the mechanisms underlying effective exposure (e.g., How much arousal needs to be evoked to have sufficient exposure?) we will be able to determine the application of Virtual Reality Exposure Therapy (VRET) and when it would be indicated. Currently the US Army is trying to make PYSD an injury rather than a disorder. Discussion focuses the advantages and disadvantages of this on DSMV and treatment costs, effectiveness and delivery agent.


Foa E. et al. (2007 Prolonged Exposure Therapy for PTSD. Therapist Guide: NY: Oxford Press.

INSTITUTE OF MEDICINE (IOM) 2007 Committee on Treatment of PTSD

Melamed, B.GSpecial Issue: Strengthening Our Soldiers (SOS) and Their Families: Contemporary Psychological Advances Applied to Wartime Problems. Journal of Clinical Psychology in Medical Settings: June 2011 18 (2).

Peterson et al. (2011) Assessment and Treatment of Combat-Related PTSD JCPMS 18 (2) 164-175.

Rizzo et al. (2011) Virtual Reality Goes to War. 176-188

Stetz et al. (2011) Technology Complementing Military Behavioral Health Efforts at Tripler Army Medical Center. JCPMS,v0l 18-2188-196.

Keywords: cognitive therapy, prolonged exposure, virtual reality

CORRESPONDING AUTHOR: Melamed Barbara, University of Hawaii;



Nishi D.1, Koido Y.2, Nakaya N.3, Sone T.4, Noguchi H.5, Hamazaki K.6, Hamazaki T.7, Matsuoka Y.8

1 National Disaster Medical Center, Department of Psychiatry, Tokyo, Japan

2 National Disaster Medical Center, Head Office, Japan Disaster Medical Assistance Team, Tokyo, Japan

3 Kamakura Women’s University, Department of Nutrition and Dietetics, Kamakura, Japan

4 Tohoku Fukushi University, Department of Rehabilitation, Sendai, Japan

5 National Center of Neurology and Psychiatry, National Institute of Mental Health, Tokyo, Japan

6 University of Toyama, Department of Public Health, Toyama, Japan

7 University of Toyama, Department of Clinical Sciences, Toyama, Japan

8 National Center of Neurology and Psychiatry, Translational Medical Center, Tokyo, Japan

Background: The Great East Japan Earthquake left about 20,000 dead or missing. Previous studies showed rescue workers are at high risk for posttraumatic stress disorder (PTSD). This study aimed to determine whether fish oil supplementation could attenuate PTSD symptoms among rescue workers following the Great East Japan earthquake.

Methods: In this single-blind, randomized trial, rescue workers who provided consent to participate were randomly allocated to a fish oil plus psychoeducation group or a psychoeducation alone group. The primary outcome was PTSD symptoms assessed by the Impact of Event Scale-Revised (IES-R) at 12 weeks after fish oil supplements were shipped to the participants. All analyses were by intention to treat.

Results: Of the 172 participants enrolled between April 2 and 12, 2011, 86 were assigned to each of the two groups. Only 1 participant in the psychoeducation alone group was lost to follow-up. When adjusted for age, sex, and IES-R score at baseline, no significant difference in primary outcome was seen between the two groups (-0.9, 95% CI, -3.0 to 1.2; P = .39). Remarkably, change in the IES-R score of women in the two groups from baseline to 12 weeks was -3.9 (95% CI, -7.5 to -0.3; P = .04) when adjusted for age and IES-R scores at baseline.

Conclusions: This trial did not show the effectiveness of fish oil supplementation for the prevention of posttraumatic stress symptoms in rescue workers. However, supplementation reduced PTSD symptoms significantly in women. Fish oil may offer a safe strategy for preventing PTSD in women.

Keywords: Posttraumatic stress disorder, Fish oil, Omega-3 fatty acid, Prevention, Earthquake, Randomized controlled trial

CORRESPONDING AUTHOR: Nishi Daisuke, National Disaster Medical Center;



Nybergh L.1,2, Taft C.3,4, Krantz G.1,2

1Department of Public Health and Community Medicine, Institute of Medicine, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden

2The Västra Götaland Region Competence Centre on Domestic and Sexual violence, Gothenburg, Sweden

3Institute of Health and Care Sciences, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden

4The University of Gothenburg Centre for Person-Centred Care, University of Gothenburg, Gothenburg, Sweden

Background: The World Health Organization’s Violence Against Women instrument (VAWI) assessing psychological, physical and sexual intimate partner violence (IPV) was developed to standardize methodologies and facilitate cross-cultural comparisons of exposure to violence. It has been used widely but few studies have investigated its psychometric properties. Furthermore, few studies have investigated such properties for instruments assessing IPV separately for women and men in randomized, population-based samples.

Aim: To explore the psychometric properties of the VAWI in a randomized cross-sectional study in a Swedish male (N = 399) and female (N = 573) population aged 18-65 years.

Methods: Internal reliability and validity were assessed by means of Cronbach’s alpha and principal components analysis (PCA). External validity was assessed by comparing exposure rates with published prevalence rates and with those obtained from a concurrently administered instrument (NorVold Abuse Questionnaire); moreover, a known group’s comparison was performed among the female sample.

Results: Cronbach’s alphas were satisfactory. For women, a pre-determined three-component solution largely corroborated the hypothesized three-component conceptual model of the VAWI. The instrument was able to discriminate between groups known from previous studies to differ in exposure to physical and/or sexual violence. Past-year prevalence of physical and sexual violence was similar to that reported in other Nordic studies; however, earlier-in-life prevalence was lower in the current study. For men, the PCA did not corroborate the hypothesized model and other constructs were found based on the severity of the violence items. Past-year prevalence of physical and sexual violence was higher than in other Nordic studies; earlier-in-life prevalence of physical violence was lower and sexual violence was higher. Reported exposure rates were higher than those obtained from the NorVold Abuse Questionnaire for both women and men.

Conclusions: The VAWI indicated good validity and internal reliability in a Swedish population. However, the underlying constructs seem to differ for women and men, which points to the need for research instruments assessing IPV to be validated separately in male and female samples.

Keywords: Gender, methodological issues

CORRESPONDING AUTHOR: Nybergh Lotta, Gothenburg University;



Almendros C.1, Carrobles J. A.1, Gamez-Guadix M.2, Garcia Sanchez R.1, Salazar N.1

1 Universidad Autonoma de Madrid, Biological and Health Psychology, Madrid, Spain

2 Universidad de Deusto, Clinical Psychology, Bilbao, Spain

The Experiences in Close Relationships - Relationship Structures Questionnaire (ECR-RS, Fraley, Heffernan, Vicary & Brumbaugh, 2011) was designed to assess two dimensions of attachment: avoidance and anxiety, in multiple contexts, deriving from the widely used Experiences in Close Relationships – Revised (Brennan, Clark & Shaver, 1998). The aim of this work was to examine the psychometric properties of the ECR-RS in Spanish women reporting over a partner relationship.

Two groups of women participated in this study. One was composed of 120 women victim of intimate partner violence (IPV), living on shelters or attending women assistance centers. Their mean age was 35.80 (SD = 11.18), they have been a mean time of 9.92 years (SD = 9.74) in the relationship and, for those who had left (90.6%), they had been out a mean time of 2.13 years (SD = 2.91). The second was made up of 112 women Spanish university students from the Community of Madrid. Their mean age was 23.98 (SD = 6.04). Mean time in the relationship was 3.71 years (SD = 4.86) and 38.4% of them had finished the relationship a mean time of 3.15 years (SD = 3.63) before. A cross-sectional design for obtaining data was used. Beside the ECR-RS, several instruments for the measurement of psychological abuse (Subtle and Overt Psychological Abuse Scale; SOPAS; Marshall, 1999), physical and sexual abuses (Revised Conflict Tactics Scales; CTS-2; Straus et al., 1996) and psychological distress (Brief Symptom Inventory; BSI; Derogatis, 1975) were used.

Results: A descriptive analysis of the items showed low item-total correlation values for items 4 and 10 of the original ECR-RS for the sample of women victims of IPV. Factorial analyses showed adequate indicators for the original factor structure. Both the avoidance and anxiety subscales showed appropriate internal consistency values, and both correlated with the different forms of abuse and psychological distress.

Conclusions: This study provides preliminary psychometric properties of the ECR-RS for Spanish population as applied to partner relationships and how attachment and abuse in partner relationships affect women’s health.

Keywords: Measurement; Women's health

CORRESPONDING AUTHOR: Almendros Carmen, Universidad Autónoma de Madrid;



Rodríguez-Carballeira A.1, Almendros C. 2, Saldaña O.1, Martín-Peña J.1, Escartín J.1, Porrúa C.1, Varela-Rey A.1

1 Universidad de Barcelona, Social Psychology, Barcelona, Spain

2 Universidad Autonoma de Madrid, Biological and Health Psychology, Madrid, Spain

The aim of this work was to study the psychometric properties of the English version of the Escala de Abuso Psicológico Aplicado a Grupos (EAPA-G). This is a new instrument intended to assess the severity of implementation of various abusive strategies perpetrated by manipulative groups.

These strategies can be classified into six categories (Rodríguez-Carballeira et al., 2005): emotional abuse, isolation, manipulation and control of information, control of private life, indoctrination within an absolute and Manichean belief system, and imposing an exclusive/unique and extraordinary authority. The severity of each of the abusive strategies was evaluated through a Delphi study.

The first version of the EAPA-G was in Spanish and it was composed of 92 items on a 5-point Likert scale. Now there are English and Japanese versions and a reduced version of 52 items in the three languages.

Two samples, the first comprising 144 self-identified former members of various abusive groups, and the second comprising 206 students from a Southern University in the USA who were former members of a variety of non abusive groups, participated in the study. Participants responded to a battery of instruments that included the EAPA-G, the Group Psychological Abuse Scale (GPA; Chambers, Langone, Dole and Grice, 1994; Almendros, Carrobles, Rodríguez-Carballeira and Jansà, 2003), which is a preexisting scale to assess psychological abuse in manipulative groups, which is limited in contents to our view, and other instruments to assess the characteristics of the victims and their environment, the situation of victimization, and psychological distress.

The factorial structure, internal consistency, diagnostic validity, and discriminatory power of the English version of the EAPA-G were examined. The items analysis showed that the 52 items selected for the reduced version were appropriate. The factorial structure fits with the initial theoretical proposal. The scale seems to have adequate psychometric properties in terms of reliability and convergent validity with the GPA.

Therefore, the EAPA-G seems to be a useful instrument to measure psychological abuse perpetrated by manipulative groups. Assessing psychological abuse is important given its potential impact on the mental health of the people involved in these groups.

Keywords: Measurement; Assessment

CORRESPONDING AUTHOR: Almendros Carmen, Universidad Autónoma de Madrid;



Rivas-Diez R., Sánchez-López MP. Universidad Complutense de Madrid, Personalidad, Evaluación y Tratamientos Psicológicos II (Psicología Diferencial y del Trabajo), Madrid, Spain

Introduction: Violence gender has caused considerable social alarm. Better awareness of the characteristics and problems of the female victims is necessary to be able to provide adequate psychological attention.

Objectives: To identify the specific characteristics of PTSD in female victims of gender violence, stating what are the symptoms of this disorder are usually present, identify some of the most important variables that characterize women seeking assistance this problem (type of abuse, duration and frequency, if living with the abuser, etc.).

Methods: Participants: The sample consists of 97 Chilean battered women. These women attended to different Centers of Women (National Women´s Service) in various regions of the capital of Chile (Santiago).

Instruments: Semi-structured interview for victims of abuse: assesses sociodemographic characteristics of victims and circumstances of abuse, it was designed for this research. The PTSD Symptoms Severity Scale (Echeburúa et al., 1997): assesses the severity and intensity of the symptoms of this disorder according to the diagnostic criteria of the DSM-IV-TR (American Psychiatric Association, 2000) in victims of different traumatic events.

Results: 75.3% of the participants developed the PTSD disorder. The results show that the most typical symptoms of PTSD are: re-experiencing (the presence of unpleasant and recurring memories about the abuse and psychological and physiological distress on recalling the events); avoidance symptoms (avoidance of thoughts, feelings or conversations related to what has been experienced, loss of interest in significant activities and restriction of emotional life); and hyperactivation symptoms (permanent state of hypervigilance and startle response). The frequency and severity of the violence (not the duration of abuse) are the two variables referring to the situation in greater influence on the level of traumatic symptoms.

Conclusions: This data will be useful to understand the problems and consequences of abuse and to target interventions to be made to alleviate the plight of these women in cases where it appears PTSD.

Keywords: Women´s health, gender

CORRESPONDING AUTHOR: Rivas-Diez Raquel, Univ. Complutense de Madrid;



Mercado D., Santos CA.

National Autonomous University of Mexico, School of Psychology, Mexico City, Mexico

The couple’s violence is a public health issue, it is systematic, occurs in a long period and in conditions that suit its perpetuation. Some women are capable of getting away from this context, even though it could take them years to do so.

The objective of this study was to describe some of the contingent conditions for either separation or permanency into the couple’s violence. Twenty seven women volunteered, all with couple’s violence, they were already going to a support institution for domestic violence. Twenty of them were separated from the aggressor, 7 were still into the relationship. A semi-structured interview was applied.

Results: showed more terrorist violence in separated women and more situational violence in those that were not. When the violence started women did not reply violently, they tried to avoid it with several strategies, when they did not work was when they began to defend themselves violently, still some did not defend themselves. The ones that were separated were more defensive and had more non violent confrontation strategies. Eighteen percent had never tried to split, the rest had between 1 to 8 tries. The main reasons to separate were: intense violence, infidelity and drugs. The main reasons not to go out were: economic 34%, fear of dealing with life alone 25%, love 10%. In the group that remained in the relation 14% had learn to set limits. In contrast, when they split away temporarily, only 8% had economic disturbances but 65% because of reasons related to lost, missing, love and loneliness. They returned to the relationship because of the aggressors promises. Twenty four percent of them attributed violence to the, aggressive, overbearing and sexism characteristics to their partner, and 17% to drug addictions.

The perception of lack of success in avoiding violence and of a blurry future of the relationship was stronger in the separated women, and of being partially capable of avoiding violence and of being listened was higher in the ones that were not separated. Intensification of violence and lack of solution perspectives seem to be important for women’s take the decision of run out from couple violence. Formal psychological and legal support enhances woman’s empowerment to end with this public health problem.

Keywords: Public health, assessment, couple-focused, couple violence

CORRESPONDING AUTHOR: Mercado Dolores, National University of Mexico;



Mercado D., Salazar A. V., Viveros A. L.

National Autonomous University of Mexico, School of Psychology, Mexico City, Mexico

The purpose of this studio was to evaluate the process of psychological support therapy to women in violence situation offered by a government institution. The permanence of women in couple’s violence can be explained by cultural factors that adjudicate women the responsibility for the wellbeing of the family members, the submissive role to male authority, fear associated with separation, such as financial capability, not being able to come along with the family, to loneliness or the increase of violence, as well as psychological defenses such as negation or violence normalization. For a woman to get free from a couple’s violence situation she should change beliefs, behaviors and emotions that keep her inside and do not allow her to leave couple’s violence. This program is targeted to strengthen the women and help them to free from the violent situation.

Three hundred and two women volunteer which attended to a psychological support program for attention to couple’s violence victims, 56 were the first time they attended, 100 with from 2 to 4 sessions, 80 with 5 to 8 sessions, 66 with 9 to 13 sessions. The instrument “Feminine believes, behaviors and emotions towards couple’s violence” was used, it has 56 items that are responded by a Likert scale of 6 spaces from never to always. It evaluates believes, behaviors and emotions that hold back women from getting out of a violence situation, as well as an aspiration factor for a better life. It is a transversal design.

ANOVA produced, with exception of the factor Aspiration for a better life, significant effects with a p < 0.05 in the subscales of: Irrational Responsibility, Guilt, Submission, Dependency, Fear to change, Negation and Violence normalization, in all of the cases the significance was because the measures decreased as the number of sessions increased. This indicates the gradual response in getting rid of guilt beliefs, submission, dependency and fears related to the right of living violence free life. It is suggested that when the women looked for psychological help, they had already started the process to free themselves from violence. And that therapy support gave them those tools and strength to feel secure of their decisions they have taken and the ones they will take.

Keywords: Social support, Measurement, Health behavior, Quality of life

CORRESPONDING AUTHOR: Mercado Dolores, National University of Mexico;



Zara A.

Istanbul Bilgi University , Department of Clinical Psychology, Istanbul, Turkey

The sexual violence is one of the major problem towards children in Turkish society where these issues involves many psychological, social and cultural factors which need to be assessed in order to be altered. The violence towards children in a society is not only the responsibility of the aggressors but also it is the responsibility of all individuals in that society. The society as a whole should recognise the violence problem and do something about it to prevent it happening. One of these prevention methods is to increase public awareness on violence and trauma towards children in order to develop appropriate and healthy attitudes in individuals. In order to achieve this, many mental health workers should be able to work together. Therefore, Istanbul Bilgi University Psychology students have set up the BILGI AÇIK KAPI (BAK) Group ( as a project in order to:

1. Increase the public awareness on the effects of sexual violence on children,

2. Provide effective coping and problem solving information to hard-to-reach groups such as traumatised people,

3. Provide financial and professional support to NGO’s working towards ending sexual violence.

Keywords: Sexual abuse, mental health, prevention, PTSD, violence, trauma

CORRESPONDING AUTHOR: Zara Ayten , Bilgi University, Istanbul;



Győrffy ZS.1, Torzsa P.2, Sándor I.1, Csoboth CS.1, Novak M.1, Kopp M.1

1 Semmelweis University, Institute of Behavioural Sciences, Budapest, Hungary

2 Semmelweis University, Department of Family Medicine, Budapest, Hungary

Objectives: Violence against women is a serious abuse of basic human rights and has been declared a major public health concern. The relationship between physical abuse and physical and psychological symptoms is well-known, however data regarding the association between physical abuse and sleep disorders is limited.

Aim: To document the prevalence of reported abuse and investigate the association between physical abuse and insomnia among females.

Method: Cross-sectional analyses were conducted on the female sample (N = 6987) of the Hungarostudy 2002, a nation-wide representative survey. The survey contained sociodemographic questions and a Hungarian version of Athens Insomnia Scale (AIS). To analyze differences among physically abused and non-abused women, independent t-tests were used. Binary logistic regression was used to determine the association between physical abuse and sleep disorders.

Results: Physical abuse was found to be associated with sleep disorders. Abused women reported higher prevalence of sleep problems than non-abused women (p < 0,05). In the abused women’s group we found higher (>10) AIS scores and all of the items of AIS reported higher prevalence than non-abused women. Physical abuse was found to be associated with sleep disturbances (OR = 1,707), problems with staying asleep (OR = 1,552) and decrease of daytime performance (OR = 2,024) after controlling the effect of age, smoking, coffee consumption, presence of pain, shift work, depressive symptoms and healthcare utilization.

Conclusions: Women experiencing physical abuse have a significantly higher risk of sleep disorders. The relationship between physical abuse and insomnia deserves further investigation in order to determine the possible pathways of this association.

Keywords: Women's health, Sleep disorders

CORRESPONDING AUTHOR: Győrffy Zsuzsa, Semmelweis University, Budapest;



Bord S., Gesser-Edelsburg A., Baron-Epel O.

University of Haifa, School of Public Health, Haifa, Israel

Background: Alcohol impaired driving (AID) increases both the chance of being involved in a traffic accident, and the severity of the injury. The drivers' attitudes and perceptions towards AID have been shown in the literature to be associated with AID.

Objective: To identify attitudes and perceptions associated with reported driving after various quantities of alcohol consumed.

Methods: Data were collected between August and October 2010 from 610 internet users aged 19-35. The study questionnaire included socio-demographic data, attitudes and perceptions towards AID and self reported driving after various quantities of alcohol consumed: (a) reported driving after no alcohol consumed (b) reported driving after drinking 1-2 servings of alcoholic beverages (“Legal” AID) (c) reported driving after drinking 3-4 servings of alcoholic beverages ("Illegal” AID), and (d) reported driving after drinking 4 servings of alcoholic beverages or more (“Extreme” AID).

Results: Twenty five percent of the responders reported "Illegal" or "Extreme" AID. "Illegal" and "Extreme" AID were associated with age, where the older respondents (26-35) reported higher frequency of AID. In addition, perception of the punishment severity and perceived quality of driving were also associated with both "Illegal" and "Extreme" AID. Responders who reported "Illegal" or "Extreme" AID perceived the punishment severity and their quality of driving as higher. However, drivers' perception of the risk of being involved in an accident due to AID was associated only with "Illegal" AID. Drivers reported driving after drinking 0-2 alcoholic beverages perceived the risk as higher compared to drivers reported "Illegal" AID. Gender was only associated with "Extreme" AID, where men reported more "Extreme" AID compared with women.

Conclusions: Men reported a higher frequency of driving after drinking 4 servings of alcoholic beverages or more, however, driving after 2-3 servings was equally reported by men and women. The perception of the risk of being involved in an accident due to AID may only prevent those reporting "Illegal" AID, but not those reporting "Extreme" AID. These findings can help develop effective oriented intervention programs and mass media campaigns to reduce AID.

Keywords: Alcohol, Attitude(s), Risk perception

CORRESPONDING AUTHOR: Bord Shiran, University of Haifa, Haifa;



Coriale G.1, Bilotta E.2, Cosimi F.1, Porrari R.1, De Rosa F.1, Ceccanti M.1

1 Sapienza University of Roma, Department of Clinical Medicine, Roma, Italy

2 Sapienza University of Roma, Department of Developmental and Social Psychology, Roma, Italy

Introduction: In the last decades big progresses have been made in the clinical use of Cognitive-Behavioural Therapy applied to alcohol abuse (Monti, 1999; Sibilia, 2001). CBT implies that excessive alcohol use is a maladaptive way of coping (Marlatt, 1985;Bandura 1986). Coping problems can be solved through a series of combined cognitive and behavioural interventions (Kadden, 1994). We conducted a randomized experimental study to test the efficacy of Cognitive-Behavioural Counselling (CBC) in reducing alcohol abuse and enhancing compliance compared to Motivational Enhancement Counselling (MEC).

Methods: Sample: Ninety three participants affected by current alcoholism were enrolled in the study. Participants were randomly assigned to two experimental conditions: CBC (N = 44; mean age: 47.6; s.d.: 10.3) and MEC (N = 48; mean age: 45.8; s.d.: 9.6). Participants were recruited from a 15-day inpatient alcohol program in the Alcohol Abuse Center of the Faculty of Medicine, Sapienza University of Rome, Italy.

Measures: A questionnaire containing the Lifetime Drinking History-L.D.H. (Skinner & Sheu, 1982) and Time Line Follow Back –T.L.F.B. (Sobell & Sobell, 1992) were used to assess alcohol consumption from the first year of regular drinking to the present and specific amounts of alcohol use in the last month before enrolling in the rehabilitation program.

Data Analyses: The Kaplan-Meier curve was calculated to observe the compliance after three months from the beginning of the rehabilitation programs. A series of Anova were performed to test the differences between the two groups concerning alcohol abuse.

Results: The two groups (CBC and MEC) did not differ on alcohol consumed and severity of alcohol dependence. The Kaplan Meier curve showed that after three months of treatment, 82% of CBC participants remains in the rehabilitation program, versus the 40% of the motivational group (p < .05).Moreover, the CBC group participants consumed less alcohol units (mean:13,3; SD: 35,9) than the motivational group counterparts (mean: 56,9; SD: 105,9) (t = -1,9; p < .05). These preliminary results suggest CBC counseling may be more effective in terms of compliance and alcohol units consumed than motivational counseling.

Keywords: Alcohol(ism), CBT, Compliance

CORRESPONDING AUTHOR: Coriale Giovanna, Sapienza University, Rome;



University Sultan Zainal Abidin, Centre for Clinical & Quality of Life Studies, Kuala Terengganu, Malaysia

The vast majority of drug addicts often suffer from negative consequences and complicated life situation. To achieve drug abstinence, both coping ways and satisfaction towards medical care are crucial issues. This study intended to 1) describe the baseline patient satisfaction (PS) level and preferred coping strategies and 2) assess PS and coping mechanisms pre- and post-intervention. Patients on Methadone Maintenance Treatment (MMT) in Terengganu, Malaysia were randomised into either MMT or MMT plus Auricular Acupuncture (M + A) groups. All received the standard MMT while M + A participants underwent concurrent AA session thrice weekly for 2 months (total = 24 sessions, each session = 30 minutes). The following outcomes were evaluated pre- and post-intervention: PS (using Patient Satisfaction With Pharmaceutical Care Questionnaire) and coping style (utilising the Malay Brief COPE). Data analysis was carried out using SPSS 16.0 employing descriptive and non-parametric statistics. Participations were received from 97 eligible male patients (median age = 36.0 years; Malay = 97.9%; single = 57.8%; rural residents = 59.8%; ≥SPM education/Cambridge O’ level = 56.7%; ≥15 years of addiction = 58.8%). After screening for dropouts (attendance rate of <8 sessions and failure to complete entire study), only 68 patients were considered for subsequent analysis (MMT = 40; M + A = 28). At pre-intervention, both groups did not differ significantly in the parameters investigated. During post-intervention, no significant difference was detected for satisfaction level but coping-wise, Substance Use was significantly and more frequently adopted by M + A patients compared to MMT respondents (p < 0.05). On separate analysis, those who received MMT alone adopted Active Coping, Venting and Self-Blame significantly more frequent post-intervention (p < 0.05). Nevertheless, no significant difference for coping styles of M + A patients was exhibited over-time (p > 0.05).The addition of AA therapy into the standard MMT treatment did not seem to influence PS and their coping ways. MMT patients were frequently driven by their emotions (negative coping) when facing addiction problems.

Keywords: addictive behaviors, complementary and alternative, coping, outcome expectations

CORRESPONDING AUTHOR: Lua Pei Lin, Universiti Sultan Zainal Abidin;



Lua P. L., Talib N. S.

Universiti Sultan Zainal Abidin, Centre for Clinical & Quality of Life Studies , Kuala Terengganu, Malaysia

Methadone substitution treatment for opioid dependency has so far received a reasonable level of acceptance throughout Malaysia. However, the evidence for Auricular Acupuncture (AA) as a potential complementary therapy for drug addiction problems is still limited. Our study intended to compare 1) the clinical outcomes of Methadone Maintenance Treatment (MMT) alone and MMT plus AA (M + A) with regard to methadone dose and smoking habit and 2) health-related quality of life (HRQoL) profile pre- and post-intervention. Participants from MMT centres in Terengganu, Malaysia were randomly assigned either to MMT or M + A. Both groups received the standard treatment of MMT while M + A respondents underwent concurrent AA session thrice weekly for 8 weeks (each session = 30 minutes). The following outcomes were evaluated pre- and post-intervention: daily methadone dose, number of cigarettes smoked/week and HRQoL status (using WHOQOL-BREF). Data was analysed employing descriptive and non-parametric statistics (SPSS 16). A total of 97 eligible male patients (MMT = 42; M + A = 55) consented participation (median age = 36.0 years; Malay = 97.9%; single = 57.8%;≥SPM education/Cambridge O’ level = 56.7%). Attendance rate of <8 sessions and non-completion of post-intervention questionnaires were considered as dropouts. Pre-intervention, both groups (MMT = 40; M + A = 28) only differed significantly by HRQoL profile (better for MMT patients). Post-intervention, M + A patients reported significantly reduced number of cigarettes smoked (p = 0.004) compared to the MMT cohort, whereas no significant difference was detected for methadone dose and HRQoL outcomes. On separate group analysis, the number of cigarettes smoked by the MMT cohort had also significantly been lowered (p = 0.001) although their drug dose and HRQoL outcomes did not exhibit any over-time statistical significance. For M + A patients, except for methadone dose, both cigarette number and HRQoL outcomes have been significantly improved post-intervention (p < 0.05). The relatively encouraging effects of AA on smoking habit and overall well-being imply that it could be beneficial as an adjunct to MMT in managing drug addiction problems and requires extensive investigations due to limited studies of this nature in our country.

Keywords: addictive behaviors, complementary and alternative, quality of life, substance abuse

CORRESPONDING AUTHOR: Lua Pei Lin, Universiti Sultan Zainal Abidin;



Barati M.1, Allahverdipour H.2

1 Hamadan University of Medical Sciences, Public Health, Hamadan, Iran

2 Tabriz University of Medical Sciences, Health Education & Promotion, Tabriz, Iran

Introduction & Objective: The prevalence of substance abuse among college students is increasing drastically and requires immediate skill-based substance abuse intervention such as assertive skills. The purpose of this study was to develop the healthy behavior to change the subjective norms of students in order to decrease their tendency towards substance abuse.

Materials & Methods: A pre and post nonequivalent control group design study carried out on college students. A total number of 140 students were selected through randomized cluster sampling and randomly assigned to the intervention (n = 70) and the control (n = 70) groups. The data-gathering tool consisted of a self-report questionnaire assessing the variables of moral, descriptive, and injunctive norms. After the diagnostic evaluation, assertive skills promoting program was applied to persuade the participants against substances abuse. Respondents in the control and experimental groups completed questionnaires at baseline and 2 months after the intervention.

Results: The result showed that educational manipulation had significant effect on intervention group’s average response for moral norms (t = -3.36, P < 0.001), descriptive norms (t = -3.07, P < 0.003), and injunctive norms for persuading substance abuse (t = -3.79, P < 0.000).

Conclusion: These findings suggest that assertive skills training would be an efficient tool in drug abuse prevention programs among adolescents that should also be included in the comprehensive school health programs.

Keywords: Adolescents, Assertiveness Skills, Subjective Norm, Substance Abuse




Barati M.1, Allahverdipour H. 2

1 Hamadan University of Medical Sciences, Public Health, Hamadan, Iran

2 Tabriz University of Medical Sciences, Health Education & Promotion, Tabriz, Iran

Background and Objectives: Existing data show that using psychoactive drugs has increased among youths in recent years. Meanwhile, theory of planned behavior is an effective method to prevent non-healthy behaviors. Using this model as a theoretical framework, the aim of the present study was to evaluate the effect of educational preventive programs and resistance skills against substance use and perceived behavior control among university students in Hamadan.

Materials and Methods: A quasi-experimental study was carried out among university students in Hamedan city during 2008-2009. A total number of 140 students were selected through randomized cluster sampling and were randomly assigned to intervention and control groups. A questionnaire, based on the theory of planned behavior, was applied to assess the variables of attitudes toward substance use, subjective norms, perceived behavior control, intention and ecstasy use.

Results: The result showed that educational programs had significant effect on the average response for attitude toward drug abuse (P < 0.001), subjective norms (P < 0.001), perceived behavior control (P < 0.001), intention (P = 0.013) and ecstasy abuse (P = 0.004) in intervention group.

Conclusion: These findings suggest that applying the theory of planned behavior along with preventive methods are efficient tools for preventing the drug abuse.

Keywords: Ecstasy, Substance Abuse, University Student, Hamedan




Suka M.1, Miwa Y.2, Ono Y.2, Yanagisawa H.1

1 The Jikei University School of Medicine, Department of Public Health and Environmental Medicine, Tokyo, Japan

2 Tokyo Health Service Association, Tokyo, Japan

Background: Japan has the highest smoking prevalence among the G7 countries. After setting Healthy Japan 21 in 2000, the Japanese government has accelerated its tobacco control efforts.

Objective: To examine recent changes in smoking behavior of Japanese workers with evolving national tobacco control policies.

Methods: Using annual health examination data of Japanese workers aged 20-59 years (51,000 men and 29,000 women), age-adjusted smoking prevalence was calculated for each year between 2001 and 2010. Those who smoked daily in each year were followed to ascertain their smoking status at one year, calculating smoking continuation rates. If they had stopped smoking at one year, their smoking status was ascertained again at two year, calculating smoking resumption rates.

Results: For male workers, smoking prevalence was 50.2% in 2001, and has steadily declined every year (≤-2% year-on-year) since the Health Promotion Law, including a clause restricting smoking in public places, was enacted in 2003. It sharply dropped to 36.7% (-8.5% year-on-year) in 2010 when tobacco prices increased by 1.4 USD/pack (+36.7%). Annual smoking continuation rates were stable at around 95% between 2002 and 2009 while implementing non-price measures (no smoking designations, advertising restrictions, warning labels, youth access regulations, and health insurance coverage for smoking cessation treatments), then dropped to 91.2% (88.2% for 1-19/day smokers, 93.8% for 20+/day smokers) in 2010. Annual smoking resumption rates fluctuated between 20-27% independently of national tobacco control policies. For female workers, smoking prevalence rose from 15.5% in 2001 to 17.0% in 2003. It subsequently entered a downward phase, reaching 11.4% in 2010. No significant change was found in annual smoking continuation rates (fluctuating between 86-91%) or annual smoking resumption rates (fluctuating between 19-31%).

Conclusion: Smoking prevalence has declined in recent years, especially for male workers. The implementation of national tobacco control policies may in part contribute to the decline in smoking prevalence. The drastic increase in tobacco prices in 2010 seems the single most effective measure to prompt smokers to quit or reduce smoking. It is important for smokers and quitters to have continuous support to avoid continuation and resumption of smoking, along with creating smoke-free work environments.

Keywords: Tobacco Control, Behavior Change, Worksite health

CORRESPONDING AUTHOR: Suka Machi, The Jikei University;



Satran C.1, Drach-Zahavy A.2, Hammond SK.3, Baron-Epel O.1

1 The University of Haifa, Department of Public Health, Haifa, Israel

2 The University of Haifa, Department of Nursing, Haifa, Israel

3 University of California at Berkeley, Department of Public Health, Berkeley, USA

Background: Israel has a national law restricting smoking in public places, including pubs since 2007. The local authorities are obliged to enforce the law.

Aims: 1) To assess the levels of Second hand smoke (SHS) in pubs in Israeli towns; 2) To assess the enforcement of the law by the local authorities and to identify the association between SHS in the pubs and the reported enforcement; 3) To identify barriers and enhancers of the law enforcement.

Methods: Passive airborne nicotine devices were used to measure indoor SHS in non-smoking areas in 72 pubs in 29 Israeli towns. In addition, quantitative and qualitative face-to-face semi-structured interviews were conducted with 73 local authority's (48 managers and 25 elected officials), in 25 towns. Data was collected during 2009-2010. The interviews were analyzed using textual content approach for categories and themes identification.

Results: SHS was found in 92% of the pubs, while the median nicotine concentration in the pubs was 14.3μg/m3 [SD = 23.2].

Although enforcement is the local authorities' duty by law, only one local authority reported full enforcement of the law; six reported partial enforcement and 18 do not enforce the law in pubs at all.

There was no correlation between the levels of enforcement of the law and the airborne nicotine in the pubs.

The main themes we identified as barriers to law enforcement were lack of resources, and conflicts of interests between enforcing the law and the pubs financial losses. There were mixed reactions to the ban on smoking in pubs and to the effectiveness of fines.

Conclusions: Generally, law enforcement was low and did not result in decreasing levels of SHS in the pubs. There is a need for a national intervention, both among pub goers and among local authority officials to raise enforcement. This may be achieved by developing a national enforcement agency and public campaigns to ensure smoke-free area in pubs.

Keywords: Secondhand smoke, tobacco control, policy, law enforcement, local authorities, pubs

CORRESPONDING AUTHOR: Satran Carmit, The University of Haifa;



Gebhardt WA.1, Van der Heiden S.1, Dijkstra A.2, Willemsen M.3

1 Leiden University, Department of Health Psychology, Leiden, The Netherlands

2 University of Groningen, Social Psychology, Groningen, The Netherlands

3 Maastricht University, CAPHRI, Department of Health Promotion, Maastricht, The Netherlands

An online-survey study with over 1000 smokers was conducted to investigate perceived effects of the Dutch smoking ban in hospitality venues on smoker self-concepts and smoking behavior.

15% of the respondents reported to smoke less since the ban and 9% smoked more. Higher socio-economic status (SES) smokers were more likely to have reduced smoking (18% vs. 10%; X2 = 6,48; p = .04). 80% of respondents reported to have done one or more serious quit attempts since the ban.16% of responders had become (much) more motivated to quit, while 13% had become (much) less so. For 10% smoking had become (much) less part of their self-identity (smoker identity), while another 10% said that it had become (much) more so. Being a non-smoker (abstainer identity) had become a (much) stronger part of their identity for 16% of smokers, but for 20% this was (much) less the case. Higher SES smokers reported a stronger decrease in smoker identity and a stronger increase in abstainer identity. 28% of smokers had become (much) more concerned with their smoking (self-awareness), while 9% had become (much) less so. Moreover, 22% had become (much) more concerned with the impression they made on others while smoking (other-awareness), while 11% had become (much) less so.

Regression analyses revealed that all measures, particularly the difference in abstainer identity and self-awareness, were strong correlates of the change in motivation to quite (R2 = 35%). Smaller, but significant relationships were found between the reduction in number of cigarettes smoked and the differences in abstainer identity and self-awareness (R2 = 19%).

Among continuing smokers salient differences exist regarding how the ban has affected self-conceptions, motivation to change and acceptance of future policies. About 1/5 of smokers is more motivated to quit and has changed their self-conceptions accordingly, while about a similar number is less motivated and is more robust in their views and behavior.

Keywords: smoking policy social class

CORRESPONDING AUTHOR: Gebhardt Winifred, Leiden University, Leiden;



Londoño Pérez C.1, Rodriguez I.2

1 Universidad Católica de Colombia, Departament of Psychology, Bogotá, Colombia

2 Universidad Católica, Departament of Psychology, Bogotá, Colombia

The present study, that used a quasi-experimental pre-test post-test design for paired groups, aimed at assessing the effect of an intervention based on the so called Precautions Adoption Process (PAP) in the reduction or cessation of smoking in university students from three Higher Education Institutions. The research took into account some key elements of PAP: motivation, vulnerability perception, susceptibility, cost and benefit, decisional balance and change, as a result of cognitive functioning and planning in the first place, and later to the passage through seven consecutive stages. Starting from these elements, an intervention program was developed and implemented in six work sessions. At the end, results from pre-test and post –test measurements of both the experimental and control groups were compared. In order to classify participants for each one of these groups several instruments were used: The Classification of Cigarette Consumers Questionnaire (C4) by Londoño, Rodríguez & Gantiva (in press), the Expectations Regarding Cigarettes Questionnaire (CEC) by Londoño & Rodríguez (2007) and the Motivation Questionnaire (Temptation). Results showed significant differences between groups in the level of consumption, expectations and motivation (Londoño & Rodríguez, 2007). These and other important findings are discussed.

Keywords: Precaution Adoption Process, cigarette consumption, secondary prevention and adolescents

CORRESPONDING AUTHOR: Londoño Constanza, Universidad Católica de Colombia,



Csala I., Egervari L., Dome P., Lazary J.

Semmelweis University, Department of Clinical and Theoretical Mental Health, Budapest, Hungary

Background: It is proven that withdrawal symptoms can mitigate the success of quitting. Depression plays an important role in success rate of quitting, however data on relationship between quitting outcome and depression are contradictory. Furthermore, this problem has been complicated by the new quitting agent, varenicline due to its depressogenic side effect. The aim of our study was to examine the relationship between depression, withdrawal symptoms and quitting outcome.

Methods: We recruited 255 smokers from 15 Hungarian Quitting Centers. Cessation was supported by varenicline (n = 164) or only by psychoeducation (n = 91). Treatment protocol consisted of 4 consultations within 3 months (0, 2, 4, 12 w). Zung Self Rating Depression Scale (ZSDS), Fagerstrom Test for Nicotine Addiction (FTND), and Minnesota Nicotine Withdrawal Scale-Self report (MNWSS) were completed at each consultation. Quantity of smoking was monitored by breath CO measure. Parental Bonding Instrument (PBI) was used for measure of early childhood experiences by questions on mother’s behavior.

Results: We found that success rate of quitting depended on depression score and withdrawal symptoms: persons with low ZSDS0w score had 1.6-fold higher chance to quit smoking (p = 0.038); while increased MNWSS2w score almost doubled the risk for quitting failure (p = 0.43). By the end-point of treatment ZSDS decreased in total sample (p = 0.001) and also in subgroup of patients with successful treatment (p = 0.005). Moreover, higher ZSDS score at baseline predicted consequently higher MNWSS scores at each consultation (all p-values <0.0001). Besides, ZSDS score was determined by maternal ‘affectionless control’, which was assessed by the PBI (p = 0.004). These findings were independent form type of therapy.

Conclusion: Baseline depression, influenced by early life experiences, seems to play an important role in quitting success via influencing withdrawal symptoms. Therefore, screening the candidates for symptoms of depression, as well as providing adequate treatment before initializing cessation is recommended in order to avoid repeated failures.

These studies were supported by the Norvegian Financial Mechanism (HU0125).

Keywords: smoking, depression

CORRESPONDING AUTHOR: Csala Iren, Semmelweis University, Budapest;



Scalici F., Schulz P J.

University of Lugano, Institute of Communication and Health, Lugano, Switzerland

The increase of young smokers in European countries has become a serious problem. Different approaches had been developed to face this issue: public campaigns and school-based interventions just to name a few. To address this problem, a new approach based on parent-child communication has been developed in the literature (Ramos, Jaccard & Dittus 2010). Parents are viewed as change agents who are valuable sources of information and advice to shape their children’s behaviors. To increase parent-child communication level is a good way to either prevent or reduce tobacco consumption among adolescents. The literature suggests that parent-child communication is a “protective factor” to prevent adolescents’ risk behaviors (Dittus, et al. 1999; 2000; Litrownik et al. 2000; Whitaker & Miller 2000) and that parents influence their children especially with regards to health issues (Steinberg 2001).

Against this background, we conducted an empirical study to evaluate parent-child communication in the field of tobacco consumption. Data were collected via self-administered questionnaires among a random sample of 11 to 16 year-old students from all middle schools in Ticino (N = 5’560). In our paper, we will first present results concerning the adolescents’ perception of communication quality with their parents, the relationship satisfaction and the trustworthiness (Ramos, Jaccard, et al. 2006). Secondly, data regarding adolescents’ perception of the peer group relation will be analyzed based on the theoretical framework of Fishbein & Triandis’s expectancy and social norms model (2001). Finally, the results of this study will be discussed in the perspective of a culture specific parent-based intervention model that give parents information and skills to help their children avoid the negative consequences of tobacco consumption.

Keywords: Adolescents, Prevention, Smoking, Parent-child transactions, Risk behaviors

CORRESPONDING AUTHOR: Scalici Francesca, Lugano University;



Sirichotiratana N.1, McKnight-Eily L.2, Arrazola R.3, Merritt R.3, Malarcher A.3

1 Mahidol University, Public Health, Bangkok, Thailand

2 Centers for Disease Control and Prevention, Epidemiology and Biostatistics, Atlanta, USA

3 Centers for Disease Control and Prevention, Epidemiology, Atlanta, USA

Introduction: There are a few research studies on the psychosocial correlates of smoking among adolescents in many countries. These correlates need to be identified to target those who are at high risk of cigarette smoking and providing smoking prevention and intervention efforts.

Objectives of this study are to

a) explore the prevalence of current smoking, and

b) to explore the prevalence and significance of associated psychosocial smoking correlates by sex among Thai students grade 7 through 9.

Method: The Global Youth Tobacco Survey (GYTS) is a school-based, cross-sectional survey which provides systematic global surveillance of youth tobacco use prevalence and related behaviours. A two-stage cluster sample design was used. A total of 19,874 students, represented 5 regions of Thailand completed the survey. Student participation was voluntary and anonymous using self-administered survey procedure.

Results: Among current smokers, 60.1% reported thinking that smoking is harmful compared to 85.1% of non-current smokers. More than 2 out 3 current smokers reported exposure to second-hand smoke at home (69.2%) in comparison to less than half of their non-smoking peers (44.3%). There were some significant differences between non-smoking female and male students. Female non-current smokers (88.5%) were significantly more likely to report believing that smoking was harmful than males (80.8%) More than 4 out of 10 (46.1%) female non-current smokers and male non-current smokers (42.1%) reported second-hand smoke exposure at home.

Discussion: Current smoking was found to be correlated with many of the psychosocial factors examined in this study. Results provide insight into potential influences on Thai adolescents decision to smoke. The significant correlates should be viewed as opportunities to target anti-tobacco efforts among adolescent populations.

Conclusions: The findings suggest that cigarette smoking is a significant problem among adolescents in Thailand. The associations found in this analysis can assist in identifying areas of further exploration for research and targeted prevention efforts to address current smoking among adolescent students in Thailand.

Recommendations: Further research examining the aspects of peer influence, culture and sex differences in the correlates of current smoking are needed to focus tobacco prevention and smoking cessation efforts.

Keywords: Tobacco control, Smoking

CORRESPONDING AUTHOR: Sirichotiratana Nithat, Mahidol University;



White V., Bariola E., Wakefield M.

Cancer Council Victoria, Centre for Behavioural Research in Cancer, Melbourne, Australia

Background: While research suggests that GHW labels increase adolescents’ cognitive processing of labels and awareness of smoking related diseases, the longevity of these effects is not known. Australia introduced 7 GHW in 2006, with a further 7 GHW introduced in 2007.

Aim: To assess the impact of GHW labels on adolescents’ cognitive processing of labels, cigarette pack image and awareness of illnesses 5 years after their introduction.

Method: Four cross-sectional surveys of students aged 13-17 from major urban areas in one Australian state undertaken: i) prior to GHW introduction (Baseline N = 3660); ii) 6-months (1st follow-up (1FU, N = 2650), iii) two years (2FU, N = 3359) and iv) 5 years (3FU, N = 3842), after GWH introduction. Students answered questions on cigarette pack exposure, cognitive processing of warning labels (1 “never” to 5 “every time”), pack image and awareness of smoking related diseases. Students were classified into smoking status groups based on cigarette use and smoking intentions. ANOVA examined change in mean scores and χ2 change in proportions. Analyses adjusted for age and gender.

Results: Among students seeing cigarette packs in past 6 months (65-75% of respondents) cognitive processing of labels increased significantly between baseline and 2FU (all p < 0.01). However, cognitive processing declined between 2FU and 3FU (all p < 0.01) with mean scores at 3FU similar to or lower than baseline (e.g. frequency of attending to warnings; means: baseline = 2.6, 1FU = 2.8, 2FU = 2.9, 3FU = 2.6). Decreases were consistent across smoking groups. In contrast, pack image became progressively more negative (p < 0.01) and less positive (p < .01) over time (e.g., negative image means: baseline = 3.0, 1FU = 3.3, 2FU = 3.6, 3FU = 3.9). Proportion of all students aware that smoking causes mouth cancer, emphysema, gangrene and stroke (GHW label messages) increased over the study period including between 2FU and 3 FU (all p < 0.01).

Conclusions: Cognitive processing of GHW reduced among adolescents after 5 years. However as awareness of GHW labels’ health messages increased and the pack image became more negative over the entire study period, results suggest GHWs may contribute to a more enduring impact on improved awareness of health effects of smoking and denormalisation of tobacco use.

Keywords: adolescents, smoking, graphic warning labels

CORRESPONDING AUTHOR: White Victoria, The Cancer Council Victoria;



Seo D-C.1, Torabi MR.1, Chin M-K.2, Lee CG.1, Kim N.1, Huang S-F.3, Chen CK.4, Mok MC.5, Wong P.6, Chia M.6

1 Indiana University, Applied Health Science, Bloomington, USA

2 HOPSports Inc., HOPSports, Valencia, USA

3 Tzu Chi University, Physical Education Center, Hualien, Taiwan

4 University Sains Malaysia, School of Medical Sciences, Kelantan, Malaysia

5 The Hong Kong Institute of Education, Department of Psychological Studies, and Assessment Research Centre, Hong Kong, China

6 Nanyang Technological University, NIE, Nanyang Walk, Singapore

Purpose: To examine the level of moderate physical activity (MPA) and vigorous physical activity (VPA) among a representative sample of college students in six East Asian economies and compare their relation with weight category, alcohol consumption and cigarette smoking.

Setting: Twenty-one colleges in 6 East Asian economies (response rate = 78%).

Subjects: College students (N = 16,558).

Analysis: Multiple logistic regression models of MPA and VPA were separately performed for each economy, controlling for age, gender, living area before college, military experience, paid employment, and religion. All the analyses were performed using SAS 9.2with clustering effects accounted for.

Results: Being a heavy drinker increased the odds of engaging in VPA in 5 economies (adjusted odds ratio (AOR) = 1.56 to 2.65). Cigarette smoking was not associated with MPA in any economy and was only associated with VPA in China (AOR = 1.54) and Taiwan (AOR = 1.48), indicating smokers are more likely to engage in VPA than nonsmokers.

Conclusions: The relation between college students’ VPA and alcohol consumption and between MPA and cigarette smoking is similar across the East Asian economies whereas the relation between VPA and smoking varies substantially.

Keywords: Alcohol, Physical activity, Tobacco use

CORRESPONDING AUTHOR: Seo Dong-Chul, Indiana University, Bloomington;



Bob M.1, Lotrean L.2, Gabor-Harosa F.2, Schmidt N.1, Mocean F.2

1 University of Medicine and Pharmacy Cluj-Napoca, Department of Morphology, Cluj-Napoca, Romania

2 University of Medicine and Pharmacy Cluj-Napoca, Department of Community Medicine, Cluj-Napoca, Romania

Introduction: The educational environment of society and family has tremendous influence on personality development and behavior in teenagers.

Objectives: Our research aimed at identifying the main causes of distress in school environment in teenage students.

Methods: We ran an observational, descriptive study. An original 38 items-questionnaire was completed by a valid population sample of 267 teenage students (100%) in 4th, 6th and 9th grade from a rural school.

Results and discussions: Our study reveals that school-induced stress and fatigue three or more days every week were accused by 17% of 4th grade students, and was significantly increased among 6th graders (38%, p < 0.05 at Chi2 test) and 9th graders (49%). Fatigue during week-end was declared by 16.7% of 4th graders, and was significantly increased in 6th graders (38.8%) and in 9th graders (52.5%). The main causes for school-related stress and fatigue according to students are: parents pressure for high grades (80%), not enough sleep (50%), not enough leisure time (46%), not enough workout (42%), too many classes or too difficult subjects (37.9%), too elaborate home assignments (34,7%), etc.

The main school violence manifestations identified by students were: students hitting students (40%), fights between students (39%), destruction of school property (31%), alcohol consumption by students (25%), students hitting teachers (25%), students swearing at teachers (25%).

Conclusion: The school-related stress, fatigue and violence identified in this teenage population sample are results of defective education on communication strategies, received in school and at home.

Better communication between student, school and family is important, since it should lead to an increased stress resistance that prevents school-related fatigue, increases tolerance to fellow students and stimulates active involvement in health-promoting activities at individual and community level.

Designing and implementing an interdisciplinary model of healthy educational environment should keep teenagers healthy and health-oriented, enabling motivated study in school and at home, hence preventing stress, intellectual fatigue and school violence.

Keywords: Stress, Fatigue, Social stress, Environment, Health promotion, Community intervention, Public health

CORRESPONDING AUTHOR: Bob Mihai, University of Medicine, Cluj;



Hansen AM.1, Hogh A.2, Garde AH.3, Persson R.3

1 University of Copenhagen, Department of Public Health, Copenhagen, Denmark

2 University of Copenhagen, Department of Psychology, Copenhagen, Denmark

3 National Research Centre of the Working Environment, Copenhagen, Denmark

Background: It has been demonstrated that targets of bullying report more problems such as more psychological distress, somatic, depressive and anxiety symptoms, as well as stress and poorer general health than non-bullied employees. Sleep is a major path for restitution and vital for our health and well-being. Bullying is a work stressor that affects the health and well-being of the targets. Since bullying may induce stress, and stress may cause sleep problems, it seems conceivable that the negative health effects observed among bullied are mediated via poor sleep.

Purpose: To estimate the risk for subsequent sleep problems at follow-up two years later among bullied and witnesses of bullying.

Methods: A total of 3382 respondents (67.2% women and 32.8% men) completed a baseline questionnaire about their psychosocial work environment and health. The overall response rate was 46%. At follow-up two years later 2273 (response rate 33%) responded and of these 1671 also participated at baseline (49% of the 3382 respondents at baseline).

Results: We found a significant linear association between the frequency of bullying at baseline and poor sleep in terms of disturbed sleep, awakening problems and quality of sleep at baseline and at follow-up. Similar associations were found between witnessing bullying and sleep problems. We also found increased OR for long-term sleep problems among occasionally bullied and partly among frequently bullied. However, the associations weakened when adjusting for sleep problems at baseline. We did not find increased OR for long-term sleep problems among witnesses of bullying.

Conclusion: We found that reporting bullying at baseline predicted disturbed sleep and awakening problems among occasionally bullied and non-significantly among frequently bullied. Witnessing bullying at baseline did not predict poor sleep at follow-up.

Keywords: Bullying, witnesses, disturbed sleep, awakening problems, somatic symptoms

CORRESPONDING AUTHOR: Hansen Åse Marie, University of Copenhagen;



Alves J., Maia A.

University of Minho, School of Psychology, Braga, Portugal

The impact of incarceration on health, especially in women, has not been an aim of research. The purpose of this study is characterize the health status of women in prison (N = 148), including the analysis of the impact of incarceration on the perception of health status of these women, comparing two groups: those who perceive their current health as better (54.7%, N = 81) and those who perceive their current health as poor (45.3%, N = 67) when compared to the time before arrest. Participants filled out self-report questionnaires (medical history, physical and psychological complaints, anxiety and depression) and a health risk behaviours checklist. Univariate analysis revealed that the ones that report improvement in health have less physical (t (146) = 2.76,p =. 001) and psychological complaints (t (146) = 3.17, p =. 002), anxiety (t (146) = 2.48, p =. 014) and depression (t (146) = 1.97, p =. 05). Previous medical supervision (x2 (1) = 7.01, p =. 008) and chronic diseases (x2 (1) = 10.04, p =. 002) are associated with a decrease of health quality, but previous substance use (x2 (1) = 8.24, p =. 004) is associate with an increase in quality. A logistic regression analysis was run in order to evaluate the contribution of these variables on the health perception. The full model was significantly reliable (x2 (7) = 34.45, p = .000) and accounted for between 20.8% and 27.8% of variance. Overall 68.9% of predictions were accurate. However only previous medical supervision, drug use and chronic disease were significant predictors of the impact of imprisonment on health perception. The values of coefficient revealed that lack of previous medical supervision increase the odds of positive impact by a factor of 2.38, the absence of chronic diseases increases the odds of positive impact by a factor of 14.67, and having used drugs increases the odds of positive impact by a factor of 66.0. These results show the need to take into account previous health conditions to understand the impact of prison on health, and specially the relevance of some conditions as drugs consumption. The positive impact of imprisonment on drug users and women who hadn't medical supervision, reinforcing the idea that incarceration provides opportunities to act on the health of risk population.

Keywords: Women's health; Health Behaviors; Prison

CORRESPONDING AUTHOR: Alves Joana, Universidade do Minho, Braga;



André S.1, Cunha M.1, Rodrigues V.2

1 Instituto Politécnico de Viseu, School of Health, Viseu, Portugal

2 Universidade de Trás-os-Montes e Alto Douro, School of Health, Viseu, Portugal

The Strokeis a disease that threatens the quality of life in the elderly not only for its high incidence and mortality, but also by increased morbidity it causes, especially physical dependence and / or emotional changes. And the care of dependent elderly at home by their relatives (carers) requires the adoption of a widely varied range of strategies for him to "deal", noting that many empirical studies document the association of socio-demographic, clinical and with psychosocial quality of life and mental functioning of informal caregivers. In this context, the objective of the study is the mental health of informal carers.

The research model adopted follows the model cross sectoral or cross, following a line of analysis explanation, with which it seeks to explore how personal and situational variables have an impact on mental functioning (mood and mental health), the caregiver informal. A non-probability sample of convenience, was composed of 636 carers (83.8% female and 16.2% male) aged M = 50.19 years. The protocol of data collection included Questionnaire Assessment of Informal Caregiver overload; Inventory Beck Depression Inventory and Scale Screening for Mental Health.

The results showed that 62.8% of caregivers did not have depression, and 16.1% have mild depression, moderate in 12.0% and only 9.1% had depression serious. The score on the mental health, reflecting that 49.5% have good mental health, 37.1% have poor mental health and 13.4% is reasonable health.

Carers with more positive mental functioning, scored with better self-concept, lowest overhead in size implications for personal life, satisfaction with the family role, needs and reactions to emotional overload, more social support, better functionality and family better socioeconomic level. Carers with poorer mental functioning, i.e., poorer mental health, depressive symptoms had more severe and scored with a greater vulnerability to stress, a greater burden on the dimensions family support, financial burden, perception of efficacy and mechanisms of control and trait of neuroticism more sharp.

The results support that the variables age, socioeconomic status, family function, overload, social support, self-concept, personality traits, vulnerability to stress, age of the dependent and the dependency ratio predict the mood of carers. The variables age, socioeconomic status, family function, overload, social support, self-concept, personality traits, vulnerability to stress, age and the dependent elderly dependency ratio predict mental health of informal caregivers, which suggests that health professionals should include in the planning of health actions that are addressed.

Keywords: Mental health, Depression, Carers, Health behaviors

CORRESPONDING AUTHOR: Cunha Madalena, Polytechnic Institute of Viseu;



Lucidi F.1, Grano C.2

1 Sapienza University of Roma, Department of Development and Socialization Processes Psychology, Roma, Italy

2 Sapienza University of Roma, Department of Psychology, Roma, Italy

Caring for a family member with Alzheimer disease (AD) is generally regarded as a chronically stressful process, with potentially negative physical health consequences, concerning, in particular, stress hormones, antibodies, and global reported health. Several authors argue that research is needed that relates caregiver stressors to illness and clarifies mediating roles for psychosocial distress and emotional regulation. To these issues, 3 studies will be presented. The studies involved 737 participants between 60 and 96 years of age. Of these, 126 were caregivers of patients with Alzheimer disease, 268 were caregivers of patients with arthritis or cardiovascular disease, and 343 were no caregivers. In the first study, we compared the scores on negative affect variables and quality of sleep across groups. Measures included the Geriatric Anxiety Inventory (GAI; Pachana et al., 2007), The Geriatric Depression Scale (GDS; Yesavage et al.,1983), the Maastricht Questionnaire (Appels et al., 1987) to measure Vital Exhaustion, and the Pittsburgh Sleep Quality Index (Buysse et al.,1989). Between groups ANOVA indicated that Alzheimer patients’ caregivers exhibited greater health risk on all the measures evaluated.

In the second study, we were interested in investigating whether self-regulative variables and health behaviors may mediate the relationship between AD Caregiver burden and psychological distress. Measures included the Screen for Caregiver Burden (Vitaliano et al. 1991), the Perceived Stress Scale (PSS; Cohen et al., 1983), the Revised Scale for Caregivers Self-efficacy (Sfeffen et al., 2002) and the International Physical Activity Questionnaire (Craig et al., 2003). To measure psychological distress we used the same measures of the first study. Structural equation models were used to test these relationships. Results indicated that self-efficacy and physical activity mediated the relationship between caregiver burden and psychological distress. In the third study we evaluate the efficacy of a program aimed to emotionally support AD caregivers. Within group ANOVA indicated that the program decreased the level of caregivers’ burden. Implications for future interventions aimed to decrease caregiver burden and psychological distress in AD caregivers are presented.

Keywords: Caregiver, Health Behaviours

CORRESPONDING AUTHOR: Battagliese Gemma, Sapienza University, Rome;



Costrikina I.1, Korg T.2, Bocharov O.3

1 Moscow State University of Psychology and Education, Department of Social Intellegent, Moscow, Russia

2 Fitness Center, Kineziology Department, Moscow, Russia

3 City Government of Moscow, Department of a Youth Policy, Moscow, Russia

Health and investment in health is a problem for many people from different countries because wealth, social mobility and many factors e.g. quality of life depend on health. More and more people are involved in processes imposing high cognitive load. Fifty years ago high cognitive load corresponded with high professional and social level only, whereas today a modern, different type of work causes high level cognitive load. Leaving behind questions related to general intelligence and ability to keep up with cognitive load, we focus on the issue of saving and promoting mental and somatic health.

The majority of the population is involved in computer activity and have high level of cognitive load similar to those who are involved in intensive visual work. Moreover, maintenance workers who are working in forced postures experience not only increased load on the spine and ligaments, but also an increase in postural muscle activity to maintain postural balance. Cognitive load and general physical load correlate with cognitive process, emotional state, and general motor activity.

The purpose of the study was to study the effective methods of rehabilitation and psycho-physiology regulation. Our research included 300 participants (operators, microscopists, active users of PC) between age 18-60, with experience from 3 up to 30 years and refraction from -6 , 0 up to 4.5 diopters. According to the survey more than 70% of them were in need of rehabilitation. We used three types of rehabilitation: 1. sessions including vibrating massage and gymnastics (general developmental exercises); 2. sessions of segmental acupressure in combination with general developmental exercises; 3 sessions of segmental acupressure combined with corrective exercises. We recommended complex rehabilitation to people with asteno-physical complaints with a pronounced degree of chronic fatigue, high levels of situational and personal anxiety.

As a result of treatment astheno-physical complaints disappeared (90%), and the degree of chronic fatigue significantly decreased (2.5). There was a decreasing trend in situational and personal anxiety. Accommodation volume increased by an average of 1.48 diopters.

The study revealed significant statistical differences between groups of different therapies. Differences were found in the level of anxiety (0.005), self-rated physical health, self-efficacy, and gender differences.

Keywords: Health behaviors, Quality of life, Self-efficacy, Physical activity, Psychophysiology

CORRESPONDING AUTHOR: Costrikina Ines, Psychology University, Moscow,



Varga M .1, Van Furth E. F.2

1 Semmelweis University, Institute of Behavioral Sciences, Budapest, Hungary

2 Center for Eating Disorders Ursula, -, Leidschendam, Netherlands

Orthorexia nervosa (ON) is an alleged eating disorder that surfaced in the media some ten years ago.

Aim: To review literature on the prevalence and risk factors of orthorexia nervosa.

Methods: We searched Medline and Pubmed using several key terms relating to ON and we checked the reference list of the articles we found. From these articles we extracted data on prevalence and risk factors.

Results: 11 evidence based studies were found. The prevalence rate for ON was 6.9% in the general population and ranged from 35-58% in the risk groups. However these studies used different methods to asses ON and different study populations. Healthcare professionals, medical students, artists are at a higher risk for ON. Risk factors include obsessive compulsive features, eating related disturbances and higher socioeconomic status. The annual number of papers on ON has increased in recent years.

Discussion: The definition and diagnostic criteria of ON are poorly defined. This makes a comparison between studies difficult. The validity and the psychometric properties of the assessment instruments for ON are weak. Further studies with improved assessment instruments are needed to identify specific ON symptoms and characteristics of individuals with ON.

Keywords: orthorexia nervosa, health, eating behaviours, risk groups

CORRESPONDING AUTHOR: Varga Márta, SE Inst. of Behavioral Sciences;



Gomez-Peresmitre G.1, Acosta MV.2, Pineda G.3, Platas Acevedo S.1, Guzman Saldana R.4

1 Universidad Nacional Autonoma de Mexico, Faculty of psychology, Mexico City, Mexico

2 Universidad de Almeria, España, Facultad de Humanidades y ciencias de la Educacion, Almeria, España

3 Universidad Autonoma de Baja California, Facultad de ciencias Administrativas y Sociales, Ensenada B.C., Mexico

4 Universidad Autonoma del Edo. de Hidalgo, Instituto de Ciencias de la Salud A.A. de Psicologia, Mexico City, Mexico

Background: The increased frequency of binge eating behavior and its relationship to overweight and obesity has been expressed as an international health problem, i.e., the tendency to binge eating is associated with body mass index. A positive association between binge magnitude and body mass index has also been shown.

Objective: To detect the risk factors predictors for binge eating behavior related to body image (ideal and actual figures, body dissatisfaction and BMI) and to disordered eating (restricted dieting, body weight and eating behavior concerns, psychological compensation, internal and external control eating behavior).

Participants: The total non-probabilistic sample was N = 525: Mexican women (n = 253, M = 16.5 years, SD = 1.3) and Spanish women (n = 272, M = 17.2 years, SD = 1.6)

Hypothesis: The Mexican group’s risk factors related to body image and to disordered eating will produce the highest beta weights (β), as well as the major explained variance (R2) in the binge eating behavior, compared with the Spanish group.

Instruments: The instruments showed good psychometrical properties.

Results: Four significant risk factors were found for Mexican women model (eating behavior of psychological compensation, concerns by weight and food, BMI, and eating internal control) with ‘eating behavior of psychological compensation’ the most important (β = .77, p = .000). The explained variance on the dependent variable (binge eating) was (R 2ajust  = 0.69). Three significant risk factors (eating behavior of psychological compensation, BMI, and eating external control) compounded the Spanish model. Eating behavior of psychological compensation was also the important factor (β = 0. 62, p = 0.000). The explained variance on binge eating behavior was R 2ajust  = 0.42. Based on the results obtained, the hypothesis was accepted.

Discussion: The features of the risk factor predictors and their emotional nature gained the highest beta weight in both groups. The groups shared BMI factor as a predictive of binge eating behavior.

Keywords: binge eating, risk factors, obesity

CORRESPONDING AUTHOR: Gomez-Peresmitre Gilda, National University of Mexico;



Nikolaeva N., Abdulsamadova L., Meshkova T.

Moscow State University of Psychology and Education, Clinical Psychology and Special Education, Moscow, Russia

Family and psychological features influence eating behavior of children and adolescents. We suppose that maternal/paternal parenting style can provoke some eating behaviors in adolescent girls, as dieting, restrictive eating, emotional eating, and can cause eating disorders (ED). The aim of this study was to investigate parental styles and adolescent girl’s personality traits influencing on the risk of eating disorders (ED). 107 school girls (mean age 15.3, Sd = 1.3) were tested by Eating Attitude Test (EAT-26, Garner et al., 1982), Parent-Adolescent Interaction Inventory (PAII, Markovskaya, 2006), and Risk Factors of Eating Disorders Inventory (RFEDI, Meshkova). EAT-26 consists of 26 items and focuses on eating behavior problems (dieting, bulimic behavior, weight preoccupation etc.). High EAT-26 total scores suggest the risk of ED. PAII consists of ten 5-point Likert scales (total 60 items) about adolescent’s opinion of maternal/paternal parenting (directivity, punishment use, overcontrol, emotional contact, acceptance-rejection, cooperation, agreement, consistency, maternal/paternal authority, good relationships). RFEDI was developed in Russian language for measuring risk factors of ED, including attitudes towards eating and body shape, social environments, personal traits (Perfectionism, Emotional Instability, Alexithymia etc.). Spearman rank correlations have shown, that there were positive relationships between EAT-26 total scores and maternal overcontrol (R = 0.41, p < 0.05), and negative relationships with paternal/maternal consistency (R = –0.32; R = –0.27, p < 0.05). Maternal overcontrol correlates negatively with paternal consistency (R = –0.29, p < 0.05). Positive relationships between daughter’s perfectionism, daughter’s alexithymia and mother’s overcontrol were found (R = 0.30; R = 0.30, accordingly, p < 0.05). Positive relationships between girls EAT-26 total scores and their perfectionism (R = 0.37, p < 0.05), alexithymia (R = 0.40, p < 0.05), and emotional instability (R = 0.37, p < 0.05) were shown. We suppose that relationships in families with overcontrolling mother determine family parenting style that can provoke some psychological traits as perfectionism and alexithymia, and contribute to ED of adolescent girls.

Keywords: Health Behaviors, Eating Behaviors, Personality, Parenting Style

CORRESPONDING AUTHOR: Nikolaeva Nataliya, MSUP, Moscow;



Garip G.1, Yardley L.1, Brasher K.2, Bridger R.2

1 University of Southampton, School of Psychology, Southampton, United Kingdom

2 Institute of Naval Medicine, Royal Navy, Gosport, United Kingdom

Background: Overweight and obesity in the Royal Navy (RN) in the UK have reached concerning rates, which have implications for the operational capability of the RN. Obesity-related health problems result in considerable financial costs for the RN and in lost man days at work. Various types of weight management support exist in the RN; however, some overweight and obese personnel continue to struggle with their weight. Adapting an existing web-based weight loss programme may be a cost effective way for supporting overweight and obese personnel with their weight management efforts. This study aims to understand what factors in the RN environment overweight and obese personnel perceive as influencing their weight management experiences.

Methods: Twenty-one overweight and obese personnel took part in a one-to-one, face-to-face, semi-structured interview. Transcripts were analysed using inductive thematic analysis as described by Braun and Clarke (2006).

Findings: Participants perceived the following factors as influencing their weight management experiences in the RN: the naval environment and culture, influences of others, motivations to manage weight, perceptions of self with regard to excess weight, perceptions of weight management, and explanations for successful and unsuccessful weight management.

Discussion: Findings suggest that even in an environment where resources for weight management are easily accessible and available; some overweight and obese RN personnel may lack the motivation, knowledge and skills to make use of these resources and to successfully manage their weight. The interviews provided new insights about weight management in a predominantly male sample, and the findings were useful for informing modifications to the existing web-based weight loss programme.

Keywords: health behaviour change; weight loss

CORRESPONDING AUTHOR: Garip Gulcan, University of Southampton, UK,



Diaconescu L V.1, Mihailescu A .1, Dumitru O.2

1 University of Medicine and Pharmacy Carol Davila, Bucharest , Department of Medical Psychology, Bucharest, Romania

2 Hospital Prof Dr Al. Obregia, Department of Psychiatry, Bucharest, Romania

Background: Undergraduate medical students experience a lot of distress during their study (Spangler et al, 2002) when they make efforts to cope with both academic and adjustment issues. Coping styles adopted may be active or avoiding strategies, which may be followed by health risk behaviors (Loureiro et al, 2008). The aim of the study was to establish the level of stress and find coping strategies, potential risk behaviors at undergraduate medical students and study the relationship between them.

Methods: The participants were 152 students randomly selected from first year of medical university: 71 foreign students (mean age 21.48years) and 81 Romanian students (mean age 19.42 years). We have administered Higher Education Stress Inventory, HESI (Dahlin et al), COPE questionnaire (Carver et al), and a life-style inventory and a questionnaire about adjustment problems, developed by us and used for the first time. T-test, one way ANOVA and p < 0.05 as level of significance were used in statistic analysis.

Results: All students reported high academic stress, with no significant difference between Romanians and foreigners (total score on HESI: 72,80 vs 71,11). Romanians had more complaints on HESI factors "workload", “financial problems” and “worries” (p < .001). As coping strategies, Romanian students preferred planning, suppression of competing activities, use of emotional support (p < 0,001), while for foreign students the most frequent were positive reinterpretation, mental and behavioral disengagement, substance use (p < 0,05).

We remarked adjustment problems significantly different in foreigners compared to Romanians: distance from family (F = 21.95, p < 0.001), distance from friends (F = 10.83, p < 0.001), problems with accommodation (F = 11.36, p < 0.001). All students are employing the same methods for helping them adjust. There were health behaviors changes in both groups of students with significant differences (p < 0.05) for consuming more coffee in Romanians and more smoking in foreigners.

Conclusions: Psychological counseling is necessary from the first year of student’s life in order to address the inappropriate coping strategies and risk behaviors in the first months of faculty which could be alarm signals regarding adjustment to stress in their future career as physicians.

Keywords: Stress, Coping, Health behaviors

CORRESPONDING AUTHOR: Diaconescu Liliana Veronica, UMF, Bucharest;



Lin MH.1, Chen TN.1, Lee CH.1, Hsu HC.1, Wang BY.2, Lin LH.3, Kao WC.4

1 Chang Gung University of Science and Technology, Department of Nursing, Tao-Yuan, Taiwan

2 Landseed Hospital, Department of Nursing, Tao-Yuan, Taiwan

3 Shuang Ho Hospital, Department of Nursing, Taipei, Taiwan

4 Chang Gung University of Science and Technology, Department of Information Management, Tao-Yuan, Taiwan

Background: Quality of sleep is essential element for learning and memory. Students with sleep disturbance would affect cognitive ability and decrease learning performance.

Purpose: The purpose of this study was to explore the relationship between quality of sleep and learning satisfaction on nursing college students.

Methods: A cross-sectional with correlation study design was employed. 200 students were recruited from the nursing college in northern Taiwan. Pittsburgh Sleep Quality Index and Learning Satisfaction Scale were used for data collection. SPSS for window 17.0 was used for data analysis.

Results: Findings showed: (1) 53% of participants rated their sleep quality as poor; (2) the global learning satisfaction of participants varied between highly satisfaction and satisfaction; (3) the global learning satisfaction was significantly negative related to “subjective sleep quality”, “use the sleep pill”, and “daytime dysfunction”(p < .05), finally, students who were interested in nursing can be explained 10.2% of the total amount of variances in learning satisfaction.

Conclusions/implications for clinic practice: The findings can provide information regarding nursing students’ sleep status and learning satisfaction to school teacher. The information would be helpful as evidences when laying out nursing curriculum to strengthen students’ sleep hygiene and learning of affective domain in the future.

Keywords: Abnormal sleep, Health education

CORRESPONDING AUTHOR: Lin mei-hsiang, "Chung Gung, ROC";



Zana Á.1, Konkoly Thege B.1, Limpár I.2, Henczi E.3, Golovics P.4, Hegedűs K.1

1 Semmelweis University, Behavioural Science Institute, Budapest, Hungary

2 3Q Educational & Training Center, Budapest, Hungary

3 Zala County Hospital, Zalaegerszeg, Hungary

4 Semmelweis University, Faculty of Medicine, Budapest, Hungary

Research aims: The study examined the association between profession and fear of death. Knowing the attitude of healthcare workers towards death is very important, because their efficiency is associated with their fears. Our aim was to explore which attitudes related to death and dying arouse the strongest fear in participants and find out which training or other intervention will help the helpers to make death-related communication more open, decreasing inner anxiety and improving communication with dying patients and relatives.

Methods: Our quantitative survey took place between 2006 and 2011 in Hungary. Physicians, medical students and other healthcare workers, priests, psychologists, and non-healthcare workers (N = 1062) were asked about their attitude to death by means of the Multidimensional Fear of Death Scale (Neimeyer & Moore 1994, Zana et al 2006).

Results: Profession was significantly associated with the total MFODS score (p < .001) and with all fear of death factors, with the only exception of the seventh factor expressing fear for the body after death. The only systematic trend that emerged was that priests usually had the lowest scores. A notable exception was the sixth factor measuring the fear of conscious death, for which psychologists had the lowest scores. Further, concerning the second factor expressing fear of the dead, doctors and other healthcare workers did not differ substantially from priests. In this case, these groups showed significantly less fear compared with psychologists and non-healthcare workers.

Conclusions: Fear of death seems rather to be present in professions dealing less directly with the dead and dying. Knowledge of the most fearful components helps to find targeted assistance in the work and the daily life, too.

Keywords: Fear of death, mental health, profession, carers

CORRESPONDING AUTHOR: Zana Agnes, Semmelweis University, Budapest;



Popa Velea O.

University of Medicine and Pharmacy Carol Davila - Bucharest, Department of Medical Psychology, Bucharest, Romania

Aim: This study examined the association between burnout syndrome and the distribution of preferred coping strategies at doctors working with incurable patients in several representative Romanian clinical services.

Method: 43 doctors, dealing daily with incurable adults, 57 dealing daily with incurable children and 44 controls were tested using COPE questionnaire (Carver et al., 1989) and Maslach Burnout Inventory (Maslach & Jackson, 1986) to determine their preferred coping strategies and burnout scores. The average experience of participants with palliative patients was in all cases higher than 7 years, with a mean of 15,33 (adults) and 16,44 (children). Statistical analysis comprised unpaired Student's t test and one way analysis of variance (ANOVA) to evaluate the effects of coping and demographic variables on burnout scores. Relationships between these variables and burnout were examined by using Pearson correlation coefficients. The relative contribution of different factors to burnout was evaluated using hierarchical linear regression analysis.

Results: Doctors working with incurable cases had a much more substantial use of emotion-centered strategies, such as positive reinterpretation, mental and behavioral disengagement, focus on emotions, denial and religious coping (p < 0,05). Denial, mental disengagement and religious coping were especially prevalent in doctors dealing with children with incurable diseases, compared to other two groups (p < 0,05). The burnout score was higher in both groups of doctors dealing with incurable patients, compared to the control group.

Discussions: The results of this study show a high inefficiency of Romanian doctors working with palliative cases to deal with daily professional stress. Supplementary actions (including psychotherapeutic assistance and active screening for burnout) should be used, to ensure a better efficiency and work satisfaction of these doctors.

Keywords: burnout, palliative, coping strategy

CORRESPONDING AUTHOR: Ovidiu Popa Velea, UMF Carol Davila, Bucharest;



Nan H.1, Lee P.1, McDowell I.2, Stewart SM.3, Lam TH.1

1 The University of Hong Kong, Department of Community Medicine, Hong Kong, China

2 University of Ottawa, Department of Epidemiology and Community Medicine, Ottawa, Canada

3 University of Texas Southwestern Medical Center at Dallas, Department of Psychiatry, Dallas, USA

Aim: Depression occurs commonly in people with chronic illness and is predicted to become one of the two most burdensome diseases worldwide by 2020. Family support is an important Asian cultural value that we hypothesized could protect people with chronic illness from developing depression. We investigated variables associated with depressive symptoms in a Chinese sample with chronic conditions, focusing on the possible protective role of family relationships.

Methods: Data were obtained from the Hong Kong Jockey Club FAMILY Project cohort study in 2009 - 2011, which included 6,195 respondents (age ≥15) with self-reported chronic conditions. Depressive symptoms were recorded using the Patient Health Questionnaire-9 (PHQ-9). Demographic and lifestyle variables, stressful life events, perceived family support and neighborhood cohesion were also assessed.

Results: The prevalence of depressive symptoms (PHQ-9 ≥5) was 17.0% in those with at least one chronic condition, and was more prevalent in women than in men (19.7% vs. 13.9%; p < 0.001). Satisfaction with family support followed life stress and number of chronic conditions in explaining the third largest variance (standardized coefficients of -0.11, 0.42, and 0.14 respectively, all p < 0.001) in multivariate analyses where body mass index, problem drinking, physical inactivity, and unmarried status were significantly but weakly associated with depressive symptoms. Higher family satisfaction played a stronger protective role against depressive symptoms among women compared to men (p < 0.01).

Conclusion: Acute life stress, including diagnosis of a disease, explains most variance with depressive symptoms in chronically ill Chinese individuals. The culturally salient variable, family support may be an important protective factor in Chinese cultures for individuals with chronic conditions.

Keywords: Depressive symptoms; chronic conditions; family functioning; Chinese; PHQ-9

CORRESPONDING AUTHOR: NAN Hairong, University of Hong Kong, HK;



Idaiani Sri

Ministry of Health of Republic of Indonesia, National Institute of Health Research and Development, Jakarta, Indonesia

Background: Aceh Province is the first province in Indonesia that has been developing the community mental health program. since 2007. The purpose of this study was to compare the functional status of psychosis patients who received community mental health program in community health centers and patients who was only treated to mental hospital.

Methods: This study was conducted in 2011 in Aceh. The design of this study was cross sectional, subjects were psychosis patients; consisted of 194 from community health centers and 112 from mental hospital. The patients were 230 male and 76 women, the average duration of illness was13, 6 years. Patients live in Banda Aceh and partly in the district of Aceh Besar. The rater’s were11 mental health nurses who had trained for this study. The data was collected by visiting patient in their house. The functional status of patients was assessed by Health of Nations (HoNOS) Aceh version that have been tried in advance and had been assessed the agreement among nurses. The numerical data was assessed by two different test of the mean, while the categorical data was assessed by chi square.

Results: The mean of functional status of patients from community health centre was 6.8 and 7.1 for mental hospital patients (p = 0.00)

Conclusion: patients who received community mental health services have a better functional status than patients who only seek treatment at a mental hospital. The community mental health program should be continued to patients with mental disorders, especially for psychosis patients.

Keywords: community mental health, Aceh, functional status, psychosis




Cunha M., Lopes P., Aparício G., Albuquerque C.

Instituto Politécnico de Viseu, School of Health, Viseu, Portugal

The state anxiety is an emotion commonly experienced by surgical patients and documented in the literature as a determinant of their well-being, arrogating to preoperative visit as protector of its occurrence and an important indicator of patient satisfaction. Thus, we studied the state anxiety in order to:

- Explain the influence of socio-demographic variables in state anxiety;

- To determine the influence of preoperative visit at the level of state anxiety.

The transversal observational study was conducted in a non-probabilistic sample of 180 pre-surgical patients (55.6% women and 44.4% men) with mean age of 57.25 years, using the Zung Anxiety Scale.

The level of anxiety is high in 51.7% patients (worse in women), mild in 39.4% and moderate in 8.9%. The state anxiety is higher in women (M = 37.39) than men (M = 34.01) (U = 2852.5, p =. 001), and also more severe in the less educated (H = 12,949, p =. 024 ) and older (r =. 233, p =. 002). Age explains 5.4% of the variability in state anxiety. Patients who received preoperative visit were less anxious, but without statistical significance (X2. =. 756, p =. 685).

It is inferred that sex, age and education influence the anxiety state, imposing consider them when planning a visit to the preoperative surgical patients.

Keywords: State Anxiety; Surgery

CORRESPONDING AUTHOR: Cunha Madalena, Polytechnic Institute of Viseu;



Lidell M., Aumiller B., Kluhsman B., Dominic O., Spleen A., Perry-Smith R., Lengerich E.

Penn State Milton S. Hershey Medical Center, Public Health Sciences, Hershey, USA

Purpose: This study examined (1) motivating factors (social influences) for prostate cancer screening with education and with the cognitive element of informed-decision making; (2) the role of social support in prostate cancer screening; and (3) the intention to be screened among medically underserved, low-income African American (AA) men of the recommended screening age of ≥ 50 years and older residing in Harrisburg, Pennsylvania.

Methods: 151 eligible AA engaged in one of five community-based prostate screening offered. Survey 1 (pre-test) and Survey 2 (post-test) assessing soicodemographic variables (age, sex, race/ethnicity, marital status, level of education, level of income, poverty level, insurance status, and employment status) and screening health behaviors (prostate screening status, intention to screen, attitude, belief and knowledge about prostate cancer and screening, attendance of a prostate cancer education session, role of social influence on their decision-making to get screened, and cues to action to get screened for prostate cancer) were administered prior to screening.

Results: We found significant differences (p = 0.04) between agreement on the necessity of screening by race and ethnicity. The social construct indicated that on average screening decisions for men in all groups were affected by their social structure. Men who attended the screening session without an education session (compared to men attending the screening with an education session) were more influenced by their social contacts (p = 0.03). Differences in individual social measures for AA were also observed. AA were more likely to agree with the following statement, “My church thinks I should be screened” (p = 0.03). AA were in agreement with self-efficacy for screening than non-AA men (p = 0.03). 42% of the individuals who attended the prostate cancer screening reported being influenced by another individual in their decision to be screened for prostate cancer. Most participants indicated their significant other had informed them of the opportunity to be screened for free and that significant other gave additional information important to their decision.

Conclusions: A targeted approach for prostate screening among AA may be better than the non-targeted approach.

Keywords: health disparities, self-efficacy, low-income- minority groups, prostate cancer screening

CORRESPONDING AUTHOR: Dominic Oralia, Penn State;



Consedine N.1, Reynolds L.1, McCambridge S.1, Bissett I.2

1 University of Auckland, Psychological Medicine, Auckland, New Zealand

2 University of Auckland, Surgery, Auckland, New Zealand

Background: Patients increasing role in treatment decision-making has lead to study of the links between emotions and decision-making. This literature is limited in two ways. First, many studies are cross-sectional, allowing commentary about links but not causality. Second, research has focused on fear and embarrassment but neglected disgust despite theory suggesting it may be a highly health-relevant emotion; symptoms, screening tests, treatments, and their side effects frequently contain disgust elicitors. Because disgust promotes the avoidance of elicitors, it may impact health decision-making.

Methods: 55 men and women completed dispositional measures of disgust sensitivity and frequency before a laboratory visit. Participants were randomized to an olfactory disgust induction or a control condition before completing behavioral decision-making tasks deliberately structured to highlight the more versus less disgusting aspects of colorectal cancer symptoms, screening, drug treatment options, side effects, and surgical choices.

Results: Manipulation checks on experience and behavior confirmed the elicitation of disgust in the experimental condition. Although there were no main effect differences in decision-making across conditions, 2 (condition) x 2 (high/low trait disgust sensitivity(DS)) ANOVA and chi-square analyses showed that decisions were predicted by both trait DS and by interactions between condition and trait DS. Greater trait DS predicted greater delay when confronted with hypothetical symptoms requiring fecal testing, a greater likelihood tolerating embarrassing over disgusting drug side effects, and ranking disgusting side effects (e.g., flatulence, diarrhea) as more off-putting to treatment. Further, high DS persons in the disgust condition were more likely to delay when hypothetical symptoms required collection of a fecal sample and required greater prompting to touch a stoma bag.

Conclusions: Prior work implies that emotions such as fear and embarrassment encourage behavioral “avoidance” in decision-making contexts. The current study extends this work by highlighting the causal role of disgust in colorectal cancer decision-making, suggesting that state and trait disgust may interact to “push” patients down distinct decisional pathways.

Keywords: emotions; decision-making; cancer

CORRESPONDING AUTHOR: Consedine Nathan, University of Auckland, Auckland;



Smith KJ., Schmitz N.

McGill University, Psychiatry, Montreal, Canada

Background: Within the scientific community there is an interest in psychological variables that are associated with self-care and physical complications in type 2 diabetes. The majority of research in this field concentrates on depression, an outcome shown to be strongly associated with the performance of the self-care regimen and physical outcomes. However, there is evidence that anxiety could also be important to assess. The aim of this study was to assess the impact of clinically significant anxiety on self-care behaviours and physical complications after controlling for depression.

Methods: The Evaluation of Diabetes Treatment study is a longitudinal community-based telephone survey of 2,000 Quebec residents with type 2 diabetes. The baseline portion of this interview was conducted in autumn 2011. Participants were administered a variety of questionnaires including sociodemographic questions, healthcare behaviours and presence of depression (PHQ-9). Clinically significant anxiety symptoms were assessed using a cutoff of ≥10 on the GAD-7. Data were analysed using logistic regression and adjusted for sociodemographic variables and depression.

Results: Preliminary results from 1,689 participants indicate that the prevalence of clinically significant anxiety in this population is 35.3%. Presence of clinically significant anxiety is associated with an increased likelihood of reporting poor eating habits, (1.90 (1.46-2.48), often forgetting to take medication, (1.91 (1.20-3.05), 1 diabetes complication, (1.67 (1.25-2.24) , 2 or more diabetes complications, (2.59 (1.93-3.46), 1 chronic condition, (1.61 (1.14-2.28), 2 or more chronic conditions (2.84 (2.04-3.95) and reporting poor diabetes control (2.03 (1.54-2.68).

Discussion: This data provides evidence that even after controlling for presence of depression, clinically significant anxiety is associated with decreased performance of self-care behaviours and an increased likelihood of having physical complications. This data indicates the importance of anxiety in diabetes and the need for further research into this psychological outcome.

Keywords: Anxiety; Diabetes

CORRESPONDING AUTHOR: Kimberley Smith, McGill University;



Vereczkey A.1, Czegle I.2, Margittai É.1, Higi V.1

1 Versys Clinics, Human Reproduction Institute, Budapest, Hungary

2 Semmelweis University, Department of Medicine, Budapest, Hungary

Endometriosis is the abnormal growth of endometrial cells in a location outside of the uterus, e.g. on the ovaries, salpinges, outer surfaces of the uterus or intestines and elsewhere in the pelvic cavity. Endometriosis affects women in their reproductive years, and is one of the leading causes of pelvic pain and infertility in U.S. and Western Europe. The reasons for the decreased fertility are not completely understood, however they involve anatomical, biochemical and hormonal factors.

In severe endometriosis – and in case of inadequate response to medical treatment - the definite solution is surgical, typically carried out by laparoscopy. Endometrial implants may be excised or obliterated by CO2 laser. While surgical treatments are effective, the recurrence rate of the disease is quite high, and repeated operations might result in the destruction of reproductive tissues, mainly the ovaries.

An important task is the preservation of patients’ fertility with the commonly available methods, since many women are nulliparous in the moment of the diagnosis. Fertility preservation is a newly acknowledged technique for preserving eggs, ovarian tissue, testicular tissue and sperm, mostly in case of malignancy. In our study we aimed to examine women’s approach for fertility preservation with severe endometriosis and to map the circumstances, types and conditions which they would undertake to preserve their fertility. Our preliminary results based on data gained from Hungarian women affected by endometriosis (ave.age: 33.88) shows that 94.5% of the patients were aware of the fact that endometriosis decreases chances for pregnancy, 27.8% heard about fertility preservation, 55.5% would surely, 38.9% would probably consider undertaking the method to preserve their fertility. Their compliance for this technique underlies the importance of widening the indication list for fertility preservation, and to enlarge our study for international endometriosis centers.

Keywords: health behavior, OB-GYN disorders

CORRESPONDING AUTHOR: Vereczkey Attila, Versys Clinics, Budapest;



Antal M., Bugán A.

University of Debrecen, Faculty of Public Health, Institute of Behavioural Sciences, Debrecen, Hungary

I prepared my study in 2011 to measure the quality of the psychological immunity of the different maternal status of fertile-age women. There was a distinction between three basic categories in relation to motherhood-statuses: groups of the fertile age childless women, the pregnant women and the 0-2 year-old child care mothers.

Principally, it seems highly important that womankind due to biological and social function are an establishing potency for the following generation. Furthermore, based on analogy of the procedure of the body and soul as a result of the early mother-child relationship, the psychological condition of women is cardinal and a predestinative factor determining the later quality of life of their children. Therefore, the focus of interest was to emphasise what kind of general characteristic can be shown between various women's statuses, what significant changes can be observed in the psychological immune profile of the different life situations women, especially for socially active mothers. During the research I used the three subsequents and factors of the Psychological Immune System Inventory, published in 1997 by Olah and Stattin. The ultimate goal of my investigation is to indicate the positive psychological effect of the community, which I believe to be inherent in the form of group, as a naturally psychological factor, without the intervention of experts to assist the individual to a better psychological development and maintenance. This thesis was demonstrated by using the complete group of mothers, separately studied the group of the “community visitor” and the "stay at home" mothers, observing the potential difference in their psychological condition. Although, there were no chance for longitudinal researches, the most heterogeneous samples possible had been used, meaning education, age and residence, the results were submitted to correction statistical procedures. The results suggest that the above mentioned women statuses show significant differentiations in their psychological immune profiles, which could be stronghold to planning mental health promotion programs. A prominent and important research experience was, that the factors of mental coping skills of socially active " community visitor "mothers outweigh the so-called "stay at home" group largely, presumably they possess more stable mental structure and broadcast it toward their offspring and the social environment, thus underlining the long-term and natural psychological preventive impact of community life.

Keywords: women's health, mental health, parent-child transactions, social support, health promotion, prevention

CORRESPONDING AUTHOR: Antal Margarita Zoe, University of Debrecen, Debrecen;



Sipos K., Győry-Gritz ZS., Tóth L.

Semmelweis University, Faculty of Physical Education and Sport Sciences , Budapest, Hungary

The aim of the study is the examination of the relationship of coping styles, self-efficacy and physical self-concept in connection with demographic questions (age, gender, marital status, number of dependent children, etc), physically active/inactive lifestyle, smoking habit, frequency of medicine use. Sample (N = 155) contains five groups: emergency medical technicians (n = 19), medical nurses (n = 55), optometrists (n = 47), midwifes (n = 13), physiotherapists (n = 11), and students of recreation (n = 10) of evening courses at the Semmelweis University.

Male/female ratio is 18,7 /81, 3%; average age is 33,67 (SD = 8,57). Physically active subjects (N = 74); smokers: 31% of the sample. The sample is divided into subgroups according to demographic variables, smoker/no-smoker, and physically active/ sedentary lifestyle.

Methods: The Hungarian versions of the Lifestyle Defense Mechanisms Inventory’s two subscales (RED/NH), the Schwarzer et al (1993) “Generalized SE”, “SE Towards Physical Exercise” and “SE Towards the Temptation to Smoke” scales; together with the Physical Self-Concept subscale of the Tennessee Self-Concept Scale are the psychometric variables.

Results: gender difference occurs in mean age (p <0,000) and number of dependent children (p <0,001). Females’ age and number of children for them are higher. Smokers – non-smokers’ comparison reveals higher self-efficacy towards the temptation to smoke (p <0,000), and self-efficacy towards physical exercise (p <0,014) for non-smokers.

Four factors are determined according to factor analysis. Factor 1 (self-efficacy towards the temptation to smoke: 0,868; cigarettes per day: -0,817), factor 2 (physical self-concept: 0,892; generalized self-efficacy: 0,764; and self-efficacy towards physical exercise: 0,486), factor 3 (number of dependent children: 0,897; calendar age: 0,848; factor 4 (need for harmony: 0,792; rational/emotional defensiveness: 0,775).

In the Linear regression analysis model the generalized self-efficacy is the most frequent significant predictor of physical self-concept in different subgroups. The second significant predictor of physical self-concept is the self-efficacy towards physical exercise.

Keywords: physical self-concept, self-efficacy, lifestyle defense mechanisms

CORRESPONDING AUTHOR: Sipos Kornél, Semmelweis University, Budapest;



Borland R.

Cancer Council Victoria, Melbourne, Australia

This paper draws on over 25 years of evaluating the impact of tobacco control interventions and the difficulties smokers have in controlling their smoking to theorise about the role of affective factors (emotions, urges etc) in relation to cognitive efforts at self-control. The theory distinguishes between two systems which are tuned to different contingencies for action: one a reactive, system, essentially our animal selves which is tuned to environmental contingencies and which is the medium through which we behave, and the second our conceptual selves which acts in relation to a conceptualisation of what the person would like to achieve; i.e., their goals. It is theorised that affective charge is the prime determinant of action. Addictions are quintessential examples of where the two systems generate conflicting behavioural tendencies. Rationally generated goals, unless imbued with some affective force, are not sufficient to overcome affectively charged action tendencies to persist in addictive behaviours that emerge from conditioned and other associations with the behaviour we might want to change. It is further theorised that affective reactions to behaviours are retained in memory more strongly than conceptualisations of the source of the affect. It will be so in any situation where experience does not negate the affective reaction. Consequence of this is that reactance to what may be seen as an unnecessary or exaggerated linking of behaviours with negative consequences (e.g., fear evoking communications), may result in undesirable short term outcomes, but will have long term positive effects on inhibiting those behaviours as long as the affective associations are maintained. It is most likely for believed future adverse consequences as immediate experiences do not directly negate the anxiety created by the possibility. Self-regulatory action involves imbuing behaviours with the appropriately valenced affect that will stimulate the desired behaviour change. Recent research on smoking cessation will be used to demonstrate the plausibility of the theory.

Keywords: Health Behaviour Change, Theory

CORRESPONDING AUTHOR: Borland Ron, Cancer Council Victoria;



Urzua A.

Universidad Católica del Norte, Department of Psychology, Antofagasta, Chile

Despite the increased research involving quality of life (QoL), there are no studies to explore the impact that it might have on an assessment. This assessment is based on the importance that the children give to each one of the domains that compose their QoL. Therefore, the existing differences in the evaluation are analyzed with a quantitative methodology and under a correlational transversal design. When this evaluation takes place, each child understands the importance of each dimension that is inquired of them in the evaluation. This assessment evaluated 600 children from public, private, and semi-private schools in the city of Antofagasta. Each child had an average age of 12 years old, and the assessment was distributed equally by gender, using a specific questionnaire by the name of KIDSCREEN-27. Results show differences in the perception of the QoL between genders, types of schools, and differences in age. These results are maintained considering the raw scores as decided by importance. There are minor differences between the domain best evaluated and worst evaluated. When ranking by importance, the most evident aspects are age and type of school. The discovered results contribute to the understanding of the cognitive processes involved in the QoL evaluation.

Keywords: quality of life, childhood

CORRESPONDING AUTHOR: Urzua Alfonso, Univ. Católica del Norte, Chile;



Inouye J.1, Li D.2, Davis J.3, Arakaki R.3

1 University of Hawaii, Department of Nursing, Honolulu, Hawaii, USA

2 University of Hawaii, Department of Public Health Sciences, Honolulu, Hawaii, USA

3 University of Hawaii, Medicine, Honolulu, Hawaii, USA

Background: Diabetes is a chronic disease that affects about 11.3% of all people aged 20 years and older in the United States according to the 2011 National Diabetes Fact Sheet. Asian Americans are among the fastest growing racial and ethnic groups in the United States with higher prevalence of diabetes (8.4%) than non-Hispanic whites (7.1%). To assess the association between self-efficacy (MDQ), health beliefs (DHBS), health behavior (SDSCA), and health outcomes such as glycosylated haemoglobin (HbA1c), depression, quality of life (DQOL), and general health (SF-36) in Asian and Pacific Islander adults with type 2 diabetes, we used structural equation modeling (SEM) in a cross-sectional study of behavioral and physiological factors from 207 Asian and Pacific Islanders with type 2 diabetes.

Methods: Using the SEM approach, we proposed that health beliefs (DHBS) and self-efficacy (MDQ) are directly related to each other; self-efficacy (MDQ) directly affects health behavior (SDSCA) and health behavior directly affects health outcomes such as glycosylated haemoglobin (HbA1c), depression, quality of life (DQOL), and general health (SF-36).

Results: The final SEM models show that self-efficacy (MDQ) has a positive association with both health beliefs (DHBS) and health behavior (SDSCA). Higher health behavior (SDSCA) scores were associated with lower HbA1c values, lower depression scores, higher quality of life, and better self-appraised general health.

Conclusion: The SEM models indicated the association of self-efficacy and health beliefs on health behavior, and health behavior has direct effects on multiple health outcomes. The SEM models highlighted the important role of self-efficacy during the process of producing the final health outcomes. This provides some evidence for the focus on self-efficacy in future intervention-based studies among Asian and Pacific islanders with type 2 diabetes.

Keywords: Depression, Diabetes, Health behaviors, Health beliefs, Quality of life, Self-efficacy

CORRESPONDING AUTHOR: Inouye Jillian, University of Hawaii at Manoa;



Nakata T.

Hokusei Gakuen University, School of Welfare, Sapporo, Japan

The aim of this study is to examine the relationship between health behaviors and social stratification. It is often said that healthy lifestyle forms a connecting link between health and social class. However, there are some exceptions. For example, people who have to work in collaboration with their colleagues tend to have a meal together. Therefore, the relationships are tested qualitatively using ordered logit regression analysis in this study.

This study employed "Japanese Study of Stratification, Health, Income, and Neighborhood (J-SHINE)", which was a large-scale dataset for examine concerning social stratification and health in 2009. The sample included people who is from 25 to 50 years old male and female (n = 4381). And participants resided in 23 wards and neighboring cities in the Metropolis of Tokyo, Japan. The independent variables in this study were three health habitus, which were "alcohol drinking" and "exercise" and 'smoking'. And dependent variables were age, gender, status in employment, household income, educational level, marital status, length of business hours, size of the companies that respondents were working, and Self-Rated Health.

The results of the analysis are as follow; 1) some high-status characteristics affect health behavior and vice versa. For example, low status in employment related to drinking and exercise habit and who is working in big firms tend to be non-smoker. 2) Some high-status aspects incline to bad habit. High status in employment tends to drinking and low status in employment tends not to drink. 3) There are some contradictory results. Both high and low income have an impact on drinking.

This results from this study that applies non-linear models show that both high and low social statuses connected with healthy lifestyle. To seek the other factors that mediate the relationship between social class and healthy behaviors, like ideologies like healthism or behaviors that is internalized by discipline, remain to be solved.

Keywords: Health behaviors, Social class

CORRESPONDING AUTHOR: Nakata Tomoo, Hokusei Gakuen Univ., Sapporo;



Hong O.1, Chin D.1, Feld J.2, Vogel S.2

1 University of California, San Francisco, School of Nursing, San Francisco, USA

2 NorthShore University, HealthSystems, Illinois, USA

Background: Hearing loss due to noise exposure is a significant problem among about over one million firefighters in the US. This permanent and irreversible problem can be almost 100% preventable by the use of personal hearing protective devices (HPDs).

Purposes: To apply TTM and determine stages of change in hearing protection behavior; and to examine relationships of the stages of change with cognitive perceptions on the use of HPDs and hearing ability in firefighters.

Method: A total of 461 US firefighters (mean age = 45years, Caucasian or White = 80%, male = 92%) who completed hearing tests and the pretest survey as a part of ongoing hearing protection and cardiovascular disease prevention interventions were included. Hearing ability was assessed by a standard audiometric test. Stage of change was determined using the algorithm developed by the research team. Cognitive perceptions on the use of HPDs and hearing ability were compared by the stage of change.

Results: The majority of participants (64%) were in the preparation stage and less than 7% were in the active stage (action/maintenance).Participants in the active stage demonstrated significantly greater benefits, self-efficacy, and interpersonal influence; and fewer barriers than those in the inactive (precontemplation, contemplation, or preparation) stages. Objectively measured hearing ability was significantly better for firefighters in the active stage.

Conclusion: The study demonstrated the usefulness of TTM for firefighters’ hearing protection behavior and supports a stage-matched tailored intervention to move firefighters from the inactive stages to the active stage of hearing protection use, in turn to prevent hearing loss.

Keywords: stages of change, hearing protection, cognitive perceptions, firefighters, hearing ability

CORRESPONDING AUTHOR: Chin Dal Lae, University of California, SF;



Kuosmanen P.1, Pekkarinen S.2, Kempas K.2, Melkas H.2, Valve R. 1, Karisto A.3

1 University of Helsinki, Centre for Continuing Education, Lahti, Finland

2 Lappeenranta University of Technology, Lahti School of Innovation, Lahti, Finland

3 University of Helsinki, Department of Social Research, Helsinki, Finland

The paper focuses on 'hStick' (health stick), an innovative concept being developed in a large Finnish R&D project focusing on two innovative concepts, the hStick and the 'mStick' (reminiscence stick). The hStick is a modernised version of the so-called SOS Passport, in which various health-related data may be saved. It includes the basic information (blood group, illnesses, medication, etc.) that are needed in the case of acute illnesses or injuries. The hStick functions as a means for self-care as well as promotion of one's own health, because a comprehensive selection of information on health and health behaviour may be saved in the stick (e.g., results of various clinical measurements and fitness tests). It may also include the personal living will.

There is an ongoing trend in Finland that health care customers are encouraged to take more responsibility for their health. A problem arises when a service provider or a customer him/herself needs to have access to the customer's health information. Health care information systems of different service providers are still not compatible; customer information is not transferred between information systems of different service providers. This often leads to a situation where no-one - even the patient/customer him/herself - has a holistic perception of his/her health condition. One aim of the hStick is to gather the personal health information in one place and stimulate people to monitor and promote their own health more systematically.

This research assesses impacts and usability of the hStick in different environments. The development of the contents and structure of the hStick have been conducted with a user-driven perspective. In the first phase, the hStick was piloted among five user groups. During the pilots, user experiences were collected and analysed with the help of various techniques (focus groups, interviews, observation, ethnographic techniques).

The results show that the hStick can be accepted easily and is quick to implement when it functions as a means for monitoring one's own health, learning self-care and giving feedback (e.g., concerning physical exercise related to one's personal targets). The stick has also proven to be useful when travelling abroad. Main challenges concerning the hStick are related to information security and fear of viruses.

Keywords: health promotion, technology, participatory research

CORRESPONDING AUTHOR: Valve Raisa, University of Helsinki, Lahti;



Morris K.1, Swinbourne A.1, Harrison S.2

1 James Cook University, Psychology, Townsville, Australia

2 James Cook University, Tropical Medicine and Rehabilitation Sciences, Townsville, Australia

Background and Objectives: In Australia, public health messages have warned of the dangers of excessive UV exposure for more than thirty years, predominantly through promoting increased sun protection and decreased deliberate sun tanning. Research has pushed for increased knowledge of risks, and a reduction in positive attitudes toward tanning. These messages target the reflective, intentional element of behaviour. While this approach has shown some success, it is limited in its ability to be adapted to regions such as North Queensland where comparatively few people intentionally sunbathe. Despite this, the incidence of skin cancer in North Queensland is among the highest in the world. This would indicate that much of the damage due to UV exposure happens whilst going about normal daily activities - by incidental sun exposure. Incidental exposure is not planned or deliberate, thus theoretical modeling used in research should reflect this. The overall aim of the current study is to adopt a dual-processing framework to examine the psychosocial variables associated with incidental sun exposure.

Method: The current study explored perceptions associated with sun-related prototypes. Prototypes are social constructs with social consequences. In a sun protection paradigm these are perceptions about the typical person who deliberately suntans, the typical person who protects themselves from the sun, and the typical person who acquires a tan incidentally. Semi-structured interviews were initially conducted as an exploration followed by a survey which sought to identify the specific characteristics of each of the ‘prototypes’.

Results: Preliminary results indicated that distinct prototypes exist within a sun protection paradigm. Unlike perceptions surrounding incidental tanners and sun protectors, participants held negative perceptions toward the deliberate tanner prototype. Furthermore, individuals tend to align with the incidental prototype - despite engaging in deliberate tanning behaviours. These unrealistic self-perceptions may influence whether individuals attend to health promotion messages which aim to reduce deliberate tanning behaviours.

Conclusions: Individuals’ prototype perceptions may influence not only sun protective behaviours but also attention to health information. Alignment with a ‘prototype’ that is incongruent with actual behavior, while holding negative perceptions toward the deliberate tanner may polarise individuals and inhibit behavioural change. Thus, current health promotion campaigns may not be applicable to North Queensland and other climates where comparatively few people deliberately tan.

Keywords: Health behaviour, Health promotion, Sun safety

CORRESPONDING AUTHOR: Morris Kayla, James Cook University;



Vurnek Zivkovic M., Dediol I., Ljubičić I., Šitum M.

University Hospital Centre Zagreb, Zagreb, Croatia

Background: Melanoma is one of the most aggressive skin tumours which accounts for only 3% of all skin cancers, but is responsible for more than 80% of all skin cancer related deaths. One of the major risk factors for melanoma is ultraviolet radiation, which makes sun protection extremely important. Sun protection is a major issue for melanoma patients who have 500 greater chance of developing another melanoma than the general population.

Objective: In this study we examined the perception of melanoma and sun behaviours among melanoma patients and we compared their results with the general population.

Methods: In total, 240 participants were included in the study: 120 patients suffering from melanoma and 120 participants from the general population. The Sun Behaviour Patterns Questionnaire and the Brief Illness Perceptions Questionnaire were used in this study to assess sun behaviours and perception of melanoma.

Results: Melanoma patients have negative attitude towards sunbathing: 63% avoid sunbathing and 25% spend time in the sun only during swimming in the sea otherwise seeking shade, while participants in the control group have more positive attitude toward sunbathing and spend more time in the sun. Results indicate too short time of using sunscreen protection during the year and too small number of people using adequate SPF value, in both melanoma and control group.

Conclusion: The results show inaccurate perception of melanoma, relatively good knowledge about ultraviolet radiation and slightly negative attitudes towards sun protection among both melanoma patients and the general population. These results will be used to develop an educational programme and to create leaflets and posters about melanoma for the patients, but could also serve as a basis for the health prevention campaign for melanoma.

Keywords: cancer, health behaviours

CORRESPONDING AUTHOR: Vurnek Zivkovic Maja, UHC, Zagreb;



Tsui HY.1, Lau TF.1, Wang R.2, Chen H.3, Liu C.4, Liu J.5

1 The Chinese University of Hong Kong, Centre for Health Behaviours Research, School of Public Health and Primary Care, Hong Kong, China

2 Center for Disease Control and Prevention, Head Office, Dazhou, China

3 Centers for Disease Control and Prevention, Division of HIV/AIDS, Dazhou, China

4 Centers for Disease Control and Prevention, Head Office, Hengyang, China

5 Center for Disease Control and Prevention, Division of HIV/AIDS, Hengyang, China

Injecting drug use is a major driver of HIV infection in different parts of the world, including mainland China. Syringe-sharing by injecting drug users (IDU) is a very efficient way of HIV transmission. Understanding the underlying factors associated with the risk behavior is of public health importance. This study examined the use of an extended Health Action Process Approach (HAPA), incorporating the addition of anticipated negative affect after syringe-sharing, to predict behavioral intention to avoid syringe-sharing. Data obtained from a cross-sectional survey of 456 Chinese male active IDU (injecting drugs during the last six moths) between the ages of 18 and 45 in mainland China were reported. An anonymous structured questionnaire measuring specific constructs of the motivational phase of the HAPA (including conditional injecting risk perceptions (HIV acquisition as well as transmission to others), outcome expectancies, self-efficacy, and behavioral intention), anticipated negative affect, and background characteristics were developed to collect data. Of all respondents, 28.7% aged between 18 and 30; 27.9% have senior high schools education; 32.9% were currently married; 23.9% injected drugs for 10 years or more; 68.9% injected drugs at least once a day; and 11.2% shared syringes with others in the last six months. Adjusted for significant background factors (use of Methadone Maintenance Treatment or Syringe Exchange Program, multiple sex partnership, and survey sites), perceived risk of contracting HIV via syringe-sharing (Adjusted Odds Ratio (AOR) = 2.11; 95% Confidence Interval (CI) = 1.26-3.54), syringe non-sharing negative outcome expectancies (AOR = 0.58; 95% CI = 0.34-0.99), and syringe non-sharing self efficacy (AOR = 2.76; 95% CI = 1.51-5.06) predicted intention to avoid sharing syringes with others. These HAPA variables remained significant after the addition of anticipated negative affect (AOR = 1.30; 95% CI = 1.05-1.60). Both perceived risk of transmitting HIV to others via syringe-sharing and syringe non-sharing positive outcome expectancies were univariately non-significant. The study demonstrated the utility of the extended HAPA in understanding syringe-sharing behaviors among male Chinese IDU. This informs future design of theory-based interventions.

Keywords: HIV; Health Behaviors; Theory

CORRESPONDING AUTHOR: Tsui HY, Chinese University, Hong Kong;



Harmsen IA.1, Lambooij MS.2, Ruiter RAC.1, Mollema L.3, Veldwijk J.2, Van Weert YJW.3, Kok G.1, Paulussen TGW.4, De Wit GA.2, De Melker HE.3

1 Maastricht University, Work & Social Psychology, Maastricht, The Netherlands

2 National Institute of Public Health and the Environment, Centre for Prevention and Health services research, Bilthoven, The Netherlands

3 National Institute of Public Health and the Environment, Centre for infectious disease control, Bilthoven, The Netherlands

4 TNO, Quality of Life, Leiden, The Netherlands

Background: From October 2011, the Netherlands started to vaccinate all newborns against hepatitis B. The aim of the present study was to get insight in the psychosocial factors that determine parents’ intention to vaccinate their child against hepatitis B, and to test whether intention to vaccinate is a good predictor of actual vaccination behaviour. This study was conducted before the introduction of the universal hepatitis B vaccination.

Methods: In total, 2000 parents of newborns (0-2 weeks old) received a self-report questionnaire measuring intention towards hepatitis B vaccination and its psychosocial determinants (response rate 45.6%). Participants were invited for follow-up research and offered the opportunity to have their child vaccinated against hepatitis B.

Findings: The findings showed that the large majority of parents intend to vaccinate their child against hepatitis B. The intention to vaccinate was most strongly determined by parent’s attitude towards hepatitis B vaccination, which in turn was positively associated with perceived benefits of the vaccination and perceptions of their child’s susceptibility to hepatitis. The majority of invited parents had their child vaccinated at follow-up (83.7%). Intention was found to be a significant predictor of vaccination behaviour although less strong than expected.

Discussion: It is concluded that Dutch parents were positive towards hepatitis B vaccination in terms of both intention and behaviour. To further sustain parents’ positive attitudes towards hepatitis B vaccination, educational campaigns should strengthen the benefits of vaccination next to emphasizing the child’s risk to hepatitis B infection.

Keywords: Infection, Health behaviors, Decision making, Theory, Children's health

CORRESPONDING AUTHOR: Harmsen Irene, Maastricht University;



Diaconescu L V.1, Diaconescu I.2

1 University of Medicine and Pharmacy Carol Davila - Bucharest , Department of Medical Psychology, Bucharest, Romania

2 Institute of Cardiovascular Disease “Prof.dr. C.C.Iliescu”, Vascular Surgery, Bucharest, Romania

Background: Peripheral occlusive arterial disease implies damage of blood-axes of the legs; patients suffer of pain and severe ischemic lesions extending to gangrene and amputation limb-threatening. Venous disease is represented by hydrostatic varicose veins of the legs with discomfort, swelling of the legs and in advanced stages ulcerative lesions

The study’s aim was to analyze the relationship between anxiety, depression, perceived stress and social support at patients with peripheral vascular disease.

Method: The study included a number of 54 patients (38 men and 16 women, mean age = 54,98; SD = 9,31) diagnosed with arterial disease (39 patients) and with venous disease (15 patients). There were applied (before surgery) psychological tests: Anxiety and Depression Scale (HADS, Zigmond and Snaith), Perceived Stress Scale (PSS, Cohen and Williamson), The Duke-UNC Functional Social Support Questionnaire (FSSQ).

Results: Women had higher levels of anxiety and depression than men (ns), higher scores on perceived stress scale (32,94 vs 29, t = -2,26; p < 0,028) but lower scores on social support scale (25,50 vs 30,42, t = 2,13; p < 0,038). Patients with arterial disease had higher scores at anxiety (10,31 vs 8,33, t = 2,58; p < 0,012), depression (7,36vs 5,40, t = 2,05; p < 0,045) and perceived stress (31 vs 28, ns) and lower scores at social support scale (27,62 vs 32,47, t = -2,05; p < 0,045) than patients with venous disease. Both anxiety and depression positively correlated with perceived stress (0,639 respective 0,410; p = 0,01) and negatively with social support (-0,574, respective -0,522; p = 0,01). Age negative correlated with social support (-0,464; p = 0,01).

Conclusions: The indication for surgical treatment of vascular disease is a distress factor, leading to anxiety and depression. The increased anxiety at patients with arterial disease compared with those with venous disease can be explained by greater severity of this group of diseases, higher surgical risks, more frequent complications and a high risk of amputation. Low social support mainly observed in some elderly patients indicate, on the one hand the restriction of support network at this age and, on the other hand, its usefulness especially in the case of diseases that require surgery and postoperative recovery.

Keywords: Anxiety, Depression, Social support, Cardiovascular disease

CORRESPONDING AUTHOR: Diaconescu Liliana Veronica, UMF, Bucharest;



Strodl E.

Queensland University of Technology, School of Psychology, Brisbane, Australia

Endothelial dysfunction is an important risk factor for future cardiac events in coronary heart disease patients. Previous research has shown an association between psychological factors such as mood and endothelial dysfunction. This study aimed to extend this research by exploring the association between dimensions of attachment and endothelial dysfunction. A pilot study recruited 24 participants hospitalised with myocardial infarction who displayed elevated levels of Troponin or Creatine Kinase. Endothelial dysfunction was assessed using high resolution ultrasound equipment to measure Flow Mediated Dilation. The participants completed measures of depression, anxiety, anger and attachment. While there were no associations between depression, anxiety or anger and endothelial dysfunction in this study, there was a moderately strong association between endothelial dysfunction and an attachment dimension termed Relationships as Secondary. Relationships as Secondary are constructs that describe a tendency to gain self worth from achievements rather than from relationships. There are similarities between this construct and the construct of Type A Behaviour Personality. The results of the study therefore suggest that Attachment Theory, and in particular the construct Relationships as Secondary, may provide a promising psychological construct to explore the psychophysiological mechanisms associated with coronary heart disease. In addition to presenting the findings of the study, a model will also be presented that uses Relationships as Secondary to explain previous findings of a link between the experience of depression and anger with the occurrence of coronary events.

Keywords: Coronary Heart Disease; Psychophysiology




Ichikura K.1, Matsuoka S.2, Kobayashi S.3, Suzuki T.4, Nishimura K.3, Shiga T.4, Suzuki S.5, Hagiwara N.4, Ishigooka J.3

1 Tokyo Medical & Dental University, Section of Liaison Psychiatry & Palliative Medicine, Tokyo, Japan

2 Tokyo Women’s Medical University, Department of Nursing Sciences, Tokyo, Japan

3 Tokyo Women’s Medical University, Department of Psychiatry, Tokyo, Japan

4 Tokyo Women’s Medical University, Department of Cardiology, Tokyo, Japan

5 Waseda University, Faculty of Human Sciences, Saitama, Japan

Introduction: Implantable cardioverter defibrillators (ICDs) are increasingly used for the prevention of sudden cardiac death in patients with life-threatening ventricular arrhythmias. Most ICD recipients are reported to experience depressive symptoms. However little is known of the factors associated with depression in ICD recipients, especially in Japan. The purpose of this study was to identify the impact of sociodemographic, disease-specific, and behavioral factors on depression in ICD recipients in Japan.

Methods: Of all 221 ICD recipients at Tokyo Women Medical University Hospital between 2010 and 2011, 183 participated in our studies. The questionnaire consisted of Beck Depression Inventory (BDI) - 2 and Avoidance Behavior (“I have avoided activity which is likely to trigger ICD shocks.”). Multivariate logistic regression was used to calculate ORs and 95% CIs after controlling simultaneously for potential confounders. Variables considered in the models were sex, family, history of ischemic cardiac disease, history of ICD shocks, avoidance behaviors, and BDI scores.

Results: A total of 118 (64.5%) participants completed all questions in this study. Frequency of self-reported moderate depression was 22.6%; medium depression was 8.4%; and severe depression was1.9%. Avoidance behavior was the only aspect of depression independently associated with sex, family, history of ischemic cardiac disease and history of ICD shocks (OR = 1.72; 95%CI 1.09-2.71).

Conclusion: Our results indicated that most ICD recipients experienced depression in Japan, and the symptoms were related to their avoidance behavior. We recommend that healthcare professionals consider to focus on avoidance behavior when they deal with depression among ICD recipients.

Keywords: Depression, Cardiovascular disease




Laferton J.1, Auer C J.1, Shedden Mora M.1, Moosdorf R.2, Rief W.1

1 University of Marburg, Department of Clinical Psychology, Marburg, Germany

2 University of Marburg, Department of Cardiac and Thoracic Vessel Surgery, Marburg, Germany

Patients’ expectations have been identified as an important factor for treatment outcome of several medical conditions. Recent studies suggest a relationship between pre surgery expectations and recovery even after highly invasive procedures like heart surgeries. However, few studies have tried to utilize expectations to enhance patients’ health. Self regulation and illness perception theory with an emphasis on the role of expectations offer a promising framework for designing such an intervention. Purpose: The goal of this study is to evaluate an intervention prior to coronary artery bypass grafting (CABG) in order to optimize patients’ expectations. Method: 60 patients waiting for elective CABG have been randomly assigned to one of three groups: Expectation manipulation intervention (EMI), supportive therapy (SP) or standard medical care (SMC). EMI and SP patients received two individual sessions and two phone calls prior to surgery. Patients’ expectations were assessed before and after the psychological intervention. Additionally all patients were asked how much they would like to talk about their expectations concerning surgery, about their feelings concerning surgery or how much they didn’t want to talk about surgery at all. After the intervention satisfaction with EMI or SP was assessed (7 items scale; score ranging from 5-35). Results: 70.6 percent of all patients expressed the wish to target their expectations, 53.0 percent wanted to talk about their feelings and only 33.3 percent said that they would rather avoid talking about surgery. Satisfaction with the intervention was very high and did not differ significantly between EMI (M = 31.6) and SP (M = 32.4). Pre-post intervention analysis shows a significant improvement of expectations in the EMI group compared to the control groups. Long-term follow up will be finished in the future. Discussion: The results indicate that the majority of patients prefers to talk about their expectations concerning surgery and that they are very satisfied with either EMI or SP. This underlines the need for pre-surgery interventions. Most importantly patients’ expectations in the EMI group improved in comparison to both control groups. Future analysis will show whether improved expectations lead to better recovery from CABG.

Keywords: Coronary heart disease, Health beliefs, Intervention, Outcome expectations, Randomized controlled trial

CORRESPONDING AUTHOR: Laferton Johannes, Phillips University, Marburg;



Porojan MD., Poanta LI., Carstoc E., Dumitrascu DL.

University of Medicine and Pharmacy Cluj-Napoca, Department of Internal Medicine, Cluj-Napoca, Romania

Background: Cardiovascular diseases still represent the main cause of mortality in Romania. Guidelines pay a significant attention to psycho-social and psycho-educational interventions aimed to improve cardiovascular patients’ quality of life (QoL) and to reduce risk factors.

Aim of the study: To assess the QoL in patients with chronic heart failure (CHF) and the factors influencing QoL.

Material and method: The validated Romanian version of SF-36 questionnaire has been applied in 100 patients (51 females and 49 males, average age ± SD = 69 ± 12,02) diagnosed with chronic heart failure (NYHA class I to IV). 91 patients suffer from ischemic heart disease (IHD), 80 patients from arterial hypertension (AH), 40 patients from diabetes mellitus (DM) and 20 patients from chronic obstructive pulmonary disease (COPD).

Results: Questionnaire’s Alpha Cronbach analysis revealed unfavorable results for items: Role limitations due to physical health, Role limitations due to emotional problems, Social Functioning and General health.

Male gender is negatively correlated with items: Physical functioning, Energy/fatigue and Social functioning (r = 0.0527, r = 0.053, r = 0.0598). Patients’ age is negatively correlated with items: Physical functioning, Energy/fatigue, Social Functioning and Role limitation due to emotional problems (r = 0.1281, r = 0.1207, r = 0.1087, r = 0.064).

NYHA class is negatively correlated with items: Physical functioning, Energy/fatigue and Social functioning (r = 0.1976, r = 0.092, r = 0.15). Statistical analysis revealed a negative association between IHD and Social functioning and Pain scales (r = 0.1318, r = 0.0397). There are no statistically significant correlations between AH, DM or COPD and QoL domains.

Conclusions: QoL in patients with CHF is influenced, besides the disease, by many other variables. Age, sex, associated diseases and NYHA class significantly influence QoL scores.

The management of CHF must include the QoL domains, in addition to standard therapy.

Keywords: quality of life, cronic heart failure, cardiovascular disease

CORRESPONDING AUTHOR: Porojan Mihai, Cluj-Napoca Medicine University;



Matsuoka S.1, Ichikura K.2, Kobayashi S.3, Suzuki T.4, Nishimura K.3, Siga T.4, Hagiwara N.4, Suzuki S.5

1 Tokyo Women’s Medical University, Graduate School of Nursing, Tokyo, Japan

2 Tokyo Medical & Dental University, Graduate School of Medical & Dental Sciences, Tokyo, Japan

3 Tokyo Women’s Medical University, Department of Psychiatry, Tokyo, Japan

4 Tokyo Women’s Medical University, Department of Cardiology, Tokyo, Japan

5 Waseda University, Faculty of Human Sciences, Saitama, Japan

Introduction: Depression is common among patients with heart failure (HF). Depressive symptoms have a profound effect on morbidity, mortality, and health-related quality of life among patients with HF. Although physical functioning, perceptions, and social support are important in predicting depressive symptoms among patients with HF, the relative importance of each of these factors remains unclear. The purpose of this study was to determine the associations between depressive symptoms and heart failure physical functions, social support, self-efficacy, and cognitive control.

Methods: Of all 201 inpatients with HF, 165 (82.1%) participated in our survey. The subjects answered the questionnaire that comprised the following measures: demographics, clinical factors, Patient Health Questionnaire-9 (PHQ-9), the self-efficacy scale for health behaviour (subscales: active coping behaviour with disease and controllability for health), and cognitive control scale.

Results: Of the total patient group, the mean age was 61.84 years (range: 34–83 years), and 39.4% of the patients were older than 70 years of age. Overall, 61.9% were male and 38.1% were female. A total of 22.1% ware classified as having depressive symptoms (PHQ-9 > 10). Further, correlation analyses indicated that depressive symptoms were significantly associated with living alone, NYHA class, cognitive control, and controllability for health score. Including these variables in one regression equation predicting depressive symptoms indicated that controllability for health was the only variable to predict depressive symptoms independent of other significant bivariate predictors.

Conclusions: Even if there are physical limitations, controllability for health reduces depressive symptoms. This cognitive factor may play a salient role in the treatment of depression in patients with HF.

Keywords: Depression, Cardiovascular disease, Self-efficacy, Cognitive factors

CORRESPONDING AUTHOR: Shiho Matsuoka, Tokyo Women’s Medical University;



Hotoleanu C., Dumitrascu DL.

1 University of Medicine and Pharmacy Iuliu Hatieganu, Medicala II Department, Cluj-Napoca, Romania

Background: it is well known that low to moderate alcohol consumption can protect against coronary artery disease, whereas heavy drinking is associated with increased cardiovascular risk; these effects were less studied in deep venous thrombosis (DVT); several data show the decrease of the DVT risk in case of low to moderate consumption, whereas other studies failed to reveal any effect.

Aim and Method: We aimed to study the role of light to moderate, respective heavy alcohol consumption, in idiopathic DVT. We enrolled, after informed consent, 34 patients with idiopathic DVT and 34 sex and age matched controls (mean age: 61.63, respective 60.44 years old). Light to moderate alcohol consumption was defined as less than 15 drinks (alcohol units)/week or less than 5 drinks/day (4 in women); heavy drinking was defined by at least 15 drinks/week or 5/day (4 in women).

Results: we identified light to moderate drinking in 21 DVT cases (61.76%) and in 24 controls (70.58%), p = 0. 608, OR = 0.67, [95% CI, 0.2448 –1.8504], whereas heavy drinking was found in 13 DVT cases(38.24%), respective 9 controls (26.47%), p = 0.437, OR = 1.71, [95% CI, 0.6145- 4.8122], showing no significant associations with DVT (no protective role, neither risk factor). One control denied any form of alcohol consumption. Although women presented preponderantly light to moderate consumption, 14 in DVT group (66.6%) and 18 in controls, (75%), there were no significant differences according to the sex in the pattern of drinking, between DVT group and controls, p = 0.742.

Conclusions: there are no significant associations between alcohol consumption and the DVT risk. In our study, light to moderate consumption has not proved a protective role for DVT.

Keywords: alcohol, cardiovascular disease

CORRESPONDING AUTHOR: Hotoleanu Cristina, UMF Iuliu Hatieganu, Cluj-napoca;



Fazio E.1, McRae C. 2

1 University of Denver, Counseling Psychology, Denver, United States

2 University of Denver, Counseling Psychology, Denver, USA

Background: Parkinson’s disease (PD) is a chronic, progressive condition that affects the physical, emotional, and social functioning of individuals. Freed et al. (2001) conducted a double-blind sham surgery-controlled trial to investigate the effectiveness of neural tissue implantation for the treatment of advanced PD. The authors of that study examined the effects of the surgery across the dimensions of physical and neurological functioning following the one year period of the double-blind. A concurrent quality of life (QoL) study was conducted to determine if there were differences in QoL when comparing those who received the neural tissue implantation with those who received the sham surgery (McRae et al., 2004). Authors also examined outcomes based on perceived treatment, or type of surgery patients thought they received. Results indicated there were few differences based on actual treatment, but numerous differences and changes over time based on perceived treatment. While there is little research on the effectiveness of neural tissue implantation as a treatment for PD, there is even less literature on longitudinal effects of this treatment. This study examined longitudinal QoL among participants who received the neural implant surgery beginning in 1995.

Methods: Participants included 11 of the 29 people who were in the original QoL study. The remaining 18 participants had either died or could not be located. Participants completed questionnaires that assessed the Physical, Emotional and Social dimensions of QoL. Regression analyses were used to determine whether any baseline variables predicted current Physical functioning.

Results: Results indicated that perceived Social support at baseline significantly predicted participants’ Physical functioning over ten years later (p < .05). Level of Physical functioning was consistent across time; i.e., participants who reported better Physical functioning at the most recent assessment also had better Physical functioning at baseline when compared to the total original QoL sample (p < .05).

Conclusions: Results indicated that greater perceived Social support before surgery was related to better Physical functioning 10 years later in this very unique sample of PD patients.

Keywords: Social support, Parkinson's disease, quality of life

CORRESPONDING AUTHOR: McRae Cynthia, University of Denver, Denver, CO;



Chiang K.1, McRae C. 2

1 Brown University, Biological and Health Psychology, Providence, USA

2 University of Denver, Counseling Psychology, Denver, USA

Background: Parkinson’s disease (PD) is a chronic, progressive neurodegenerative disorder that primarily affects movement, but also affects emotional and social functioning. Evidence suggests that quality of life (QOL) in PD improves after Deep Brain Stimulation (DBS) neurosurgery, one of the interventions currently available to treat PD. Because most DBS studies have assessed only short-term QOL outcomes (3 to 36 months), little is known about its long-term effects. This study assessed QOL among DBS recipients approximately 8 years post-surgically.

Methods: The original sample of 28 individuals responded to assessments at baseline, 12, 24, and 36 months; 16 (6 females and 10 males) participated in the long-term follow-up study. Average age was 63.5 years (SD = 8.1); average disease duration was 20.6 years (SD = 5.7). All underwent bilateral subthalamic nucleus (STN) DBS over a one and a half year period. QOL was evaluated with the Parkinson’s Disease Questionnaire-39 (PDQ-39), consisting of 8 subscales measuring differing QOL aspects. Linear regression analyses were used to determine which demographic and disease related variables at baseline predicted QOL at long-term follow-up (M = 7.6 years after surgery; SD = 1.3).

Results: Regression analyses indicated that longer disease duration predicted less Stigma (β = -.367, t = -2.844, p ≤ .007), better Emotional Well-Being (β = -.392, t = -3.045, p ≤ .005) and greater perceived Social Support (β = -.780, t = -2.352, p ≤ .03). Age (being older) was also a predictor of less Stigma (β = -.468, t = -5.023, p ≤ .001). Time since surgery predicted greater Cognitive Impairment (β = .211, t = 2.119, p ≤ .04).

Conclusions: It appears that age and having experienced PD for a longer period of time are related to less stigma in regard to PD, which typically becomes a very obvious condition over time. Longer disease duration also appears to be associated with better emotional functioning and more social support among patients who have received DBS. Additional research with a larger sample is needed to investigate the long-term trajectory of improvement and decline in QOL and to learn more about the effect of DBS on PD patients and how to help patients cope with changes over time.

Keywords: Quality of Life, Parkinson's Disease, Deep Brain Stimulation

CORRESPONDING AUTHOR: McRae Cynthia, University of Denver, Denver, CO;



Bigatti S.1, Steiner J.2, Merwin R.3, McCracken L.4

1 Indiana University Purdue University Indianapolis, Department of Public Health, Indianapolis, USA

2 Indiana University Purdue University Indianapolis, Department of Psychology, Indianapolis, USA

3 Duke University Medical Center, Psychiatry and Behavioral Sciences, Durham, USA

4 Kings College London University, Health Psychology, London, United Kingdom

Fibromyalgia (FM) is a chronic pain condition that is often resistant to treatment. Patients with this condition often struggle for control over their pain in ways that create more disability and distress and not less. Acceptance and Commitment Therapy (ACT) is a treatment that addresses maladaptive avoidance and control and helps patients instead to channel their energy into developing a rich life in a way that allows the pain to be a part of it. The present pilot study tested whether an 8-week ACT intervention could improve physical, social, and emotional functioning of FM patients from baseline to post treatment and 12 week follow-up. To date, 24 female participants (mean age = 46.19, SD = 12.9) have been randomly assigned to an ACT or attention control group, and the final six have been recruited but not yet randomized. Method: Participants attended individual treatment once weekly for eight weeks, receiving either ACT or an education/attention control. Assessments of physical (Fibromyalgia Impact Questionnaire, PROMIS Physical Functioning Scale, Pain Visual Analog Scale, Brief Fatigue Inventory), social (PROMIS Satisfaction with Social Roles), and emotional functioning (PHQ-9) were completed prior to the intervention, immediately following treatment, and 12 weeks after completion. Results: Paired sample comparisons of ACT group revealed statistically significant improvements from baseline to post intervention, which were maintained at 12 week follow-up for overall fibromyalgia impact (t = 3.83, p = .003), depression (t = 2.60, p = 0.03), and social functioning (t = -4.99, p =0.001). Statistically significant improvements from baseline to post intervention were also found for pain (t = 2.25, p =0.048) and fatigue (t = 3.86, p = 0.003) that were not maintained at final assessment. There were no significant improvements at any time point for physical functioning. Group comparisons will be made once all data collection has ended, and presented at the conference. Conclusions: ACT shows promise as an effective intervention to reduce FM symptoms and improve functioning.

Keywords: Pain Fatigue Functioning Depression

CORRESPONDING AUTHOR: Bigatti Silvia, IUPUI, Indianapolis;



Bieler T.1, Magnusson P.1, Kjær M.2, Beyer N.1

1 Bispebjerg Hospital, Musculoskeletal Rehabilitation research Unit, Department Physical Therapy, Copenhagen, Denmark

2 Bispebjerg Hospital, Institute of Sports Medicine – Copenhagen, Copenhagen, Denmark

Background: In persons with unilateral osteoarthritis of the hip (HOA) the affected leg is weaker compared with the non-affected. HOA is a leading cause of pain, disability, poor self-reported health and limitation in social activities, and self-efficacy beliefs appear to be important in understanding the functional decline that occurs.

Objectives: The purpose of this study was to investigate the relationships between muscle strength and power, self-efficacy beliefs and physical function in a subset of patients in a randomized controlled trial investigating the short and long term effects of home based exercise, strength training and Nordic Walking in patients with HOA.

Method: Elderly persons with primary unilateral symptomatic HOA were included. Outcome measures were maximal isometric Quadriceps torque/body weight (Quadriceps torque/BW), leg extension muscle power/body weight (muscle power/BW), objectively measured physical function: timed stair climbing (Stair), 30s sit-to-stand (STS), and 6-minute walk test (6MW), self-reported physical function (WOMAC) and self-efficacy beliefs in conjunction with stair climbing.

Results: The participants (n = 30) were 70 ± 6 years (mean ± SD). The relationship between muscle strength/power and physical function was stronger in the affected leg compared with the non-affected. In the affected leg the relationship between muscle power/BW and physical function (Stair: rs = -0.788; STS: rs = 0.797; 6MV: rs = 0.823, p = 0.0001) was stronger compared to Quadriceps torque/BW (Stair: rs = -0.446; STS: r = 0.613; 6MV: r = 0.705, p < 0.013-0.0001). Self-reported physical function was significantly correlated with muscle power/BW (rs = 0.415, p = 0.02) but not with Quadriceps torque/BW (rs = 0.110, p = 0.564). The relationship between self-efficacy beliefs and muscle power/BW (rs = 0.620, p = 0.0001) was stronger compared to Quadriceps torque/BW (rs = 0.440, p = 0.02)). Self-efficacy beliefs were significant correlated with both physical function (Stair: rs = -0.540, STS: rs = 0.576, 6MV: rs = 0.606 (p < 0.001-0.0001)) and self-reported physical function (rs = 0.730, p = 0.0001).

Conclusion: In persons with HOA the relationships between muscle power/BW and objectively measured physical function, self-reported physical function and self-efficacy beliefs were stronger compared to Quadriceps torque/BW. Further, self-efficacy beliefs are related to both self-reported and objectively measured physical function.

Keywords: Chronic Disease, Musculoskeletal disorders, Disability

CORRESPONDING AUTHOR: Bieler Theresa, Bispebjerg Hospital;



Dodson S.1, Batterham R.1, Ginifer Y.1, Buchbinder R.2, McCabe M.3, Bentley S.4, Cavill S.5, Osborne R.1

1 Deakin University, Public Health Innovation Unit, Melbourne, Australia

2 Monash University, Department of Epidemiology and Preventive Medicine, Melbourne, Australia

3 Deakin University, Department of Behavioural Sciences, Melbourne, Australia

4 Deakin University, School of Medicine, Melbourne, Australia

5 Southern Health, OA Hip & Knee Service, Melbourne, Australia

Musculoskeletal conditions are a common cause of severe, long-term pain and disability. The burden of chronic disease can potentially be reduced through self-management programs, and the internet is increasingly being used as a viable delivery option. Stepping Up, a web-based self-management intervention based on best practice in adult education and CBT was developed to enable people to improve their physical and psychosocial health. A unique feature of the program was that each participant received a tailored program of between 5 and 15 modules based upon a collaborative discussion of needs and circumstances. This study aimed to test the intervention in a real world setting.

Method: Participants were 40 adults (33% men) with a range of musculoskeletal conditions. The mean age was 48 (range 22 to 85 years). Many reported a mental health diagnosis (33%), and 49% reported multiple chronic conditions. Participants took part in a low intensity program; initial phone interview, a personalised set of modules to work through independently over 4-10 weeks, weekly email support and phone review. Outcomes included pre-post questionnaires, and clinician and self-reported improvements in symptoms and behaviour.

Results: Significant improvements were observed in the Emotional Distress, Skill and Technique Acquisition and Social Integration and Support scales of the Health Education Impact Questionnaire (effect size: -0.55; 0.77; 0.43 respectively, P < 0.05 for all). Improvement in Health-related Quality of Life was very large: 0.11 utility units (P < 0.01 minimally important difference >0.06 units). Over 50% of participants gave comments of high praise about the program at follow-up, and over 90% listed specific changes in behaviour that they directly attributed to the program. The most frequent response to questioning about helpful aspects of the program was that it was the program as a whole and the way it fitted together. Conclusion: These findings indicate that the Stepping Up web-based self-management support intervention can achieve significant improvements in emotional distress, behaviours, skills, and social support. Acceptability is also very high. Future work will expand the program to other conditions and build in web-based clinician training.

Keywords: Chronic Disease, Depression, Anxiety, e-Health, Health behavior change, Musculoskeletal disorders, Self Management, Web-based

CORRESPONDING AUTHOR: Dodson Sarity, Deakin University, Melbourne;



Shakib M., Hashamian K.

Alzahra University, Department of Psychology, Tehran, Iran

Objective: The purpose of this study was to compare the efficacy of cognitive–behavioural therapy focused on graded exposure versus focused on attention management on reducing pain-related fear, pain intensity, depression and increasing the pain acceptance in Iranian chronic back pain patients.

Method: The research was employed case study with multiple baseline design with control group. 15 Iranian chronic back pain patients were selected among patients had referred to Tehran Clinics and were randomly assigned to 2 experimental and 1 control groups. Then CBT focused on exposure was applied for experimental group 1 and CBT focused on attention management was applied for experimental group 2, for 9 sessions and control group assigned into waiting–list for treatment. Pain intensity were measured as daily assessments during baseline and treatment phase and depression, fear of movement and pain acceptance were assessed weekly.

Result: The results of visual and statistical analysis indicated that there were significant differences in all variables between experimental groups 1, 2 with control group (P < 0.01) and there were significant differences in fear of movement and pain acceptance between experimental groups 1, 2 and these results remained at the 3 month follow-up period.

Conclusion: this research suggested that both treatment conditions had equal significant effects on reduction in pain intensity, depression, although CBT focused on exposure had most effectiveness on reduction in fear of movement and increase in pain acceptance.

Keywords: chronic back pain, CBT focused on graded exposure, CBT focused on attention management

CORRESPONDING AUTHOR: Shakib Minoo, Alzahra University,Ttehran;


Ruckmann J.1, Bodden M.2, Dodel R.3, Rief W.1

1 University of Marburg, Department of Clinical Psychology and Psychotherapy, Marburg, Germany

2 University of Bonn, Department of Clinical Psychology and Psychotherapy, Bonn, Germany

3 University of Marburg, Department of Neurology, Marburg, Germany

Showing empathy and understanding how others feel, think and behave, is crucial for social functioning. A close relationship between empathy, social cognition and psychological disorders is assumed. Pain empathy is as an example for empathy in general. It is modulated by different factors. These are situational variables, as well as target features and observer characteristics. Several studies have shown that empathy is also related to group membership and the social relation between the person showing empathy and the person receiving empathy (e.g. ethnicity). The current study investigates the influence of experimentally induced group membership on empathy for pain.

Thirty-two right-handed, healthy volunteers participated in an fMRI-experiment. Group membership was manipulated by a minimal group paradigm. To assess neural processes associated with pain empathy, we assessed fMRI reactions during the presentation of pictures showing hands and feet in painful and non-painful everyday situations. These pictures were experimentally assigned to either ingroup or outgroup members. Participants were instructed to empathize with persons shown on the pictures. They also had to rate the intensity of the pain the person on the photograph may have, using a visual analog scale.

There was no ingroup bias in pain intensity ratings. Although, participants watching ingroup members experiencing pain showed higher neural activation in regions of the affective pain matrix (ACC, anterior insular cortex). Higher activation in these areas indicates a stronger feeling of empathy. In neutral situations, these differences between brain activation patterns between ingroup and outgroup members were not found. Additionally, a positive correlation between self-reported empathic concern and pain-related neural activation was confirmed.

These findings confirm neural correlates of differences in pain empathy for members of ingroups and outgroups. Self-reported empathic concern and neural activation are significantly related. Our findings underline the relevance of pain empathy for interactional processes with patients suffering from pain and somatization.

Keywords: fMRI, pain

CORRESPONDING AUTHOR: Ruckmann Judith, University of Marburg, Marburg;



Riecke J., Holzapfel S., Rief W., Glombiewski JA.

University of Marburg, Department of Clinical Psychology and Psychotherapy, Marburg, Germany

Chronic low back pain (CLBP) is one of the most common health problems in Western societies. The focus of new CLBP treatments lies on tailored interventions for specific subgroups. Pain patients with substantial pain-related fear represent a subgroup, and exposure in vivo could be the indicated treatment. Purpose: We plan to include 120 patients in an RCT comparing exposure in vivo to standard CBT for fear avoidant CLBPP in an outpatient setting in Germany. The purpose of the present study is to develop a protocol to assess the feasibility of exposure in vivo (ETABP) in comparison to standard CBT. Intervention: We modified a protocol developed by Vlaeyen et al. (2007) for a German outpatient setting (psychotherapy clinic). Additionally, a comparable CBT protocol was designed. Both treatments consist of 15 weekly individual sessions. ETABP mainly comprises 5 (short form) to 10 (long form) exposures to movements that have been avoided due to fear of (re)injury. The treatments were enriched with behavioral experiments. The CBT arm includes three modules: graded activity, relaxation techniques, and cognitive interventions.

Method: 21 CLBPP were randomly assigned to ETABP or to standard CBT. The inclusion criteria were CLBP and an increased level of fear avoidance. Outcome measures were recorded at baseline, week 10, week 15 and 6 months. The primary outcomes were disability (PDI) and pain severity (NRS). As secondary outcomes fear avoidance, catastrophising and physical activity were assessed. After the intervention we investigated the global perceived effect and satisfaction with ETABP or CBT.

Results: The treatment was well accepted and satisfaction with the intervention was very high with higher ratings for CBT. In the ETABP condition more dropouts (n = 5) were observed. Short term data showed differences in physical disability with a tendency toward more reduction for ETABP than CBT.

Conclusion: The proposed ETABP protocol is an effective and accepted treatment for avoidant CLBPP in an outpatient setting. The advantages in comparison to standard CBT are a more specific approach regarding fear avoidance and the promising effects on reducing disability via pain related fear.

Keywords: Musculoskeletal disorders, randomized controlled trial

CORRESPONDING AUTHOR: Riecke Jenny, Philipps University Marburg;



Kröner-Herwig B.

Univerity of Göttingen, Clinical Psychology and Psychotherapy, Göttingen, Germany

The European guideline on chronic non-specific back pain gave a quite sobering account on the medical treatment options for this disorder, recommending only a few options as helpful and efficacious.

Since CBP is one of the most prevalent and t costly disorders in western countries, disabling individuals in their performance of daily activities and reducing quality of life, the question,

We analyzed the status of evidence of psychological and interdisciplinary interventions on the basis of meta-analyses of RCT studies and recently published original research studies.

Within a behavioral medicine perspective various treatment approaches have been examined, including the well- known self-regulations strategies like relaxation and biofeedback, the early operant techniques, the newly developed confrontation treatment based on treatment of phobias, multimodal cognitive- behavioral treatments most of the and last but not least Acceptance and Commitment Therapy including interventions from the Buddhist meditation practice. As special format we considered multidisciplinary therapy where in general psychological interventions are integrated into a multimodal systematic approach integrating different disciplines.

On the basis of a large magnitude of studies we come to the conclusion that psychological treatments have proven their efficacy and can be recommended on level I according to EBM, but we also found out that the size of efficacy is modest showing mostly small to moderate effect sizes. Not only on pain itself but also on quality of life, disability and return to work positive outcomes have been observed. Reliable differences in the efficacy of different psychological treatments have not yet been statistically maintained. The modest success has been somewhat disappointing, since earlier studies suggested a general superiority of psychological and multidisciplinary treatment strategies.

Some authors have suggested that the limits of efficacy of psychological intervention have not yet been established, as in many studies the quality of treatment has probably been low regarding the amount of intervention offered to highly chronic patients, the adaptation of the treatment to the patient’s individual syndrome and the competence of the therapists.

Keywords: back pain, psychological treatment

CORRESPONDING AUTHOR: Kröner-Herwig Birgit, Göttingen,University Göttingen;



Kröner-Herwig B., Gaßmann J.

University of Göttingen, Clinical Psychology, Göttingen, Germany

The cross–sectional study on a randomly drawn population sample of children and adolescents (n = 3399; age 9-15 yrs.) aimed at the assessment of patterns of associations between psychosocial variables and particular headache types, i.e. migraine (MIG), tension-type headache (TTH) and a headache category denoted as unclassifiable headache. A no-headache group served as a control. Data on headache and psychological trait variables (e.g. internalising symptoms), behavioural factors (e.g. physical activities) and socio-environmental factors (e.g. life events) were gathered by questionnaire. Logistic regression analyses were conducted with headache types as dependent variables. The pattern of correlations was largely congruent between the headache disorders. Associations were closest regarding maladaptive psychological traits (in particular internalising symptoms with an OR >4 regarding MIG) when compared to socio-environmental factors and particularly the behavioural factor. Unfavourable psychological traits and socio-environmental strains demonstrated distinctly stronger associations to MIG than to TTH. Psychological traits explained more variance in the occurrence of paediatric headache disorders than parental headache. Sex specific analyses showed similarities as well as differences regarding the correlations, while in general the associations were stronger in girls. A common path model as forwarded by Kato et al (2009) may explain the parallelism in bio-psychosocial vulnerability.

Keywords: Headache, children

CORRESPONDING AUTHOR: Kröner-Herwig Birgit, Göttingen,University Göttingen;



Holzapfel S., Riecke J., Rief W., Glombiewski J.

University of Marburg, Clinical Psychology and Psychotherapy, Marburg, Germany

Theoretical Background: Substantial evidence indicates that women report more fear than men (McLean et al., 2009). But, data from different countries and different pain diagnoses show that men score significantly higher on the Tampa Scale for Kinesiophobia (TSK), a self-report instrument measuring fear-avoidance beliefs in chronic pain patients (Roelofs et al., 2011). In the present study, we investigated gender specific reactions to feared movements.

Methods: 86 chronic low back pain patients (CLBP) and 41 healthy controls (HC) (55% female) were administered the Photograph Series of Daily Activities (PHODA), the TSK, the Pain Anxiety Symptoms Scale (PASS-20) and the Fear Avoidance Beliefs Questionnaire (FABQ). Afterwards they were asked to perform movements previously rated as most fearful (e.g. bending forward, lifting a water box) and to rate their state fear on a Visual Analog Scale (VAS) and a Numeric Rating Scale (NRS).

Results: Male CLBP patients scored higher on the TSK than female patients (F = 5,571; p < .05), but reported less fear on VAS (F = 3,047; p < .10) and NRS (F = 7,522; p < .05) scores. Gender differences on item-level showed significantly higher scores for males for TSK-Items 2, 7 and 17 (p < .05)(e.g. „Pain always means I have injured my body”, „If I were to try to overcome it, my pain would increase“). No gender differences were observed on other fear-avoidance measures like PASS (F = 0,071; p > .05) or FABQ (F = 0,810; p > .05). There were no gender differences in healthy controls in TSK-scores (F = 0,443; p > .05), VAS (F = 1,191; p > .05) and NRS (F = 0,103; p > .05) ratings.

Discussion: The results show that gender differences have to be taken into account when assessing and treating fear-avoidance in CLBP patients. Item analyses imply that men’s pain concepts might be more biologically oriented. Thus, therapeutic interventions should put special emphasis on changing male patients´ pain concepts towards a biopsychosocial perspective. During exposure to feared movements male patients might underestimate their actual fear.

Keywords: Pain, Gender

CORRESPONDING AUTHOR: Holzapfel Sebastian, Philipps-University, Marburg;



Golm D., Barke A., Tonassi T., Dittko N., Kröner-Herwig B.

University of Göttingen, Clinical Psychology and Psychotherapy, Göttingen, Germany

Background: The term “medically unexplained symptoms” refers to somatic symptoms, which are not caused by an organic illness or cannot be fully explained by one. Up to 50% of patients in primary care have unspecific somatic complaints. Among commonly reported symptoms are headache, palpitations and bloatedness. Up to 82% of patients fulfill partially or at least for a short time the diagnostic criteria of a somatoform disorder. A recently conducted study on patients with somatoform disorders suggested an etiological mechanism whereby deficits in emotional awareness result in patients misrepresenting emotional states as bodily symptoms. They also found that persons with somatoform disorders showed impaired performance in a theory of mind task. We hypothesized that if there was an association between emotional awareness, theory of mind and bodily symptoms, those associations should also be found in a sample of participants reporting a high level of medically unexplained symptoms.

Method: We examined 51 participants who were characterized as high (n = 28; mean age: 50.0; SD: 10.7) and low (n = 23; mean age: 42.7; SD: 12.0) symptom reporters by means of the Beschwerdeliste (BL), a questionnaire to assess unspecific bodily symptoms. The participants filled in the Emotionale Kompetenzfragebogen (EKF), a questionnaire which assesses – among other things –awareness of one’s own emotions and of the emotions of other persons. The participants also performed two theory of mind tasks: the Faux-pas Test and a computer-based paradigm to identify others’ emotions and intentions.

Results: High symptom reporters showed lower scores in the emotional awareness subscale of the EKF, but performed as well in the two theory of mind tasks as the low symptom reporters.

Conclusions: High rate of bodily symptoms seems to be associated with lower emotional awareness even in a non-clinical sample. However, in this population we failed to find any impairment in the theory of mind.

Keywords: Emotions, Health

CORRESPONDING AUTHOR: Golm Dennis, University of Göttingen;



Klaus K.1, Rief W.1, Brähler E.2, Martin A.3, Glaesmer H.2, Mewes R.1

1 University of Marburg, Clinical Psychology and Psychotherapy, Marburg, Germany

2 University of Leipzig, Medical Psychology and Sociology, Leipzig, Germany

3 University of Erlangen-Nürnberg, Department of Psychosomatic Medicine and Psychotherapy, Erlangen, Germany

Background: Single somatoform symptoms can be very impairing and might legitimate a DSM-IV diagnosis, e.g. pain disorder. Studies investigating the prevalence of somatoform complaints in the general population principally implement questionnaires. The new proposed “Complex Somatic Symptom Disorder” (CSSD) will not make a distinction between symptoms’ medical or non-medical etiology. It is unknown if current questionnaires for the assessment of somatoform disorders (i.e., the PHQ-15 which is recommended by the DSM-V work group) identify individuals suffering from CSSD.

Purpose: To evaluate the power of current questionnaires for identifying single impairing somatoform symptoms and also CSSD in comparison with a structured interview (as gold standard).

Method: Different methods and instruments were used to ascertain fifteen impairing somatic complaints in the German general population (N = 253). A structured telephone interview was conducted and participants subsequently completed two questionnaires: the “Patient Health Questionnaire” (PHQ-15, assessing usually medically unexplained complaints in the prior 4 weeks) and the “Screening for Somatoform Disorders” (SOMS-2, assessing impairing somatoform symptoms within the past 2 years).

Results: Agreement of interview-based and questionnaire-based data ranged from slight to moderate – both for PHQ-15 and SOMS-2. Maximum conformity with the interview was revealed for pain (PHQ-15: κ ≤ .39, SOMS-2: κ ≤ .27) and sexual symptoms (PHQ-15: κ = .51, SOMS-2: κ = .25). CSSD (Interview: n = 48) was especially included in the upper severity categories of the PHQ-15 (<5: 7%, 5- < 10: 25%, 10- < 15: 59%, ≥15: 73%). SOMS-2 discriminated well between subjects with and without CSSD (somatization index DSM-IV: M = 6.2, SD = 4.2 vs. M = 3.0, SD = 3.0, p < .001).

Conclusion: Depending on the assessment the collected data differed widely. Epidemiological studies should decide between valid interviews conducted by experts or economic self-rating questionnaires. In fact, studies based on self-report might have to revise prevalence rates. If CSSD will be established in DSM-V most diagnostic instruments must be validated and adapted accordingly.

Keywords: Assessment, Methodology

CORRESPONDING AUTHOR: Klaus Kristina, University of Marburg, Marburg;



Fischer S.1, Ehlert U.2, Nater U.1

1 University of Marburg, Clinical Biopsychology, Marburg, Germany

2 University of Zurich, Clinical Psychology and Psychotherapy, Zurich, Switzerland

Background and Aim: Functional somatic syndromes (FSS) are defined by clusters of bodily symptoms not explained by a medical condition. There is evidence on overlap between FSS. The validity of these nosological entities has thus been questioned. However, most studies have been conducted in patient samples, possibly being subject to referral bias. Also, in population-based studies, FSS diagnoses are usually made without controlling for differential diagnoses. Finally, no study has so far assessed 17 FSS simultaneously. The objective of our study was to estimate overlap between multiple FSS in a population-based sample.

Methods: A total of 3’054 students were recruited for participation in an online survey. To assess prevalence rates of 17 FSS (e.g., chronic fatigue syndrome, fibromyalgia), we developed and administered a questionnaire based on international research diagnostic criteria. Fulfillment of criteria led to diagnoses of ‘self-reported FSS’. Participants were labeled as having a ‘medically unexplained FSS’ if they reported that no abnormalities were detected after at least one healthcare visit.

Results: Among the 3’054 participants (mean age = 24.6, SD = 5.6), 2’242 were women (73.4%). The number of ‘self-reported FSS’ranged from one to eight, with 631 (62.2%) reporting one, 239 (23.6%) two, 92 (9.1%) three, 35 (3.5%) four, 13 (1.3%) five, three persons (0.3%) six, and one person reporting eight FSS occurring concomitantly. The range of ‘medically unexplained FSS’ was one to four, with 227 (78.6%) reporting one, 49 (17.0%) two, 12 (4.2%) three and one person reporting four FSS concomitantly.

Conclusion: This is the first study investigating a vast number of FSS. Overlap was lower compared to studies in clinical settings. Our finding of only few people suffering from multiple FSS is in line with population-based studies. However, a significant drop in overlap frequency occurred when taking into account differential diagnoses. Future research efforts on overlap between FSS should take into account referral bias when interpreting study results, and rigorous approaches in excluding medical conditions should be adopted.

Keywords: Chronic fatigue syndrome, Irritable bowel syndrome, Co-morbidities

CORRESPONDING AUTHOR: Fischer Susanne, Philipps University Marburg;



Mewes R., Rief W.

University of Marburg, Departement of Clinical Psychology, Marburg, Germany

Purpose: Many studies confirmed the association between somatoform disorders and increased health care utilization. However, most of these studies used retrospective assessments of health care utilization and were conducted in selective samples of primary or secondary care attendees. Therefore, the predictive validity of the association between somatoform disorders and health care utilization is still questionable and will be investigated in the present study.

Methods: A sample of persons with an at least mono-symptomatic somatoform disorder derived from the German general population was compared to a sample of persons without such a disorder (controls) in terms of stability of health care utilization (HCU) and predictors for HCU at follow-up. Both samples were interviewed at baseline and one year later using a structured approach asking for somatic symptoms, health care utilization in the last 12 months, and psychological factors. The baseline sample consisted of 321 persons; 1-year follow-up data were received from 244 persons (76% of baseline sample, 111 with an at least mono-symptomatic somatoform disorder).

Results: At baseline and follow-up, persons with an at least mono-symptomatic somatoform disorder showed almost twice as many doctor visits as the controls (p ≤ .001). HCU at both time points was highly correlated: r = .52 for the controls and r = .73 for the persons with a somatoform disorder (both p ≤ .001). In regression analyses using HCU at follow-up as the outcome variable and HCU at baseline, age, and gender as predictors, only HCU at baseline was a significant predictor in the somatoform disorder group (r² = .54, p ≤ .001) and HCU and higher age at baseline were predictors in the control group (r² = .32, p ≤ .001). The inclusions of diagnostically relevant psychological factors as additional predictors (i.e. health anxiety, excessive time and energy devoted to symptoms or health concerns, concerns about medical seriousness) lead to the same results.

Conclusions: Health care utilization is a very stable behaviour, especially in persons with a somatoform disorder.

Keywords: illness behaviour, longitudinal research

CORRESPONDING AUTHOR: Mewes Ricarda, University of Marburg;



Witthöft M.1, Freitag I.1, Nußbaum C.1, Bailer J.2, Jasper F.1, Rubin GJ.3

1 University of Mainz, Department of Clinical Psychology and Psychotherapy, Mainz, Germany

2 Central Institute of Mental Health, Department of Clinical Psychology, Mannheim, Germany

3 King's College London, Psychological Medicine, London, United Kingdom

Worries about potential health threatening effects of modern life (e.g. electric devices and pollution) represent a growing phenomenon in Western countries. Although research on Modern Health Worries (MHW) has increased in recent years, knowledge about the causes of MHW is still sparse. In two experimental studies, we investigated whether typical television news reports affect MHW. In Study 1, 130 college students were randomly assigned to a 10 minutes film on either a patient suffering from idiopathic environmental intolerance (IEI) or a control film about cystic fibrosis. Although a main effect of the IEI film on MHW was not detectable, participants high on the personality trait of absorption revealed increased MHW after watching the IEI film. Thus, absorption proved to be a significant moderator in the first study. In Study 2, 83 college students were randomly assigned to either a film on the dangers of electromagnetic fields or a control condition (a film about mobile phone theft). Worries about radiation (but not other MHW) were found to be elevated after watching the film on the dangers of electromagnetic fields compared to the control film. Absorption did not serve as a moderator of this effect. The results of both studies reveal a significant and specific influence of short sensational mass media reports on MHW. The influence of potential moderators such as absorption remains to be clarified in future studies.

Keywords: Modern Health Worries

CORRESPONDING AUTHOR: Witthöft Michael, University of Mainz, Mainz;



Markert C.1, Fischer S.1, Ehlert U.2, Nater U.1

1 University of Marburg, Clinical Biopsychology, Marburg, Germany

2 University of Zurich, Clinical Psychology and Psychotherapy, Zurich, Switzerland

Background and Aim: Functional gastrointestinal disorders (FGID) are defined by a constellation of gastrointestinal symptoms for which (after medical examination) no structural pathology can be identified. It has previously been suggested that stress may be a risk factor for FGID. The objective of our study was to examine the role of stress in FGID.

Methods: A total of 3054 students in Switzerland were examined via a survey on physical and mental health. Subjects meeting the symptoms required for a Rome III diagnosis of an FGID were asked about healthcare visits and differential diagnoses. Sociodemographic data and information on psychiatric comorbidity was collected (Patient Health Questionnaire), and facets of stress were assessed by administering the BFI-10 (emotional instability), the CTQ-SF (childhood trauma), the LTE (life events), the SSCS (chronic stress), and the PSRS (perceived stress reactivity).

Results: Among the examined subjects (mean age 24.6, SD = 5.6, 2242 women), 3.3% fulfilled criteria for at least one FGID. Of those, 67.8% had consulted a healthcare practitioner. Prevalence rates were 57 (1.9%) for functional dyspepsia, 39 (1.3%) for irritable bowel syndrome, 14 (0.5%) for functional chest pain of presumed esophageal origin, and 2 (0.1%) for globus. Compared with subjects with no FGID, subjects with at least one FGID had a higher probability of displaying comorbid disorders (major depressive disorder: p < .001, panic disorder: p < .05, or any other anxiety disorder: p < .001). When controlling for comorbidity, stress reactivity related to social conflicts was the only significant predictor of FGID (OR = 2.79; p < .01). Emotional abuse (β = .20), critical life events (β = .23), and chronic stress (β = .44) contributed significantly to explaining 42% of total variance of overall number of somatic symptoms in FGID.

Conclusion: FGID prevalence rates and psychiatric co-morbidity were similar to previous studies (e.g. Suarez et al., 2010). Various forms of stress were found to be associated with FGID. Our results point to a pivotal role of stress in the development and maintenance of FGID. Healthcare providers are required to adequately address stress-related issues when dealing with FGID.

Keywords: web-based, Stress, Irritable Bowel Syndrome, Quality of Life

CORRESPONDING AUTHOR: Markert Charlotte, University of Marburg;



Tayama J.1, Nakaya N.2, Hamaguchi T.3, Tomiie T.4, Shinozaki M.5, Saigo T.1, Hayashida M.1, Fukudo S.5

1 Nagasaki University, Center for Health & Community Medicine, Nagasaki, Japan

2 Kamakura Women’s University, Department of Nutrition & Dietetics, Kanagawa, Japan

3 Occupational Therapy Saitama Prefectural University, Occupational Therapy, Saitama, Japan

4 Health Sciences University of Hokkaido, School of Psychological Science, Sapporo, Japan

5 Tohoku University, Graduate School of Medicine, Department of Behavioral Medicine, Sendai, Japan

Background: Patients with IBS (irritable bowel syndrome) may exhibit several pathophysiological conditions: dysmotility of the lower gastrointestinal tract, visceral hypersensitivity, and psychological abnormalities. Typical psychiatric symptoms experienced by IBS patients include severe feelings of depression and anxiety. Depression reduces the threshold for bowel sensitivity. One risk factor for depression is neurotic personality type. This study investigated two hypotheses: 1) Persons with IBS demonstrate greater neuroticism than those without IBS, and 2) degrees of association between the severity of IBS and neuroticism differ, depending on IBS subtype.

Methods: Study participants consisted of 557 university students, who completed personality assessments (Temperament and Character Inventory [TCI] and the Eysenck Personality Inventory [EPI]), the IBS severity index (IBSSI), and Kessler 6 (K6) to evaluate psychological distress. Statistical significance was analyzed via one-way ANOVA. The Wilcoxon signed rank test was used to compare the two groups. Correlation analysis was performed to determine the strengths of relationships between neuroticism and the IBSSI.

Results: The overall IBS prevalence rate was 25.7%. Significant differences in neuroticism between groups with and without IBS were not observed. Degrees of neuroticism and K6 scores were both significantly higher in persons with diarrhea-subtype IBS than in persons without IBS. Compared to groups with other IBS subtypes, the correlation between neuroticism and IBSSI was strong (r = 0.21) in the group with diarrhea-subtype IBS.

Discussion: No significant difference was observed in neuroticism scores between persons with IBS and those without it, and therefore hypothesis 1 was not supported. However, as neuroticism scores in persons with diarrhea-subtype IBS were significantly higher than in persons without IBS, hypothesis 2 was supported. In diarrhea-subtype IBS, neuroticism may increase depressive symptoms and aggravate digestive symptoms via activation of the hypothalamic–pituitary–adrenal axis.

Keywords: irritable bowel syndrome, neuroticism

CORRESPONDING AUTHOR: Jun Tayama, Nagasaki University, Nagasaki;



Toyohiro T.1, Shimizu K.2, Tayama J.3, Tomiie T.4, Saigou T.3, Kanazawa M.5, Sakurai K.2, Fukudo S.5

1 Saitama Prefectural University, School of Health Science, Department of Occupational Therapy, Koshigaya, Japan

2 Niigata University of Health and Welfare, School of Health Science, Department of Occupational Therapy, Niigata, Japan

3 Nagasaki University, Center for Health & Community Medicine, Nagasaki, Japan

4 Health Sciences University of Hokkaido, School of Psychological Science, Sapporo, Japan

5 Tohoku University, Graduate School of Medicine, Department of Behavioral Medicine, Sendai, Japan

Irritable bowel syndrome (IBS) is considered to be a physical disorder that mainly affects the bowel, and is clinically characterized by lower abdominal pain or discomfort, as well as significant psychological stress. We previously reported on the possibility of improving IBS pathophysiology through passive abdominal muscle stretching, as indicated by chromogranin A, a biochemical index of sympathetic/adrenomedullary system activity. However, the degree to which patient intervention in the areas of physical exercise and management of daily activity can improve IBS symptoms is unknown. The purpose of the present study was to investigate the effects of intervention on autonomic stress response and loco-motor activity in patients with IBS. Forty adult participants with IBS were allocated randomly to either an exercise group (EG, n = 20) or a wait-listed control group (CG, n = 20). The EG received a four-week intervention consisting of abdominal muscle stretching, physical exercise of the pelvis, and 15 minutes of walking, with constant recording by accelerometer. Salivary α-amylase (sAA) was obtained prior to the stressor (mental arithmetic performed during distracting noise) and repeatedly during recovery to measure autonomic reactivity. Heart rate variability (HRV) was also monitored throughout stress/recovery phases. Both sAA and HRV tests were performed at pre/post intervention. After the intervention, the accelerometer count (steps/day) in the EG was significantly higher than that of the CG (t-test; p < 0.01). Levels of sAA declined significantly during stress in the EG (two-factor analysis of variance; p < 0.05), and significantly lower autonomic response (LF/HF) during recovery was observed in the EG compared with the CG. Anxiety during stress was reduced in the EG. No difference between groups was found in gastrointestinal symptoms. Although no beneficial effect on IBS symptoms was observed, the four-week intervention had immediate effects on physiological variables and some neurological factors.

Keywords: Irritable bowel syndrome, Stress, Health behaviors, Physical activity

CORRESPONDING AUTHOR: Hamaguchi Toyohiro, SPU, Saitama;



Gundersen H.1, Harris A.2, Bråtveit M.1, Moen B.1

1 University of Bergen, Department of Public Health and Primary Health Care, Bergen, Norway

2 Uni Research, Uni Health, Bergen, Norway

Background: The aetiology behind odor-released somatic symptoms is unknown. Both immunological and psychiatric causes have been suggested. The aim of this study was to investigate the occurrence of immunological and psychiatric symptoms in individuals with odor-released somatic symptoms compared to individuals with similar symptoms that were not released by odor. A second aim was to investigate if individuals with somatic symptoms, both odor-released and not odor-released reported more hay fever, asthma, anxiety and/or depression compared to those without somatic symptoms.

Methods: In total 13,799 individuals, 6,007 men and 7,792 women, 40-45 years of age answered a questionnaire including 16 questions on somatic symptoms based on the ICD-10 symptom criteria of somatization disorder, whether the symptoms were odor-released, and questions about hay fever and asthma. Psychiatric symptoms were measured with the Hospital Anxiety and Depression Scale (HADS). To be characterised as individuals with odor-released somatic symptoms participants had to respond that they almost always had odor-released symptoms from at least two different organ systems.

Results: 38 (0.6%) men and 106 (1.4%) women had odor-released chronic somatic symptoms, whereas 88 (1.5%) men and 192 (2.5%) women had similar symptoms which were reported not to be odor-released. Adjusted analyses showed an increased risk of hay fever and asthma in the group with odor-released symptoms compared to those with similar somatic symptoms that were not odor-released. There were no differences between the two groups on HADS. However when we compared those who reported somatic symptoms, both odor-released and not odor-released (n = 442), with those who did not reported somatic symptoms (n = 13,375), the first group showed an increased risk of anxiety and depressive symptoms.

Conclusion: Somatic symptoms are associated with an increased risk of psychiatric symptoms, independently of whether the symptoms are odor-released or not. However, immunological symptoms like asthma and hay fever are more frequently reported in individuals with odor-released somatic symptoms. Immunological and psychiatric symptoms seem both to be associated with odor-released chronic somatic symptoms. However, immunological symptoms like asthma and hay fever are more frequently reported in individuals with odor-released somatic symptoms

Keywords: Somatic symptoms, chemical sensitivity; anxiety; depression; asthma; hay fever

CORRESPONDING AUTHOR: Harris Anette, Uni Health;



Mussgay L., Schauss S., Rueddel H.

St Franziska Stift, Psychosomatic Hospital, Bad Kreuznach, Germany

To counter the negative emotional impact of persistent tinnitus symptoms the technique of guiding attention away towards other sources of sensory input is a successful and often used therapeutic strategy. In addition to the immediate effect of attenuating the tinnitus, a sense of control is established. In order to achieve its maximal effectiveness, the attention guiding technique has to become automatic, thus requiring an extensive training phase. Our study evaluated, if the training can be efficiently supported by cell phones used to prompt patients to exercise and, in addition, to provide information about the attention guiding procedure when needed.

Included were inpatients of our Psychosomatic Hospital, suffering from tinnitus. Inpatient treatment covered a period of about 6 weeks and consisted of group therapy sessions with special emphasis on tinnitus and its management, physical exercises, skills training and individual psychotherapy. In addition the experimental group (EG, n = 16) was provided with a cell phone that prompted patients 4 times a day to carry out attention guiding exercises and to report the type of exercise chosen. Prompting was skipped, if patients had already reported self-initiated exercises. A control group (CG, n = 16) was instructed to exercise as well, however without prompting. Reporting was done retrospectively with a daily questionnaire.

In the average, EG patients exercised 3.7 times a day, CG patients 3.3 times, EG patients asked for help information 13 times during the exercise period. Regarding the type of attention guiding exercise most often relaxation was applied (22%), followed by short walks in combination with selectively attending to various sensory sources (16%), physical exercise (12%), listening to music (12%) or engaging in conversation (12%). Both groups profited significantly from treatment (pre-post, general level of functioning, p < .000). As regards tinnitus distress the EG exhibited significantly lower scores (p = .003) in the tinnitus questionnaire (TF, Goebel & Hiller) at discharge compared to CG. Catamnestic scores (6 month) were still lower in EG, albeit no longer significantly due to a subsequent decrease in CG and a slight increase in EG. Our results emphasize the introduction of e-health methods for the acquisition of automatized behaviors.

Keywords: Rehabilitation, e-health, mobile phone

CORRESPONDING AUTHOR: Mussgay Lutz, St.-Franziska-Stift;



Gottschalk JM.1, Bleichhardt G.1, Kleinstäuber M.2, Krämer AC.2, Berking M.1, Rief W.1

1 University of Marburg, Department of Clinical Psychology, Marburg, Germany

2 University of Mainz, Department of Clinical Psychology, Mainz, Germany

Purpose: Multiple somatoform symptoms (MSS) are associated with increased health care use and psychological interventions consistently did not exceed medium effect sizes. Since many MSS patients lack emotional awareness the integration of emotion regulation training could enhance the effects of psychological interventions. In this non-randomized controlled pilot study we prospectively evaluated whether CBT enriched with emotion regulation training (ENCERT) achieves higher success rates in patients with MSS than standard CBT.

Intervention: Both treatment conditions consist of 20 weekly individual sessions. ENCERT contains: 1) psychoeducation, 2) teaching relaxation techniques for coping with stress, 3) teaching non-judgmental awareness of body perceptions, 4) modifying illness behavior and accepting unpleasant body perceptions, 5) attention defocusing on positive perceptions plus emotional self-support, 6) analyzing interpretation processes to understand situational cues, and 7) change of behavior and interpretations.

Method: The study took place in the outpatient departments of the universities of Marburg and Mainz with each center providing one intervention. Patients presenting at least 3 medically unexplained somatic symptoms for a minimum of 6 months were included. Outcome assessments took place before and after completion of therapy. Primary outcome is the somatic symptom severity during the last 7 days (SOMS-7). Other outcomes are emotion regulation skills, illness behavior, general psychopathology, disability, quality of life, symptom intensity, and subjective impairment. Results: The CBT condition (n = 35) shows a significant reduction with medium effect size in both the intensity (F(1,34) = 33.85, p < .001; d = 0.62) and the number (F(1,34) = 23.29, p < .001; d = 0.66) of somatic symptoms. Full data for the ENCERT group will be available until March 2012. Preliminary analyses indicate effect sizes of > .80 for intensity and number of somatic symptoms, which are considerably higher than for the standard CBT group.

Conclusion: The results of this pilot study suggest that ENCERT could be more effective than standard CBT in patients with MSS. Our next step is the preparation of a large randomized, controlled multicenter trial.

Keywords: somatoform disorder, pilot study, CBT, emotion regulation, effectiveness

CORRESPONDING AUTHOR: Gottschalk Japhia-Marie, Universität Marburg, Marburg;



Balola M.1, Cláudio V. 1, Raimundo L.2, Vieira L.2

1 Instituto Superior Psicologia Aplicada, Health and Psychology Unit, Lisbon, Portugal

2 Instituto Superior Psicologia Aplicada, -, Lisbon, Portugal

Initial experiences established with parent figures determine the formation of early schemas, which develop during the course of life, focusing on the individuals’ relationship with their internal and external world. These schemas consist of early memories (implicit or explicit) concerning emotional experiences. Several studies have concluded that early dysfunctional schemas, lead to changes in the individuals’ relationship with themselves and with others. We researched autobiographical memories, establishing a relationship with early maladaptive schemas, attachment styles and interpersonal relations.

The sample includes 52 participants aged between 18 and 52 years old. The evaluation protocol consists of the following instruments: Autobiographical Memory Task, Diary of Involuntary Autobiographical Memories, Brief Symptom Inventory (BSI), Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), Schemas Questionnaire, Adult Attachment Scale (EVA) and Inventory of Interpersonal Problems (IIP-64). We used the Portuguese version of all the above mentioned instruments.

The results indicate a greater recall of autobiographical memories for positive valence. With regard to the level of recall of voluntary and involuntary autobiographical memories, no significant differences were found. We correlated the above results with depression and generalized anxiety. Thereafter we discussed the results highlighting the importance of information processing, early maladaptive schemas, attachment styles and interpersonal relations of the individual.

Keywords: Clinical applications, Depression, Anxiety

CORRESPONDING AUTHOR: Balola Michele, ISPA-IU, Lisbon Portugal;



Abbruzzese E A., Klingmann A., Ehlert U.

University of Zurich, Department of Clinical Psychology and Psychotherapy, Zurich, Switzerland

The chronotype describes the behavioral daytime preference. The chronotypical preference depends on several factors, such as the intensity of light irradiation and entrainment or polymorphisms of the so-called clock genes. Humans show large interindividual differences in the organization of their behavior within the course of a 24h-day. This can be specifically stated in terms of the structure of the sleep-wake cycle and can be explained by the interindividually varying adjustment of the internal biological clock to the external daytime and nighttime. Accordingly, morning types show earlier bedtimes and waking-up times compared to evening types. Evening types in particular often experience the problem of a deficient fit between their inherent biological clock and the social clock (e.g. work schedules etc.). The discrepancy between working days and free days might therefore result in a sleep deficit during the week, which is compensated at weekends. The health-related aftermaths of such “social jetlags” are not yet sufficiently clear.

Like most other endocrinological parameters, cortisol also follows a strong circadian rhythm, with a peak immediately after awakening, the so-called cortisol awakening response (CAR). The clear function of this peak has not yet been revealed. Since glucocorticoids in general are assumed to play a key role in the timing and synchronization of the internal clock and the regulation of the transcription in the DNA, a well-tuned CAR might be crucial for the synchronization of one’s own organism to the environment.

Since a stable circadian rhythm seems to be health-protective, we aimed to determine the association between the chronotype and the CAR in 25 healthy men. Our results suggest that evening types show a lower total amount of cortisol, but a significantly prolonged phase of cortisol increase within the first hour after awakening. Our data might suggest that an inadequate synchronization between inert chronotype and environment results in an extenuated CAR.

Keywords: biobehavioral mechanism, health behavior

CORRESPONDING AUTHOR: Abbruzzese Elvira , University of Zurich, Zurich;



Fouad A.1, Fahim A.1, Younis S.2, Abdel-Halim A.1

1 Suez Canal University, Community Medicine Department, Ismailia, Egypt

2 Suez Canal University, Clinical Pathology, Ismailia, Egypt

Background: Shift work is usually referred to working at times other than the day-time hours of 8:00 a.m. to 5:00 p.m. It is considered as a significant source of occupational stress and dissatisfaction that can have a marked impact on alertness, performance, safety, and health. Oxidative stress is usually associated with increased free-radical formation, causing increased concentrations of reactive oxygen species which are claimed for the pathogenesis of lifestyle-related diseases. This study aimed at investigating the relationship between shift work and oxidative stress in female nurses.

Methods: An analytical cross-sectional study was carried out in Suez Canal University hospital in Ismailia; Egypt, and involved two groups of female participants; 68 nurses representing rotating shift workers and 68 non-shift workers (non-shift nurses & non-healthcare workers). Plasma Total Antioxidant Capacity (TAC) was measured as a biomarker for oxidative stress. A self-administered questionnaire was used including sociodemographic, lifestyle and work characteristics.

Results: In this study 52.3% of shift working nurses depend on fast food, while 80.6% of non-shift workers depend on regular meals (p < 0.001) . The mean duration of employment was statistically significantly longer in shift workers compared to non-shift workers (4.25 ± 1.8, 3.45 ± 1.4, respectively; p = 0.006). There was a statistically significant decrement in TAC among shift working nurses compared to non-shift workers (1.59 ± 1.29 vs. 1.85 ± 0.95 mmol/L, p = 0.001). Irregular roster design (OR = 9.75; 95% CI = 1.35–70.24) and consequent days-off less than 2 days (OR = 1.49; 95% CI = 1.01–2.2) were the main predictors for oxidative stress among shift working nurses (p = 0.024 & 0.043, respectively).

Conclusion: Shift working nurses had a statistically significantly higher oxidative stress than non-shift workers; roster design and consequent days-off were the main predictors for oxidative stress among shift workers.

Keywords: shift work, oxidative stress, nurses

CORRESPONDING AUTHOR: Fouad Ahmed, Suez Canal University, Ismailia;



Haraszti RA.1, Purebl GY.1, Salavecz GY.1, Dockray S.2, Steptoe A.3

1 Semmelweis University, Institute of Behavioural Sciences, Budapest, Hungary

2 University College Cork, School of Applied Psychology, Cork, Ireland

3 University College London, Department of Epidemiology and Public Health, London, United Kingdom

Morningness-eveningness has been found to be coupled with impaired sleep quality and social jetlag. However, biased sleep perception has not been taken into consideration when analyzing self-administered questionnaires on sleep timing data.

Method: The Composite Scale of Morningness, Jenkins Sleep problems Scale and basic questions on estimated work day and weekend sleep length have been administered to 200 healthy working women in order to explore their sleeping habits. In addition all participants completed a sleep diary for two days.

Results: Sleep timing data validated the chronotype assessment (p = 0.000). Evening types reported poorer sleep quality (p = 0.036). No evidence was found, however, for a significant effect of chronotype on the shift of sleep timing between workdays and leisure days. Neither did calculated sleep duration differ between chronotypes. Evening types, interestingly, significantly overestimated their leisure day sleep durations.

Conclusions: More caution is needed when assessing social jetlag and sleep duration based on self-estimation. Misperception of sleep is likely to be a possible pathway along which chronotype influences perceived health.

Keywords: morningness-eveningness, social jetlag, sleep perception

CORRESPONDING AUTHOR: Haraszti Reka Agnes, Semmelweis University, Budapest;



Meininger J.1, Eissa M.2, Chan W.3, Gallagher M.4, Nguyen T.4

1 University of Texas Health Science Center at Houston, Schools of Nursing and Public Health, Houston, United States

2 University of Texas Health Science Center at Houston, Medical School, Houston, United States

3 University of Texas Health Science Center at Houston, School of Public Health, Houston, United States

4 University of Texas Health Science Center at Houston, School of Nursing, Houston, United States

Insufficient sleep has been linked to hypertension in adults, but previous studies of children and adolescents on the association between sleep duration and blood pressure (BP) have produced inconsistent results. This cross-sectional study tested the hypothesis that sleep duration, both during the day and at night, would be negatively associated with ambulatory BP measured over 24 hours in adolescents 11 to 16 years old.

The sample, which was drawn from schools in an urban area in southeastern Texas, USA, included 377 adolescents 11 to 16 years old. Demographically, the sample was 54% female, 37% African American, 31% Hispanic, 29% non-Hispanic white, and 3% other ethnic/racial groups. The sample included 9.6% who were pre-hypertensive (>90th and < =95th percentile); 4.2% who were hypertensive >95th; 21.5% had body mass index (BMI) > = 95th percentile; and 17.8% had BMI > =85th and < 95th percentile for age, gender and height. Ambulatory systolic (SBP) and diastolic (DBP) pressures were measured for 24 hours on a school day; actigraph readings and diary recordings were used to define the duration of sleep at night and naptime during the day. Covariates included demographic factors (age, gender, ethnic group, mother’s education); obesity indices (BMI, waist circumference, percent body fat); sexual maturation (Tanner stage). At the time of each BP measurement while awake, the adolescents recorded position (sitting, standing, reclining); and location (school, home, other). Mixed models were used to test day and night sleep duration as predictors of 24-hour SBP and DBP, controlling for covariates.

Controlling for duration of sleep during the day, each additional hour of nighttime sleep was associated with a SBP - 0.45 mm Hg, p = .0003; controlling for nighttime sleep each additional hour of day time sleep was associated with SBP -0.44 mm Hg, p = .0085. DBP was related to day time sleep only (-0.32 mm Hg, p = .008). These associations cannot be explained by the influence of obesity on both sleep and BP, as indices of obesity were controlled as covariates. The small magnitude of the effect size for the association between sleep and BP will be interpreted in the context of the potential impact on population health and the need for further research to explicate the role of sleep in cardiovascular and metabolic health of adolescents.

Keywords: Blood Pressure; Adolescents; Sleep

CORRESPONDING AUTHOR: Meininger Janet, University of Texas HSC, Houston;



Yamada S.1, Nakaya T.1, Yamamoto R.2, Nomura S.3

1 Iwate Prefectural University, Faculty of Social Welfare, Iwate, Japan

2 Joetsu University of Education, Division of Clinical Psychology, Health Care and Special Support, Niigata, Japan

3 Waseda University, Faculty of Health Sciences, Saitama, Japan

Introduction: Interpersonal problems are showed as factors of occurrence and maintenance of non-attendance at school. Social anxiety disorder (SAD) is one of the factors affecting interpersonal problems. Also, truant students commonly report a variety of psychological symptoms such as anxiety/depression before they completely refuse to go to school. Sato (2006) showed that the child of 10% or more shows depression at clinical level. And Individuals with SAD or depressive symptoms are often accompanied by sleep impairments. The purpose of this study was to examine SAD and depression focusing on sleep impairment.

Method: Six hundreds and forty-two junior high-school students (309 male, 333 female) completed the questionnaire which consists of (a)the Japanese version of Liebowitz Social Anxiety Scale for Children and Adolescents(Okajima et al., 2008), (b) the Japanese version of Social Anxiety Scale for Adolescents(Okajima et al., 2009), (c)the Japanese version of Depression Self-Rating Scale for Children (Murata et al.,1996), (d)the Japanese version of Pittsburgh Sleep Quality Index (Doi et al., 1998).

Result: The percentage amongst participants who suspected of SAD was 17.45% and depression was 20.71% of whole data. Also, the percentage amongst participants who had low “sleep quality” was 26.95%, “sleep onset insomnia” was 23.68%, and “Daytime Dysfunction” was 25.39%. The PSQI score was investigated with t test to examine the difference between SAD(depression) and non-SAD (non- depression). Result indicated that SAD scored significantly higher than non-SAD on “sleep quality”(t = 2.26), “sleep onset insomnia”(t = 2.59), “Sleep Disturbance”(t = 3.09) and “Daytime Dysfunction”(t =4.91,ps < .05 ~ 01). Also, depression scored significantly higher than non-depression on “sleep quality”(t = 8.88), “sleep onset insomnia”(t = 8.01), “Sleep Duration”(t = 6.30), “Sleep Disturbance”(t =7.99) and “Daytime Dysfunction”(t =8.00, ps < .01).

Discussion: These results showed that about 1/4 of junior high school students have SAD, depression, and sleep problems, and students with SAD/depression have significantly more sleep problems than those without SAD/depression. The early intervention in SAD, depression, and sleep problems is considered to become prevention of non-attendance at school.

Keywords: Anxiety, Depression, Sleep disorders

CORRESPONDING AUTHOR: Yamada Sachie, Iwate Prefectural University, T;



Yamamoto R.1, Hirota Y.2, Yamatsuta K.3, Maki I.4, Yamada S.5, Hojo R.6, Nomura S.7

1 Joetsu University of Education, Division of Clinical Psychology, Health Care and Special Support, Niigata, Japan

2 Waseda University, Graduate School of Human Sciences, Saitama, Japan

3 Sangyo-Noritsu (SANNO) University, School of Information-Oriented Management, Kanagawa, Japan

4 Osaka Kyoiku University, Department of Psychology, Osaka, Japan

5 Iwate Prefectural University, Faculty of Social Welfare, Iwate, Japan

6 Joetsu University of Education, Division of Humanities and Social Education, Niigata, Japan

7 Waseda University, Faculty of Human Sciences, Saitama, Japan

Aim: Sleep problems (insomnia or excessive daytime sleepiness) are common among Japanese undergraduates. These problems are risk factors for mental disorders and are detrimental to either their quality of life or their academic performance. Thus, it is crucial to establish universal interventions for effective self-management of sleep problems as part of the school health service. The aim of this study was to investigate sleep problems and self-management of sleep among Japanese undergraduates.

Methods: Five hundred and fifty-eight undergraduates completed a questionnaire about sleep problems, self-management of sleep and needs for educational intervention. We analyzed 492 valid responses (258 male, 234 female, mean age = 20.0 yrs, SD = 2.4 yrs.). This study was approved by the Ethics Committee of Joetsu University of Education.

Results: The percentage of the participants who had at least one kind of sleep problem was 44.7% of the whole data, while that of those who had two kinds or more was 25.0%. The largest sleep problem was “excessive daytime sleepiness” (30.9% of the participants who complained about sleep problems). The second largest one was “sleep onset insomnia” (29.1%), and 93.6% of the participants who had reported sleep problems wanted to improve the problems. On the other hand, the percentage of the participants who had consulted a physician or health specialist was only 1.4%, the percentage of those who had attempted self-treatment was only18.6%, and the percentage of those who had done nothing was 76.4%. Supposing that the students would receive evidence-based universal intervention, the educational media that the participants wanted to use the most was “text based website information” (56.8%) followed by “still picture- or moving picture-based information”. Moreover, the mean amount of time which participants might invest in the intervention was 3.1 hours, but the distribution had bimodal peaks (median = 1.5 hours, mode = 1 hour).

Discussion: Many university students have sleep problems, especially sleep onset insomnia or excessive daytime sleepiness, and want to improve their sleep, but they leave these problems unaddressed. Cost effective and high accessible internet intervention, for example using mobile phone or tablet personal computer, will be needed.

Acknowledgement: This study was supported by Grant-in-Aid for Young Scientists (B) from the Japan Society for the Promotion of Science (Project No. 23730649).

Keywords: Mental health, Health behavior, Sleep disorders

CORRESPONDING AUTHOR: Yamamoto Ryuichiro, Joetsu University of Edu, Japan;



Rónai K. Z.1, Lázár S. A. 1,2, Szentkirályi A. 1,3, Zoller R. 1,4, Gombos F. 5, Lindner A. 1,6, Zsolt L. 7, Papp I. 7, Turányi C. 1, Szőcs J. 1, Lendvai Zs. 1, Fornádi K.1,6, Molnár M. Z.1,8,9, Mucsi I.1,8,10, Bódizs R. 1, Novák M. 1,11

1Institute of Behavioral Sciences, Semmelweis University, Budapest, Hungary,

2Centre for Brain Repair, Department of Clinical Neurosciences University of Cambridge, Cambridge, United Kingdom

3Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia

41st Department of Internal Medicine, Semmelweis University, Budapest, Hungary

5Department of Cognitive Science, Budapest University of Technology and Economics, Budapest, Hungary

6Department of Neurology, Semmelweis University, Budapest, Hungary

7Department of Physics, Babes-Bolyai University, Cluj-Napoca, Romania

8Institute of Pathophysiology, Semmelweis University, Budapest, Hungary

9Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, Los Angeles, USA

10Division of Nephrology, McGill University Health Centre, Royal Victoria Hospital, Montreal, Canada

11Neuropsychiatry Program, University of Toronto, Toronto, Canada

Introduction: The prevalence of insomnia (I) and depression (D) is high among kidney transplant recipients and the comorbidity of the two disorders is frequent. According to current theory, hyperarousal of the central nervous system (CNS) might play a role in the pathomechanism of both conditions. The hypervigilant state of the CNS is characterized by high frequency activity (HFA) of the EEG. We investigated the potential relationship of isomniac and depressive symptoms versus HFA in sleep among kidney transplant recipients.

Methods: Forty-five kidney transplant recipients participated in the study (27 males and 18 females, mean age 48.2 ± 13.07 years, BMI 25.81 ± 4.01kg/m2, GFR 49.97 ± 18.05ml/min). Symptoms of insomnia and depression were measured by the Athens Insomnia Scale (AISL) and the Center for Epidemiologic Studies-Depression Scale (CES-D), respectively. After one-night polysomnography the sleep structure and detailed spectral profile were characterized. HFA was assessed by the absolute spectral power within the beta1 (15.25-25 Hz), beta2 (25.25-35 Hz), and gamma (35.25-45 Hz) frequency bands.

Results: Subgroup of patients with insomnia exhibited significantly higher beta1 and gamma activity during REM sleep as compared to patients without insomnia (p < 0,005; for both comparisons). In patients with high depression score only beta1 activity was (p < 0,005) increased compared to low depression score subgroup. The AISL score correlated with the beta1 power in REM (r = 0,363; p < 0,005) and in non-REM (r = 0,317; p < 0,005), with the gamma power in REM (r = 0,317; p < 0,005) and in non-REM (r = 0,371; p < 0,005). The CES-D score had no significant correlation with the power spectra.

Conclusion: The correlation between the symptoms of insomnia and the increased neurocognitive activity of the CNS during sleep was shown for the first time in this population; thus the CNS hyperarousal might play a causal role in the emergence of insomnia among kidney transplant recipients.

Keywords: quantitative EEG, sleep disorders, insomnia, depression, kidney transplantation, hyperarousal, beta spectrum

CORRESPONDING AUTHOR: Ronai Katalin, Semmelweis University, Budapest;



Ohira M.1, Suguri K.2, Nomura S.3

1 Shiga University, Faculty of Education, Otsu, Japan

2 Nagaoka University of Technology, Management & Information Systems Engineering, Nagaoka, Japan

3 Nagaoka University of Technology, Top Runner Incubation Center for Academia-Industry Fusion, Nagaoka, Japan

Change in the secretion of salivary dehydroepiandrosterone (DHEA), a steroid hormone, while asleep and its association with subjective sleep quality were addressed. We developed our own saliva collection technique. The saliva was collected while the subject was asleep. This is a non-invasive and non-disturbing manner in contrast to the conventional blood collection method that imposes greater psycho-physiological impacts on subjects.

Subjects, eight male university students, were instructed to take a 6-hour sleep from 0:00 midnight until 6:00 in the morning in an environmentally controlled room, with heart rate (HR) recording and saliva collection. A subjective sleep quality inventory was given to subjects after awakening. In results, DHEA concentration remained at the same level for the sleep period and showed remarkable increase right after awakening: it went up approximately five times higher than that of during the night. DHEA did not show any difference among the subjects while they were asleep. In contrast DHEA was significantly higher after awakening in the subjects who marked higher score in the factor “unpleasant awakening (UA)” of the inventory. Moreover the variation in DHEA level after awakening, shows, significant correlation with the score of UA. No difference in HR was found among subjects after awakening. However, interestingly HR of the subjects who marked higher UA, and thus higher DHEA, after awakening remained significantly higher in the first half of the sleeping period.

In this study, the variations in salivary DHEA, while asleep and after awakening were successfully illustrated by our own developed saliva collection apparatus. Especially to our knowledge no study ever showed the remarkable increase of DHEA at the onset of awakening. Moreover such a remarkable releasing of DHEA was found to associate with subjective sleep quality and HR in the first half of the night. Since DHEA is known to increase against psychosocial stressors just like cortisol, higher DHEA releasing at awakening might be a part of physiological stress-related response. In conclusion our new methodology could open the possibility of the idea of biochemical assessment of subjective sleep state, i.e. the objective estimation of “Quality of Sleep” in our daily life.

Keywords: Psychoneuroendocrinology, Research methods

CORRESPONDING AUTHOR: Ohira Masako, Shiga University, Otsu;



Hinge Carlsson R.1, Netterstrøm B.1, Hansen AM.2, Hurwitz Eller N.1, Blønd M.3, Lindhart Nielsen M.1, Kristiansen J.2

1 Bispebjerg Hospital, Department of Occupational and Environmental Medicine, Copenhagen, Denmark

2 National Research Centre of the Working Environment, -, Copenhagen, Denmark

3 Nykøbing Falster Hospital, Department of Occupational Medicine, Copenhagen, Denmark

Objectives: The aim of this study was to investigate the association between reorganization and changes of physiological stress markers.

The hypothesis is that:

1. Reorganization causes changes in physiological stress markers during follow up in the form of increased sympathetic activity, increased HPA-axis activity catabolism of the metabolic system and decreased activity of the immunological system.

2. These changes can be explained by different exposure related to the reorganization.

Methods: The follow-up study OSH (Organization, Stress and Health) studied the health consequences of a major reorganization of non-state public offices effectuated in Denmark on 1 January 2007. In 2006 and 2008 we collected clinical and questionnaire data from 359 participants. During follow-up 201 employees merged (Merger group), 113 got new jobs (New job group) and 45 stayed in the same job (Control group).

The physiological stress markers included: Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate variability (HRV; total power (TP) and low frequency/high frequency (LF/HF), work and sleep), salivary cortisol at awakening (S0), awakening cortisol response (ACR), serum dihydroepiandosterone (DHEA-S), glycated haemoglobin (HbA1c), high density lipoprotein cholesterol (HDL), total cholesterol (TCHOL), body mass index (BMI) and waist hip ratio (WHR).

Changes in levels of these physiological stress markers (2006-2008) were analysed.

Results: SBP, S0, ACR, HbA1c, TCHOL, BMI and WHR increased significantly whereas HDL cholesterol decreased among women. Among men, ACR, HbA1c and BMI increased significantly whereas HDL and TP, work decreased. However, no significant differences between the exposure groups could be detected.

Conclusion: We found significant association between reorganization and changes of physiological stress markers. However, this observation could not be explained by different exposure related to the reorganization.

Keywords: psychophysiology, stress

CORRESPONDING AUTHOR: Hinge Carlsson Rikke, Bispebjerg Hospital, Copenhagen;



Dannehl K.1, Euteneuer F.1, Schwarz MJ.2, Rief W.1

1 University of Marburg, Clinical Psychology and Psychotherapy, Marburg, Germany

2 Ludwig-Maximilian University Munich, Psychiatry and Psychotherapy, Munich, Germany

Background: Cell-mediated immune activation may play a role in the pathogenesis of depression as indicated by findings of increased soluble tumor necrosis factor receptors (sTNFR) levels and recent meta-analytic evidence for elevated soluble interleukin 2 receptor (sIL-2R) concentrations. However, little research has been done on how these soluble cytokine receptors are differently related to specific features of depression. Therefore, we aimed to compare circulating levels of the soluble cytokine receptors sIL-2R, sTNF-R1 and sTNF-R2 in patients with depression disorder and healthy controls. We also explored the potential relationship between these cytokine receptors and different features of depression.

Methods: We included 25 patients with major depression and 22 healthy controls. Serum levels of sIL-2R, sTNF-R1 and sTNF-R2 were analyzed. Psychometric measures included the assessment of cognitive-affective symptoms, somatic symptoms, avoidance behavior and current mood states.

Results: Patients with depression showed increased levels of sIL-2R (p < 0.01) compared to healthy controls. Differences in sTNF-R1 (p = 0.094) and sTNF-R2 (p = 0.078) marginally failed to reach significance. Correlational analyses revealed that increased concentrations of sIL-2R were related to somatic measures (i.e. Screening for somatoform symptoms severity index, number of somatoform symptoms, somatic subscale of the Beck Anxiety inventory, somatization subscale of the Brief Symptom Inventory) but not to avoidance behavior, cognitive-affective variables or current mood states.

Conclusion: The blood levels of sIL-2R were significantly higher in patients with depression than in controls. Moreover, there are differences in associations between sIL-2R and distinct features of depression.

Keywords: Soluble interleukin 2 receptor; Soluble tumor necrosis factor receptor; Depression; Somatic symptoms; Anxiety; Mood states

CORRESPONDING AUTHOR: Dannehl Katharina, Philipps Universität Marburg;



Euteneuer F.1, Mills PJ.2, Rief W.1, Ziegler MG.3, Dimsdale JE.2

1 University of Marburg, Department of Clinical Psychology and Psychotherapy, Marburg, Germany

2 University of California, San Diego, Department of Psychiatry, San Diego, USA

3 University of California, San Diego, Department of Medicine, San Diego, USA

Several stress-related conditions that are considered to involve sympathetic overactivation are accompanied by increased levels of inflammatory immune markers. Chronic sympathetic overactivity is accompanied by increased stimulation of the beta-adrenergic receptor (beta-AR). While prior research suggests that one mechanism by which sympathetic stimulation may facilitate inflammation is via beta-AR activation, little work has focused on the relationship between circulating inflammatory immune markers and beta-AR function within the human body (in vivo). We examined whether decreased beta-AR sensitivity, an indicator of prolonged beta-adrenergic overactivation and a physiological component of chronic stress, is related to elevated levels of inflammatory immune markers. Ninety-three healthy participants underwent the chronotropic 25 dose isoproterenol test to determine in vivo beta-AR function. Circulating levels of C-reactive protein, interleukin 6, and soluble tumor necrosis factor receptor 1 were assessed. Beta-AR sensitivity was lower in people with higher C-reactive protein concentrations (r = 0.326, p = .003). That relationship remained significant after controlling for sociodemographic and health variables such as age, sex, ethnicity, body mass index, mean arterial blood pressure, heart rate, leisure-time exercise, and smoking status. No significant relationship was found between chronotropic 25 dose and interleukin 6 or soluble tumor necrosis factor receptor 1. This study demonstrates a link between in vivo beta-AR function and circulating inflammatory immune markers in humans. Future studies in specific disease states may be promising.

Keywords: Stress, immune function

CORRESPONDING AUTHOR: Euteneuer Frank, Philipps University, Marburg;



Defrancesco M., Libaert J., Kinzl J.

Medical University Innsbruck, Department of General and Social Psychiatry, Innsbruck, Austria

Background: Bariatric surgery is the method of choice in the treatment of morbid obesity. Different genotypes of the serotonin transporter gene (5-HTT) are known to impact the prevalence of psychiatric disorders and the psychosocial state in obese individuals. In this study, we examined the influence of the 5-HTTLPR polymorphism on physiologic and psychosocial measures in morbidly obese women after bariatric surgery.

Methods: We examined women 1 to 5 years after bariatric surgery using a semi-structured interview and the Beck Depression Inventory, the Ardelt-Moorhead Quality of life questionnaire, the NEO Five-Factor Inventory and a Resilience scale. The 5-HTTLPR polymorphism (s/s, s/l, l/l) was genotyped using mouth swabs. The influence of genotype on outcome variables was analysed by one-way ANOVA, independent t-test and analysis of covariates.

Results: 73 women were enrolled in this study between January 2004 and September 2009. Significantly lower quality of life (p

Conclusion: Quality of life, mood, and resilience but not weight loss after bariatric surgery are negatively influenced by the s-allele of the 5-HTTLPR polymorphism. We recommend considering the genotype of the 5-HTTLPR polymorphism for optimal post-operative care following bariatric surgery.

Keywords: Genetics, Obesity

CORRESPONDING AUTHOR: Defrancesco Michaela, Psychiatry Innsbruck;



Garvin P.1, Raetegui RAS.2, Winquist F.2

1 Linköping University, Department of Medicine and Health Sciences, Linköping, Sweden

2 Linköping University, Department of Physics, Biology and Chemistry, Linköping, Sweden

In recent years, assessment of alpha-amylase in saliva (sAA) has gained much interest as a potential marker in psychobiology, suggested to at least in part reflect adrenergic activity. It is not clear however how study designs should be optimized when assessing sAA. As of today, most studies use fixed time points when collecting saliva for evaluation of sAA.

In this study we have been following three subjects in everyday life settings, two male students and one male professor. Assessments of sAA were made starting as possible after awakening continuing throughout the day. The three subjects were followed under two days (n = 14 to 31 per day). In parallel, a simple log was kept during the days of assessment, to track down physiological and psychological stressful events throughout the day.

The results reveal that some, but not all, peaks in sAA could be explained by reported stressors such as physical activity or taking a cold shower. There were however several peaks and considerable variation of sAA level that cannot be easily explained by reported stressors. Of note, the level of sAA at awakening was almost identical for two subjects when comparing the two consecutive days.

Based on these data, we conclude that it may be cumbersome to use sAA at fixed time points. We propose that sAA just after awakening may be the time point of highest relevance, when studying sAA as a marker in psychobiology.

Keywords: Stress; Methodology; Psychophysiology

CORRESPONDING AUTHOR: Peter Garvin, Linköping University, Linköping;



Haraszti RA.1, Purebl GY.1, Salavecz GY.1, Dockray S.2, Steptoe A.3

1 Semmelweis University, Department of Behavioural Sciences, Budapest, Hungary

2 University College Cork, School of Applied Psychology, Cork, Ireland

3 University College London, Department of Epidemiology and Public Health, London, United Kingdom

Diurnal preference has been defined by sleep timing and validated by body core temperature rhythms. Social jetlag theory recently drew attention to the importance of shifts between actual sleep timing on work days and preferred sleep timing on weekends. Yet, it is unclear if other rhythms of the body can perform a shift between work days and weekends in order to adapt better to social time.

Methods: The Composite Scale of Morningness was administered to 200 healthy working women. Each subject has undergone two 24 hour sessions, one over a working and one over a weekend day. Sessions involved periodic sampling of saliva for cortisol analysis, actigraphy and heart rate variability monitoring via Actiheart (Cambridge Neuroscience) and Ecological Momentary Assessment to determine happiness, stress level, frustration, pain, fatigue, sense of control and degreee of haste. Data were analyzed by TSA Cosinor 6.3.

Results: The phase of negative emotion- and cortisol level rhythms were coupled to chronotype (p < 0.05). Negative emotions also significantly manifested phase shifts towards later timepoints on weekend days. None of the biological measures showed a similar pattern. Actigraphy confirmed diurnal preference assessment and showed social jetlag phenomenon in both chronotypes.

Conclusions: Preference of sleep timing is not likely to be able to phase-shift hormonal parameters, while it has a clear influence on emotions. Autonomous tone oscillates on a circadian fashion but it does not tend to correlate with morningness-eveningness.

Keywords: Morningness-eveningness, salivary cortisol, heart rate variability, ecological momentary assessment

CORRESPONDING AUTHOR: Haraszti Reka Agnes, Semmelweis University, Budapest;



Nagy T.1, Harmat L.2, Kovács K J.3, Polyák Á.3, Bárdos GY.4, Fülöp M.1

1 Hungarian Academy of Sciences, Institute of Cognitive Neuroscience and Psychology, Budapest, Hungary

2 Karolinska Institutet, Department of Neuroscience, Stockholm, Sweden

3 Hungarian Academy of Sciences, Institute of Experimental Medicine, Budapest, Hungary

4 Eotvos Lorand University, Institute of Health Promotion and Sport Sciences, Budapest, Hungary

Introduction: Although Hans Selye’s stress theory distinguished positive and negative stress (or eustress and distress) (Selye, 1975), 20th century research almost exclusively focused on the latter (cf. Denson, Spanovic, & Miller, 2009). Lazarus and Folkman’s (1984) coping model stated that cognitive evaluation of the stressor is essential since only those stimuli are likely to enhance negative effects of stress which are considered threatening. That is why people are capable of enjoying activities which can be seen as dangerous or stressful in different circumstances (Csíkszentmihályi, 1990). Such an example is competition which can be considered a distressing or joyful activity (Fülöp, 2009). According to our hypotheses, eustress activates the sympathetic part of the stress system – similar to distress –, but does not activate the HPA system. We did not opt out the possibility that eustress might even attenuate the HPA activity, given that people often use eustress inducing activities for recovering from stress (e.g. Reinecke, 2009).

Aim of the study: To examine psychophysiological and endocrine effects of a non-physical competitive activity which is considered both pleasant and arousing by participants.

Method: Based on a pilot study we chose to use a video game contest (Nagy, 2011). Participants (40 healthy, young males) had to compete in pairs against each other. We used within-subject approach and analyzed cardiovascular and psychological measures through 8 phases (baseline, 6 competition phases and recovery). Pre- and postcompetition saliva samples were also taken to measure cortisol and testosterone changes. We used two independent groups. In the first there was no distinction according to the outcome of the competition, in the second, the winner gained more reward than the loser.

Results: Participants reported positive feelings and heightened arousal, which was supported by cardiovascular (HR and HRV) measures. In contrast, salivary cortisol levels were significantly decreased under both conditions (η p 2 = .38). However cardiac reactivity showed different patterns for the two groups: the equally rewarded group displayed a gradually increasing sympathetic activity while the unequally rewarded group had gradually soothing response (η p 2 = .23).

Keywords: Stress, Coping, Psychoneuroendocrinology, Psychophysiology, Cardiovascular reactivity, Cortisol




Nater U.1, Dimulescu I.2, Unger E.2, Rajeevan M.2

1 University of Marburg, Clinical Biopsychology, Marburg, Germany

2 Centers for Disease Control and Prevention, Chronic Viral Diseases Branch, Atlanta, USA

Background: Salivary alpha-amylase (sAA) is used extensively as a marker of the autonomic nervous system (ANS) in behavioral medicine. While it is known that salivary alpha-amylase gene (AMY1) copy number variation (CNV) correlates with its expression, there are no reports on the impact of AMY1 gene dosage on its use as a marker of ANS regulation. In this study, we evaluated the contribution of AMY1 CNV to inter-individual differences in basal and stress-related sAA activity.

Methods: Subjects belonged to the first follow-up surveillance of chronic fatigue syndrome in GA, USA. Baseline sAA morning profile and awakening response (AAR) at 0, 30, 45 and 60 minutes after awakening were determined for 613 subjects. Stress reactivity in sAA was determined in a subset of 41 healthy subjects undergoing the Trier Social Stress Test (TSST). AMY1 CNV was determined using whole blood DNA and LightCycler 480 based quantitative PCR. AMY1 and 36B4 (reference gene) reactions were done in triplicate. CNV was calculated based on absolute quantification using a 2-fold standard curve ranging from 40ng to 0.625ng per reaction of Coriell DNA NA07919 reported to have 2 copies of AMY1/cell.

Results: AMY1 CNV ranged from 1 to 15 diploid copies/cell. Subjects were classified into eight CNV groups for association with sAA morning profile and AAR. AMY1 CNV showed a positive gene dosage response with sAA morning profile (p = 0.003), AAR (p = 0.0070), area under the curve total (AUC total) (p = <0.001), and AUC increase of the morning profile (p = 0.003). Subjects in the stress reactivity study were classified into three CNV groups. In agreement with AAR, subjects with higher copies of AMY1 exhibited higher sAA reactivity (p = 0.021) and higher AUC total (p = 0.023) in the TSST. All significant associations between AMY1 CNV and sAA measurements were independent of potentially contributing factors (age, sex, race, illness status).

Conclusion: AMY1 CNV was identified as a key genetic determinant of inter-individual differences in basal and reactive levels of sAA. Past and future studies using sAA as a marker of ANS should be interpreted in the light of the contribution of this heritable genetic variation in stress signaling.

Keywords: stress, biobehavioral mechanisms

CORRESPONDING AUTHOR: Nater Urs, University of Marburg, Marburg;



Kuebler U.1, Wirtz PH.2, Sakai M.3, Stemmer A.3, Ehlert U.1

1 University of Zurich, Clinical Psychology and Psychotherapy, Zurich, Switzerland

2 University of Bern, Biological and Health Psychology, Bern, Switzerland

3 Swiss Federal Institute of Technology Zurich, Nanotechnology Group, Zurich, Switzerland

Acute psychological stress induces changes in circulating blood leukocytes, but its effect on leukocytes in peripheral tissues is largely unknown. Activated tissue macrophages are important in early phases of wound healing particularly by killing microbes. We hypothesized that (a) acute psychological stress reduces the microbicidal potential of human monocyte-derived macrophages (HMDM) and (b) these reductions relate to stress hormone release.

Forty-one healthy men (mean age 35 ± 1 yr) were randomized to either stress (n = 24) or control group (n = 17). While the stress group underwent the Trier Social Stress Test (TSST; combination of mock job interview and mental arithmetic task), controls did not. Assessing the microbicidal potential, we investigated PMA-activated superoxide anion (O -2 ) production by ex vivo isolated HMDM immediately before and after stress, and during recovery up to 60 min after TSST / rest. Moreover, we repeatedly measured plasma norepinephrine and epinephrine levels as well as salivary cortisol.

The groups significantly differed in their HMDM microbicidal potential (p = .01) in reaction to stress. Post hoc testing revealed that while HMDM of the control group displayed a significant increase in O -2 production over time (p = .02), the cells of the stress group did not (p = .83). Immediately and 10 minutes after stress O -2 production by HMDM was lower in stressed subjects as compared to controls (p’s < .05). Statistical mediation testing revealed that higher norepinephrine levels mediated lower amounts of O -2 responses.

Our results suggest that acute psychological stress reduces the microbicidal potential of HMDM probably by norepinephrine release. This might have implications for stress-induced impairment in wound healing.

Keywords: Psychoneuroimmunology, Stress, Injury, Immune function, Norepinephrine, Cortisol

CORRESPONDING AUTHOR: Kuebler Ulrike , University of Zurich, Zurich;



Sveinsdottir V.1, Harris A.1, Ursin H.1, Hansen Å M.2, Eriksen H R.1

1 Uni Research, Uni Health, Bergen, Norway

2 National Research Centre for the Working Environment, Copenhagen, Denmark

Musculoskeletal pain is the main reason for long-term sick leave in Norway. Non-specific conditions with no clear somatic pathology (Subjective Health Complaints – SHC) like muscle pain, mood changes, and tiredness, are prevalent all over the world. The comorbidity is high and the complaints are often attributed to “stress”. Salivary cortisol is an increasingly popular biological marker for stress, and is generally characterized by high reactivity in the morning followed by lover evening values. The purpose of this study was to investigate whether patients with low back pain (LBP) differed from the normal characteristic profile, and whether possible deviations were related to coping or SHC. The theoretical basis for the study is the Cognitive Activation Theory of Stress (CATS). 305 LBP patients on long-term sick leave participated in the study (45.8% men and 54.2% women, aged 20-60). Cortisol was measured by saliva samples upon awakening, after 30 minutes, in the afternoon and evening. The patients answered questionnaires about SHC, coping, social support, pain, fatigue, and fear avoidance. The sample showed a seemingly normal and characteristic cortisol profile with a large awakening cortisol response, and lower levels in the afternoon and evening. However, there were some weak but significant negative correlations between cortisol reactivity (awakening response and cortisol decrease) and severity of SHC, pain and fatigue. The lack of stronger significant findings is remarkable with respect to the expected associations between cortisol, health, and coping.

Keywords: Cortisol, stress, psychoneuroendocrinology, health, coping, social support, pain, fatigue

CORRESPONDING AUTHOR: Sveinsdottir Vigdis, Uni Health, Bergen;



Svitavsky M.

University of Innsbruck, Cardiology, Innsbruck, Austria

The following article presents a psychosomatic model for behaviour-related blood pressure regulation. From this model can be derived scientifically verifiable hypotheses which were investigated for instance in our parallel published study "Reduced perception of stress increases cardiovascular strain for infarct patients" (ICBM 2012). A simple feedback loop represents a process in medicine with which a measured value is compared with a nominal value for a control variable which is to be kept constant and is reported to a regulating centre (regulator), whereby in the case of a difference (control deviation), which itself is the result of the influence of disturbance variables, control signals are sent to a correction mechanism (actuators): negative feedback. In the psychosomatic feedback loop model of blood pressure regulation the following elements are defined as follows: Nominal value = resting diastole, control variable = measured value of the diastole at the time x, disturbance variable = psychological stress (e.g. concentration), control deviation = the measured difference of the "nominal value - control value", control unit = circulatory centre in the medulla oblongata, negative feedback = a) activation of pressoreceptors (physiological) and b) perception of stress (psychological), actuator = a) vascular smooth muscle (physiological) and b) behavioural reduction: e.g. pauses (psychological). From this model the following problem was derived and investigated in our second publication: Are there statistically significant differences in patients suffering cardiovascular illnesses between those with myocardial infarctions and those without in terms of a) stress perception, b) stress regulating behaviour and c) cardiovascular stress?

Keywords: Health behaviors, Stress

CORRESPONDING AUTHOR: Svitavsky Markus, Innsbruck University, Innsbruck;



Stahnisch W.

University of Calgary, Community Medicine Department, Calgary, AB, Canada

The massive loss of nearly thirty per cent of all academic psychiatrists and neurologists in Germany, Austria and Hungary between 1933 and 1945 in many ways also destroyed the basis of German-speaking neuroscientific and psychiatric research, as has been pointed out by many historiographical studies over the past decades. In return, the process of forced-migration of politically oppositional and Jewish scientists and physicians from Nazi-occupied Europe has often been interpreted – and was thus also downgraded in a certain way – as a process of a mere “brain gain” for the North American research landscape. Research literature on the receiving countries, such as Canada and the United States of America, has tended to primarily focus on the intellectual, academic and institutional dimensions of the forced-migration process, while the individual fate and destiny as well as the social problems of many émigré-neuroscientists are still very much under-researched. This presentation focuses on the specific case example of the Hungarian neurophysiologist Hans Hugo Bruno Selye (1907-1982), who had studied medicine at the German University in Prague and, following to his graduation, travelled for additional research training to the premier US medical school at Johns Hopkins University, Baltimore. His case example is very instructive as Dr. Selye had not been obliged to stay in North-America during times of the Nazi Regime in Central Europe, but like many émigré neuroscientists expressively decided to stay and move on to McGill University. After his arrival in Montreal, Dr. Selye pursued a most impressive career as a neurophysiologist, becoming the “father of stress” and was repeatedly nominated for the Nobel Prize in Physiology or Medicine. This presentation will primarily focus on the question of the “personal stress” for the émigré neuroscientist to build, change and adapt his research program as well as his own behaviour as a scientist, while being exposed to a very different research community (emphasis on application versus pure knowledge pursuit), finding a place as an interdisciplinary researcher in a research landscape organized in departments (interdisciplinarity versus disciplinarity in biomedical research), and finally the personal insecurity as an individual researcher abroad, who had to leave his family behind during times of Nazi and Soviet Totalitarianism in Central Europe, 1933 to 1956.

Keywords: Stress, Culture, Behavior Change, Psychophysiology

CORRESPONDING AUTHOR: Dr Stahnisch Frank W., University of Calgary, Alberta;



Pimenta F., Leal I., Maroco J.

Instituto Superior Psicologia Aplicada, Psychology and Health Research Unit (UIPES), Lisbon, Portugal

Objective: Midlife is filled with challenges and unique stressors for women; both contextual and individual characteristics might be associated with stress levels (e.g., Darling, Coccia, & Senatore, 2012).This study aims at exploring if life events and menopausal status, controlling for confounding variables, can predict stress in middle-aged women.

Method: A community sample of 1,003 Portuguese women, aged between 42 and 60 years, in pre-, peri- or post-menopause, filled in a questionnaire to collect socio-demographic, health and menopause-related, and lifestyle information. Menopausal status was determined using the STRAW criteria (Soules et al., 2001). Stress levels were measured with a validated version of the Depression, Anxiety and Stress Scales (Pais-Ribeiro et al., 2004) and life events by the Life Experiences Survey (Silva et al., 2003). Structured equation modelling was used to build a causal model between the dependent variable (stress) and the several independent ones (socio-demographic, health and menopause-related characteristics, lifestyle and life events).

Results: Significant predictors of stress included household income (β = -.074; p = .047), transition from pre- to peri-menopause (β = .082; p = .028), transition from peri- to post-menopause (β = .151; p = .003), psychological health status (β = .255; p < .001), physical health status (β = .075; p = .015) and recent life events (β = -.383; p < .001).

Conclusion: Although menopausal status was a significant predictor of stress (namely, the transition from pre- to peri-menopause, and from peri- to post-menopause), the presence of stressful life events seems to be a stronger predictor of stress-related symptoms. Other variables should be taken into account, in middle-aged women, as risk factors for the development of stress (specifically, lower income, and the presence of a health or a psychological problem).

Keywords: Stress; Women's health; Life events; menopause; structural equation modelling

CORRESPONDING AUTHOR: Pimenta Filipa, ISPA - Instituto Universitário;



Skoluda N.1, Doerr J.1, Thoma M.2, Ehlert U.3, Nater U.1

1 University of Marburg, Clinical Biopsychology, Marburg, Germany

2 Brandeis University, Psychology, Waltham, USA

3 University of Zurich, Clinical Psychology and Psychotherapy, Zurich, Switzerland

Background: Associations between stress levels in everyday life and controlled laboratory conditions remain a controversial topic. The aim of the present study was to compare psychological and physiological stress levels assessed in a real-life setting with laboratory stress levels.

Methods: Thirty-five healthy male students (age M = 24.4, SD = 2.6 yrs) took part in the study. The first part of the study consisted of a two-day period within which subjects collected saliva and rated their stress levels on a visual analogue scale immediately after awakening, 30min later, at 9am, and then every two hours for a total of nine times a day while maintaining their regular daily activities. Salivary alpha-amylase (sAA) was assessed as a marker for autonomic nervous system activity at each time point. In the second part, subjects were invited to two laboratory sessions on two separate days, with randomized exposure to either a standardized stress test (cold pressor test, CPT, stress condition) or a rest condition (reading magazines). Again, sAA and subjective stress were assessed repeatedly during both conditions.

Results: During both days, sAA levels showed a distinct diurnal rhythm, with a trough in the morning and a steady increase over the course of the day (time effect p < .001). Self-reported stress levels significantly fluctuated over the course of the two days (time effect p = .022). In the laboratory part, the CPT resulted in significant increases in sAA and in self-reported stress levels (time effect: p = .001, interaction effect, p = .001). Regression analyses revealed that overall sAA levels in everyday life predicted sAA levels in both laboratory conditions (p < .001). The same held true for subjective stress levels (p < .001). It was also found that overall subjective stress levels in everyday life predicted the psychological laboratory stress response (p = .026). Furthermore, a trend was found for the sAA awakening response predicting overall sAA in the stress condition (p = .067).

Conclusions: Stress levels in everyday life were shown to predict psychological as well as physiological stress levels in the laboratory. Further, subjects with high stress levels in everyday life experienced a more pronounced psychological stress response to a laboratory stressor.

Keywords: Stress, Psychophysiology, Measurement

CORRESPONDING AUTHOR: Skoluda Nadine, University of Marburg;



Svitavsky M.

University of Innsbruck, Cardiology, Innsbruck, Austria

The empirical study is derived from our parallel published "Regulation theory stress model" (ICBM 2012) and investigates the following questions: In a randomly selected sample of 45 outpatients at Innsbruck University Hospital, between 25 infarct patients and 20 infarct-free patients with other cardiovascular symptoms and statistically comparable infarct risk, are there statistically significant differences at: a) stress perception, b) stressreducing behaviour, c) cardiovascular strain? Statistically the infarct and control group are comparable as regards age spread, gender distribution and infarct risk profile. In an experimentally controlled induction of mental stress, all patients had to write down 130 numbers dictated from a tape in 3,5 minutes. At the same time, their heart rate (extremity ECG as per Einthoven), systolic and diastolic blood pressure (wrist blood pressure measurement as per Riva-Rocci) were measured twice before, three times during and twice after the exposure to stress at one-minute intervals. The perception of stress was measured by correlating the physiological time series measurement of systole, diastole and heart rate on the one hand, with the subjective estimated values of a four-step rating scale on the other. The control group had a statistically highly significant more sensitive perception of stress (p < .005) and took breaks during the induction of stress statistically remarkable earlier (p = .07) than the infarct group. During the stress period were in the control group both, the heart rate as well as the diastolic level, statistically significantly lower (p < .05), than in the infarct group. Within the psychosomatic feedback loop model of blood pressure regulation are a) the perception of stress = the psychological part of the negative feedback and b) breaks = the psychological part of the correction mechanism. The results of the study show that well-functioning perception of stress protects against and reduced perception of stress increases cardiovascular strain and infarct risk.

Keywords: Health behavior, Stress

CORRESPONDING AUTHOR: Svitavsky Markus, Innsbruck University, Innsbruck,



Bogolyubova O.1, Shaboltas A.1, Ababkov V.2

1 Saint-Petersburg State University, Department of Psychology, St-Petersburg, Russia

2 Saint-Petersburg State University, Department of Psychology, Saint-Petersburg, Russia

It is well known that a range of diseases and health conditions can be attributed to certain forms of high risk behavior (e.g. unprotected sexual intercourse, smoking, substance abuse). Modern research demonstrates that stress, especially chronic and/or traumatic stress, contributes to the development of these behaviors. Stress reactivity represents individual’s behavioral and biological response to new and/or stressful situations. Individual reactivity to stress is considered to be a relatively stable trait. On a biological level the release of hormone cortisol represents activation of the HPA axis in reaction to stress. The levels of cortisol expression characterize the psychobiological stress reaction of an individual and can be affected by a number of factors, including behavioral factors such as chronic stress, exposure to significant stress in childhood (e.g. in maltreated individuals) etc. The goal of this study was to investigate the connections between adverse childhood experiences, stress reactivity in two experimentally manipulated stressful situations and health related risk behaviors in a sample of young adults. The experimental situations included two different social stressors: (1) public speaking and (2) interaction with a stranger of opposite sex. Risk behaviors (sex behaviors, tobacco smoking, alcohol intake, drug use) and childhood experiences (physical and sexual victimization, neglect, exposure to domestic and community violence etc.) were assessed by means of self-report questionnaires. Cortisol was measured in saliva samples (three measures per experimental situation). Experimental situations took part on different days with an interval of no more than one week. The sample consisted of young males and females (n = 100; 20 – 30 years old) recruited via the social networking web sites and advertisement in local universities. The results of the study demonstrated relatively high rates of victimization and other types of childhood adversity in the study sample. The behavioral and biological reactions to stressful situations were described. Regression analysis was employed to demonstrate the impact of childhood stress on current psychobiological reaction to stress and self-reported risk behaviors of young adults.

Keywords: Health, Health behaviors, psychoneuroendocrinology, stress

CORRESPONDING AUTHOR: Bogolyubova Olga, SPbSU, St-Petersburg;



Buni A.

University of Tripoli, Department of Community Medicine, Tripoli, Libya

It has been estimated that stress- related disorders will be one of the leading causes of disability by the year 2020. Some studies indicated that medical students have higher incidence of stress than other students in other professions. However such studies are almost non existent or at least very few in medical schools of Libya.

Objectives: This study aimed to determine and assess the prevalence of psychological problems, causes or sources of stress, and coping strategies among medical students at the university of Tripoli, Libya.

Method: To achieve the objectives of this study, 605 students from the fourth year medical students "males 145 (24%) and females 460 (76%) were asked to complete a modified questionnaire on the "Influence of studying on student health, just one month before the Libyan revolution of February 17 - 2011.

Result: 25% of the sample study reported that they suffer psychological problems, 79% reported that their studying influenced their habits in drinking excess tea and coffee. Causes and sources of stress include fear of failure in examination 60%; crowded lectures halls 56%; fear during practical and clinical discussions 77%; insufficient time to study 86%; content of curriculum "overloading" 85%; fear of infection in hospitals 72%; anxiety from clinical and oral examination 47% and 33% respectively; fear from curriculum especially in the third academic year 57% (they call it the cemetery year)

The coping strategies used by students include religious faith 92%; talking to friends and parents 54% and 43% respectively;.70% of students reported that they had not received any education about stress management during their study.

Conclusion: Results indicated that medical students need some kind of psychological and social support, and guidance and counseling program to help them improve their academic performance ,as well as their mental and social health.

Keywords: Stress, medical students

CORRESPONDING AUTHOR: Buni Ahmed, University of Tripoli -Libya;



Csala I.1, Cserhati Z.2, Nemeth E.1

1 Semmelweis University, Institute of Behavioural Sciences, Budapest, Hungary

2 Semmelweis University, Institute of Cognitive Neuroscience and Psychology, Budapest, Hungary

Background: Medical education can be harmful for many students’ physical and mental health (Carter et al. 2001). High prevalence of depression, anxiety, and substance use has been found among medical students. Increased level of stress, which can be detected during the university especially in the examination period, may cause psychosomatic symptoms. The aim of this study was to analyze the effect of the examination period on medical students’ subjective health complaints.

Methods: We recruited 259 medical students in the term-time from the 1st, 3rd, and 5th years and we followed 140 of them in the examination period. For measuring somatization we recorded a frequency score from 0 to 4 experienced by students for 13 symptoms of Patient Health Questionnaire-15 (PHQ-15). We formed a symptomatic score for each individual by summing their frequency scores for the 13 symptoms. We used the symptomatic score to assess the general condition of the students.

Results: The symptomatic score increased in the examination period in all three groups (1st, 3rd, and 5th year students, with p < 0.001 in all groups). Comparing the groups we found that 1st year students showed higher symptomatic score than 5th year students in the term time (p = 0.019), whereas this difference disappears in the examination period. 11 of the symptoms, including stomach pain (p < 0.001), back pain (p < 0.001), headaches (p < 0.001), chest pain (p = 0.002), dizziness (p < 0.001), feeling heart pound (p < 0.001), shortness of breath (p = 0.029), constipation or diarrhea (p < 0.001), nausea (p < 0.001), tiredness (p < 0.001), and trouble sleeping (p < 0.001) showed up with a significantly higher frequency in the examination period in total sample. The most common symptoms were tiredness, headache, trouble sleeping, and back pain.

Conclusion: Examination period is stressful for medical students, therefore they show more psychosomatic symptoms than in the term time. The most vulnerable are the 1st year students, who are exposed to whole new difficulties in the university but do not have effective skills to cope with those. Rethinking of the curricula, stress management courses and student counseling could be useful to reduce stress.

Keywords: stress, health

CORRESPONDING AUTHOR: Csala Iren, Semmelweis University, Budapest;



Fukuzumi N., Aoki K., Yamaguchi S.

Tokyo Denki University, Graduate School of Advanced Technology and Science, Tokyo, Japan

Objectives: In this study the Autonomous University-life Motivation Scale was developed in the framework of the organismic integration theory (Ryan & Deci, 2000), and its reliability and validity were examined. The relationship between Autonomous University-life Motivation Scale and the stress self-rating scale for university students was also examined.

Methods: Participants were 265 university students (male; 221, female; 44). They completed the Scale of Autonomous University-life Motivation in which we expected five subscales: amotivational, external, internalized, identified, and intrinsic reasons following previous studies and the stress self-rating scale for university students (Ozeki, Haraguchi & Tsuda, 1994). The stress self-rating scale for university students consists of seven subscales, emotional response; depression, emotional response: anxiety, emotional response: anger, cognitive-behavioral response: emotional response, cognitive-behavioral response: withdrawal, somatic tiredness and activation of autonomic nervous system. Statistical Package for Social Science (SPSS version 14.0) has been used for the statistical analyses.

Results and Conclusions: The results were as follows: Positive correlation coefficient was observed between amotivational and stress responses (seven subscales) {r = 0.23 ~ 0.51, p < 0.01}. Positive correlation coefficient was observed between external and stress responses (seven subscales) {r = 0.16 ~ 0.34, p < 0.01}. Positive correlation coefficient was observed between internalized and stress responses (six subscales) {r = 0.14 ~ 0.27, p < 0.05}. Negative correlation coefficient was observed between internalized and stress responses (two subscales) {r = -0.20 ~ -0.24, p < 0.01}. Negative correlation coefficient was observed between intrinsic and stress responses (four subscales) {r = -0.12 ~ -0.24, p < 0.01}.

Keywords: Stress, Motivation

CORRESPONDING AUTHOR: Fukuzumi Noriaki, Tokyo Dneki University, Tokyo;



Hagemann L., Kaplan E., Suchday S., Veres S.

Yeshiva University, Clinical Psychology (Health Emphasis), New York, USA

This study investigates the effect of “social role burnout” (i.e. burnout related to the engagement in excessive interpersonal relationships) and personality traits, specifically Type D (negative affect/social inhibition) on baseline health indicators. A community sample of twenty-four adults (17 females, 7 males), aged 18 and older, was obtained from the New York City area. Subjects were assessed for burnout rates (Shirom-Melamed Burnout Measure), Type D characteristics (DS14) and social and interpersonal involvement (SNI). Baseline blood pressure and heart rate was also measured. It is hypothesized that personality type mediates SMBM and SNI with baseline health indicators. Results showed a significantly strong correlation between DS14 and SMBM (r = .53, p < .001). A regression analysis indicated that DS14 total scores significantly predicted diastolic blood pressure (b = -.59, t(23) = -2.42, p < .05), but was not significantly related to other variables, supporting that for this sample, personality did not prove to be a mediator. SNI was found to be unrelated to DS14 scores and health indicators. This young, socially diverse sample may engage in numerous social roles as a buffer or coping mechanism to experienced stress. Future research requires a larger, more diverse sample, including those with increased rates of familal, parental and employment roles.

Keywords: Social stress, personality, health

CORRESPONDING AUTHOR: Lauren Hagemann, Yeshiva University;



Stenlund T., Nordin M., Slunga Järvholm L.

Occupational and Environmental Medicine, Umeå University, Public health and Clinical Medicine, Umeå, Sweden

Objective: To evaluate long-term effects of two different rehabilitation programs for patients on long-term sick leave because of burnout.

Design: A randomized controlled trial (the REST-study).

Patients: Seventy patients (51 women and 19 men) with burnout answered the questionnaires at the 3-year follow-up after the end of the intervention (response rate 65%).

Methods: Patients were randomized to two different 1-year group programs: (A) cognitively oriented behavioural rehabilitation in combination with Qigong; and (B) Qigong alone. Data on psychological measures, sick leave and use of medication were compared between the programs.

Results: Patients in program A significantly felt more recovered from their burnout, reported lower levels of burnout, used more cognitive tools learned from the program, and had reduced their use of medication for depression. No significant differences were found between the groups in sick leave rates; both groups had improved.

Conclusion: A multimodal rehabilitation for patients with burnout including cognitively oriented behavioural rehabilitation and Qigong showed positive effects 3 years after the end of intervention. The results indicate that for many burnout patients on sick-leave it takes time to implement cognitive tools and to establish new behaviours.

Keywords: randomized controlled trial, stress

CORRESPONDING AUTHOR: Stenlund Therese, Umeå University, Umeå;



Kunisato Y.1, Okamoto Y.2, Okada G.2, Nishiyama Y.2, Kanai Y.3, Sasaki-Aoki S.4, Yoshimura S.2, Katsuragawa T.1, Suzuki S.1, Yamawaki S.2

1 Waseda University, Faculty of Human Sciences, Tokorozawa, Japan

2 Hiroshima University, Department of Psychiatry and Neurosciences, Hiroshima, Japan

3 Tohoku Gakuin University, Department of Human Science, Sendai, Japan

4 Hiroshima University, The Graduate School of Integrated Arts and Sciences, Hiroshima, Japan

Introduction: Anhedonia is common symptom of many mental disorders studied in behavioral medicine including major depression, schizophrenia, substance abuse and Parkinson's disease. Recently, neural substrates of anhedonia have been studied using fMRI. However resting state functional network of anhedonia remains unclear. We examined the relation between anhedonia and default mode network in resting state brain activity.

Methods: Resting-state fMRI scans were acquired for 66 right-handed adults (20 males, 46 females, mean age = 21.20 years) who completed the Snaith-Hamilton Pleasure Scale (Snaith et al., 1995), which assess the anhedonia symptoms. Participants were collected 6 minute resting state functional MRI scans on a 1.5 Tesla MRI scanner (120 EPI volumes; TR = 3 sec; TE = 40ms; flip angle = 90 deg; slice thickness = 4mm no gap). Participants were instructed to close their eyes and remain awake. After the functional scan, anatomical images were acquired. The first 5 images were discarded and the subsequent 115 images were used for further analysis. Image preprocessing was carried out using Statistical Parametric Mapping (SPM8) software. After preprocessing, group independent component analysis was carried out using group ICA of fMRI toolbox in order to identify the default mode network component. Then, we conducted a simple regression analysis to examine the correlation between the default mode network and anhedonia using SPM8, and set significant correlations at the threshold of a voxel-wise p < 0.005 (uncorrected) that belonged to a cluster of activation with an extent of at least 30 voxels.

Results: Anhedonia correlated positively with left insula (r = .50), right medial prefrontal cortex(r = .52), right precuneus (r = .45) and left temporal pole(r = .42). While, anhedonia correlated negatively with left caudate (r = -.49), left postcentral gyrus (r = -.45) and left fusiform gyrus (r = -.47).

Discussion: The findings suggest that the higher anhedonic person shows the higher functional network with insula and midline brain area, and lower functional network with caudate. Anhedonia was characterized by low functional network with caudate which relates positive emotion and high functional network with insula which relates negative emotion.

Keywords: Anhedonia, Emotions, Mood, resting state fMRI, neuroimaging

CORRESPONDING AUTHOR: Yoshihiko Kunisato, Waseda University, Tokorozawa;



Harmat L.1, De Manzano Ö.1, Theorell T.2, Ullén F.1

1 Karolinska Institutet, Department of Cognitive Neurology, Stockholm, Sweden

2 Stockholm University, Department of Stress Science and Psychosomatic Medicine, Stockholm, Sweden

Psychological flow is a subjective experience of enjoyment and concentration that typically occurs during performance of tasks that are challenging but matched in difficulty to a person's skill level (Csikszentmihalyi & Csikszentmihalyi, 1988). Here, we present data from two studies where physiological correlates of flow were measured. In study 1 , piano playing was used as a flow inducing behavior. Spontaneous differences in flow between repeated performances of the same piece were studied. State flow was rated by the participant after each performance. A significant relation was found between flow and heart period, blood pressure, heart rate variability, activity of the zygomaticus major muscle and respiratory depth. In study 2, the computer game "Tetris" was used as a model behavior, and the level of flow was experimentally manipulated. There were three conditions, corresponding to difficulty levels of the game: Simple, Optimal, and Difficult. Pilot data showed that the Optimal condition reliably evoked the highest level of flow. This design allows a within-person comparison of physiological correlates of flow (Optimal) and attention during subjective boredom (Simple) and cognitive overload (Difficult). We will compare the findings in the two studies and discuss them in relation to current models of emotion, attention and expertise, arguing that the flow state may be both phenomologically and physiologically different from effortful attention.


Csikszentmihalyi, M., & Csikszentmihalyi, I. (1988). Optimal experience. Psychological studies of flow in consciousness. Cambridge Univ Press.

Keywords: cardiovascular reactivity, psychophysiology, stress

CORRESPONDING AUTHOR: Laszlo Harmat; Semmelweis University, Budapest,



Mussgay L., Rueddel H.

St Franziska Stift, Psychosomatic Hospital, Bad Kreuznach, Germany

Deficits in autonomic cardiovascular control are hypothesized to be relevant factors contributing to the increase in morbitity in depressive cardiovascular disease patients. Convincing data, however, are still lacking. For the induction of a sad mood state music has been used occasionally. Our study bears on this issue and pursues the question, if in depressives deficits of autonomic regulation can be shown in response to a sad mood state induced by sad music.

Into the study 23 depressive inpatients of our Psychosomatic Hospital have been enrolled (age: 38 yrs; 20 women). At the beginning (t1) as well as at the end of their inpatient treatment phase (t2) patients took part in identical recording sessions in our laboratory. During both sessions measures of autonomic cardiovascular control (blood pressure (SBP, DBP), heart rate (HR), heart rate variability (HRV (TP, VLF, LF and HF) as well as baroreflex sensitivity (BRS)) were registered for 5 min in a resting state, in response to a mental challenge, and when listening to sad music. Sadness of music was rated on a visual analogue scale (0-100). State depression was assessed with the ADS.

Sadness of music at t1 was rated with 21, at t2 with 43. Two subgroups were formed by median split on the basis of the change in depression from t1 to t2 (greater improvement, n = 14; less improvement, n = 9). Depression at t1 was equal in both groups (ADS: 28 versus 29). Treatment improved scores from 29 to 11. Analysis of the parameters of autonomic control yielded highly significant differences (<.0005) between the experimental conditions (rest and music versus mental challenge for HR, SBP, DBP, TP, VLF, LF, HF, BRS). Heart rate was lower in response to music compared to rest (p = .005); systolic blood pressure was higher in music compared to rest (p = .02). Comparison of parameters of autonomic control between both groups yielded higher values of total HRV (group x condition: F = 5.3; p = .03) for mental challenge and music, and as tendency in the HF-band at rest and for music (group x condition: F = 2.9; p = .06). The VLF-band exhibited a tendency for a reduced variability at rest (group x condition: F = 2.7; p = .08).

A more pronounced improvement of depression during treatment goes along with better HRV at rest and in response to a music induced sad mood state as regards total power and within the parasympathetic frequency band. Thus or findings support the notion of HRV being an indicator of general emotional health. The reduction of HRV within the VLF range may point to a lesser degree of rumination at rest in patients with more improvement in depression.

Keywords: psychophysiology, cardiovascular reactivity, depression, emotions

CORRESPONDING AUTHOR: Mussgay Lutz, St.-Franziska-Stift;



Nomura S.1, Ito K.1, Irfan CMA.1, Hasegawa-Ohira M.2

1 Nagaoka University of Technology, Top Runner Incubation Center for Academia-Industry Fusion, Nagaoka, Japan

2 Shiga University, Faculty of Education, Otsu, Japan

The effect of color on the physiological stress-response was investigated. Salivary cortisol and dehydroepiandrosterone (DHEA) which represent one of a major stress-reaction pathways, namely hypothalamus-pituitary-adrenal (HPA) system, and the salivary immunoglobulin A (IgA), alpha-amylase (SAA), and chromogranin A (CgA) which represent the other major stress-reaction pathways, namely sympatho-adrenal medulla (SAM) system, were assessed for the subjects who were engaged in a simple mental calculation task as an acute psychological stressor.

Twenty-three male university students voluntary participated in this study. After 10 minutes of a rest period as the initialization process, the subjects were instructed to perform a simple mental calculation task for 30 minutes with wearing any one of three different color glasses, which were red, blue, and clear (control). Subsequently subjects took 15 minutes of rest as the recovering procedure with wearing the same color spectacles. All subjects went-through each color conditions with randomized order (within-subjects design). Saliva samples were collected at every 3 minutes during the experiment.

In results, all concentration of salivary secreted substances, cortisol, DHEA, IgA, SAA, and CgA, showed transient elevation during the task period and then decline in the subsequent recovery period. This is a typical physiological stress-response against acute psychological stressors as represented by the activations of HPA and SAA system. On the other hand, with regard to colors, only cortisol showed significant difference in the level for distinct spectacle conditions. Salivary cortisol showed the stress-response in each color condition. However, the total secretion of the cortisol during the task period or during the whole experiment period was significantly lower in the blue condition than that of control condition (p < .05). The total secretion of DHEA showed the same trend but not significant.

The results suggest an alleviative effect of blue color on HPA system, which is one of a major physiological stress-reaction pathway. It might be responsible in part for the close link between colors and physiology, while it is an empirical assumption that “red color makes one feel warm (Hue-heat hypothesis)” so far.

Keywords: Stress, Cortisol, Environment

CORRESPONDING AUTHOR: Shusaku Nomura, Nagaoka University of Technology;



Saeki Y.1, Miki A.1, Haginoya H.1, Kuroda R.1, Hoshino J.2, Hayashi K.3, Kawaguchi T.1

1 University of Tsukuba, Department of Nursing Sciences, Tsukuba, Japan

2 University of Tsukuba, Department of Intelligent Interaction Technologies, Tsukuba, Japan

3 Laughwell co., Ltd., Department of Community Health Sciences, Tsuchiura, Japan

Purpose: It has been known that laughter is effective in relieving stress. This study was designed to clarify whether there was a relationship between expression of laughter and relieving stress in Japanese nurses.

Methods: Fifty-six Japanese nurses who work in a university hospital participated in this study (33.7 + 9.0 yrs, M = 13, F = 43). Electrocardiogram (ECG) and digital plethysmography (DPG) in the middle finger were measured as autonomic nervous function, and Profile of Mood State (POMS) and Depression and Anxiety Mood Scale (DAMS) were used as psychological evaluations. Furthermore, “Smile Scan”, which can assess smiles in real-time and rates each smile by assessing a numerical value (0~100 points), was used to evaluate degree of smile in each subject. Following resting period with measuring ECG and DPG, Stroop Color Word Conflict Test (CWT) was applied to the subjects as a psychological stress. After that, subjects watched VTR on the screen, in which constructed some pictures inducing laughter for about 30 minutes. Approval for the present study was obtained from University of Tsukuba Ethical Committee.

Results: All subjects were divided into 3 groups depending on the rate obtained from Smile Scan; expressions group (0~25 points, N, n = 30), smile group (26~75 points, S, n = 13), loud laughter group (above 76 points, L, n = 13). Low frequency (LF) / high frequency (HF) in spectral analysis of DPG increased during CWT in all groups, indicating that sympathetic nerve activity must enhance by CWT. While LF/HF decreased immediately after the end of CWT in S and L groups, continued high level to the end of experiment in N group. In L group, LF/HF increased during watching the VTR followed by decreasing at the end of it. Psychological measurements using POMS showed improvement of many factors except confusion and affirmative mood improved in DAMS in 3 groups.

Disccusion: Since sympathetic nervous system enhanced by CWT continued high level during watching the VTR in N group, it was suggested that they might not be relieved from under stress even though they could feel improvement of their mood. It seems that the person who could laugh under condition causing laughter could psychologically and physiologically relieve their stress.

Keywords: laughter, stress, autonomic nervous system, psychological state

CORRESPONDING AUTHOR: Saeki Yuka, University of Tsukuba, Tsukuba;



Jarašiūnaitė G., Perminas A.

Vytautas Magnus university, Department of Psychology, Kaunas, Lithuania

Probably it would be impossible to find a description of a disease, in which stress was not mentioned as one of etiological or progress stimulating factors. Stress does not necessarily cause diseases directly, but it had been proved to be a disease-enhancing factor. According to K. Thompson(2006), people with negative affectivity are more responsive to stress, while positive emotions reduce the negative effects of stress on the body’s physiological systems (K. Thompson, 2006).

19 men and 71 women aged between 18 and 30 (mean age 21,9 ± 2,5) were subjects of the study. The participants were randomly assigned into 3 different groups. Two groups received 4 relaxation training sessions (progressive muscle relaxation or biofeedback relaxation) once a week, between two measurements of their reaction to an audiovisual stressor. The third group was a control group. Its reaction to the audiovisual stressor was also measured, but its participants did not receive any relaxation training. Subjects completed the positive and negative schedule (PANAS-X) created by D. Watson and L. A. Clark (1994) to measure negative and positive affectivity. Body temperature, skin conductance, heart rate and respiratory rate were recorded while measuring participants’ reaction to the audiovisual stressor.

The results of the study showed that subjects with high negative affectivity had higher psychophysiological reaction to an audiovisual stressor while individuals with high positive affectivity reacted less. Individuals having high positive affectivity showed better results in reducing their physiological reaction to an audiovisual stressor after relaxation trainings.

Keywords: Stress, emotions, relaxation, reactivity

CORRESPONDING AUTHOR: Jarašiūnaitė Gabija, Vytautas Magnus University;



Manzaneque JM.1, Vera FM.1, Rodriguez FM.1, Vadillo M.1, Bendayan R.1, Blanca MJ.1, Alonso A.2, Fernandez-Arcaz N.2

1 University of Malaga, Department of Psychobiology and Methodology of Behavioral Sciences, Malaga, Spain

2 Carlos Haya Regional Hospital, Immunology Service, Malaga, Spain

Qigong is an ancient Chinese psychosomatic discipline which aims at mind-body integration by means of specifically designed slow movements. One of the main traditions within this discipline is the Taoist school of qigong. This particular school emphasizes naturalness, and uses specific body movements and a relaxed state of mind to improve health and increase longevity. Albeit, in the last decade qigong has been demonstrated to display several physical as well as psychological benefits, Taoist qigong has not been investigated to date. Likewise, given that the influence of qigong on the immune system may account for some of its beneficial features, exploring the effects of qigong on immune parameters is not only a most interesting field of research, but it is also a clinically relevant task. Thus, the present study was specifically designed to assess the effects of Taoist qigong practice on immune cell counts in healthy subjects. Forty naive subjects participated in the study, of which twenty-three were allocated to the experimental group while the rest were assigned to the control group. Experimental subjects underwent a qigong training program consisting of five days of practice per week for the period of one month. Analysis of covariance (ANCOVA) and Mann-Whitney "U" tests were performed as statistical analyses. Results show that after completing the qigong program, experimental subjects exhibited lower levels of leucocytes, lymphocytes and LUC cells than control. Our findings, therefore, reveal that the practice of Taoist qigong for a short period of one month induced a noteworthy immunomodulatory action, which lends itself to interesting clinical implications. Future studies should assess the clinical relevance of this modulation of immune function displayed by qigong.

Keywords: Taoist qigong, immune cell counts, leucocytes, lymphocytes, immunomodulatory

CORRESPONDING AUTHOR: Manzaneque Juan M., University of Malaga; Malaga,



Vera F. M.1, Manzaneque J. M.1, Rodriguez F. M.1, Vadillo M.1, Bendayan R.1, Blanca M. J.1, Alonso A.2, Fernandez-Arcaz N.2

1 University of Malaga, Department of Psychobiology and Methodology of Behavioral Sciences, Malaga, Spain

2 Carlos Haya Regional Hospital, Immunology Service, Malaga, Spain

Qigong is an ancient form of health maintenance, dating back thousands of years, which is part of Traditional Chinese Medicine. Practice of qigong, of which there are many different systems, typically entails mind, body and breath training. Given this interesting holistic approach, within the last decade qigong has received a considerable attention in biomedical research due to its remarkable biological effects and its broad therapeutic potential profile. Albeit we have already reported effects of qigong on immune function in other investigations, measures were then assessed one day after the qigong program ended. Thus, the effects that qigong may induce shortly after practice remain virtually unknown. Therefore, this research was carried out for the purpose of shedding light on the immediate effects of the practice of qigong on immune parameters. Forty-five naive subjects participated in the study, of which twenty-five were allocated to the experimental group and the rest were assigned to the control group. The day before the experiment commenced and one hour after the last session of practice concluded, one month later, blood samples were drawn from all subjects for the quantification of immune parameters (neutrophils, monocytes, eosinophils, as well as T and B lymphocytes). Analysis of covariance (ANCOVA) was performed as statistical analyses. Results show that one hour after completing the qigong program, experimental subjects exhibited higher values in the number and the percentage of B-lymphocytes, as compared to control. These results, therefore, reveal that qigong exerts a significant immumodulatory action on a particular and relevant component of adaptive immune response. Further studies should confirm these results and fully assess the potential clinical implications that may arise from these findings.

Keywords: qigong, adaptive immunity, modulatory, B-lymphocytes

CORRESPONDING AUTHOR: Manzaneque Juan M., University of Malaga, Malaga;

Biobehavioural processes in Coronary Artery Bypass Graft (CABG) surgery: understanding mechanisms and implementing interventions



Steptoe A.

University College London, Department of Epidemiology and Public Health, London, United Kingdom

Coronary artery bypass graft (CABG) surgery is one of the most common revascularisation procedures used for coronary heart disease patients in Europe and the USA. CABG has been shown to have negative emotional effects in some patients, and both severe depression in the clinical range and subclinical milder depression are common sequelae. Moreover, depressive symptoms after CABG have been shown to be associated with a host of poorer clinical outcomes and increased mortality in these patients. Many patients continue to experience physical symptoms related to the surgical procedure, such as pain, fatigue and swelling, in the months following CABG.

This symposium will present recent data concerning the links between depression, quality of life and long-term cardiac outcomes following CABG. Research from two fields of investigation will be presented from researchers in Germany, the USA and the UK. Firstly, studies of the mechanisms underlying the relationship between depression and poor surgical recovery after CABG, including results related to impaired quality of life and sleep disturbance. Secondly, findings from intervention studies that have been designed to reduce depression in CABG patients. The symposium will illustrate the exciting opportunities for research into mechanisms and improved clinical care for patients undergoing CABG.

Symposium chair: Andrew Steptoe, University College London, London, UK.

Symposium speakers:

1. Friederike Kendel, Charité - Universitätsmedizin, Berlin, Germany: Depression, health-related quality of life, and associations with mortality.

2. Lydia Poole, University College London, London, UK: Pre-operative sleep disturbance is associated with physical and emotional recovery in the days and months following cardiac surgery.

3. Kenneth Freedland, Washington University School of Medicine, St. Louis, MO, USA: Treatment of cognitive and somatic symptoms of depression after coronary bypass surgery.

The symposium Chair will act as Discussant.

Keywords: Coronary heart disease; surgery

CORRESPONDING AUTHOR: Steptoe Andrew, UCL, London;



Kendel F.

Charité - University Medical Center Berlin, Institute of Medical Psychology and Medical Sociology, Berlin, Germany

Objectives: The aim was to investigate (1) the relationship between depression and quality of life in persons undergoing coronary bypass surgery (CABG) and (2) the association of these self-reported variables with mortality.

Methods: A total of 1559 patients admitted to the German Heart Institute Berlin between 2005 and 2008 for CABG were included in this prospective study. Survey and medical record data were obtained 1-3 days before and 1 year after surgery. Depression at baseline and follow-up was assessed using the Patient Health Questionnaire (PHQ-9), quality of life with the 36-Item Short-Form Health Survey. The bidirectional association between depression and quality of life was analysed with a cross-lagged path analytic model. Multivariable proportional hazard models were used to determine if depression and self-rated quality of life at baseline were associated with 1-year all-cause mortality.

Results: Baseline depressive symptoms predicted a decrease in health-related quality of life after CABG, but not the other way around. Poor quality of life at baseline was associated with higher rates of mortality after adjusting for the demographic, socioeconomic, and clinical risk factors.

Conclusions: The results emphasize the vitally important role self-reported parameters play in the CABG recovery process. In particular, preoperative inquiry about depression and self-rated quality of life may provide important information on patient well-being and on patient risk after the surgery.

Keywords: coronary heart disease, quality of life

CORRESPONDING AUTHOR: Kendel Friederike, Charité Berlin;



1 University College London, Department of Epidemiology and Public Health, London, United Kingdom

2 St George's University of London, Department of Cardiac Surgery, London, United Kingdom

3 University College London, Department of Epidemiology and Public Health, London, United Kingdom

The purpose of this study was to examine the relationship between pre-operative sleep disturbance and post-operative emotional and physical recovery in patients undergoing coronary artery bypass graft (CABG) surgery. Some patients show a decline in quality of life following CABG surgery and physical symptoms including pain may not fully resolve following surgery. Research has shown that sleep disturbance may contribute to poorer adaptation following CABG surgery. Sixty-nine CABG patients undergoing elective CABG surgery (with or without valve replacement) were recruited (aged 68.13 ± 9.55 years) to participate in a prospective study assessing self-reported sleep disturbance, depression symptoms, health status, physical symptoms and pain 2-3 weeks before surgery (T1) and 3-5 days (T2) and 6-8 weeks (T3) after surgery. Baseline sleep was entered in linear multiple regression analyses to predict physical and emotional recovery, with age, gender, ejection fraction, euroSCORE, baseline anxiety and depression symptoms as covariates. Sleep disturbance before surgery was associated with greater physical symptoms at T2, poorer physical health status at T3 and greater depressive symptoms at T3 (p < 0.05), but not with pain or mental health status. These results suggest that poor sleep may be implicated in recovery from CABG surgery and future work exploring the causal mechanisms may contribute to the development of interventions to promote better sleep.

Keywords: Coronary heart disease; surgery




Freedland K., Steinmeyer B., Carney R.

Washington University School of Medicine, Department of Psychiatry, St. Louis, USA

Background: Depression is an established risk factor for morbidity and mortality in patients with coronary heart disease, but there is conflicting evidence as to whether the cognitive and somatic symptoms of depression differ in terms of their prognostic significance. Recent studies suggest that somatic symptoms may be stronger predictors of medical outcomes after acute coronary syndrome, but that cognitive symptoms may be stronger predictors after CABG surgery. This research has created interest in the question of whether different forms of treatment have differential effects on cognitive and somatic symptoms of depression.

Methods: In a secondary analysis of data from 123 participants in a randomized controlled trial of treatments for depression after CABG surgery, we examined the effects of cognitive behavior therapy (CBT) and supportive stress management (SSM) on cognitive and somatic symptoms. We also modeled the effects of nonstudy antidepressant medications on these symptoms. The outcome measures were the cognitive and somatic subscales of the Beck Depression Inventory (BDI).

Results: Mixed models of both subscales yielded results that were very similar to the previously published results of the BDI total score analysis (Freedland et al., 2009). In particular, there were significant group X time interactions on both subscales (cognitive, p < .0001; somatic, p < .002), and no effect of antidepressant medication on either subscale. Subsequent tests revealed that both CBT and SSM had slightly larger effects on cognitive than somatic symptoms at the 3-month post-treatment assessment, and that antidepressants had similar (but small) effects on cognitive and somatic symptoms at 3 months.

Conclusion: These findings do not support the view that different forms of treatment may be differentially efficacious, either for the cognitive or for the somatic symptoms of depression.

Keywords: Coronary heart disease; surgery

CORRESPONDING AUTHOR: Freedland Kenneth, Washington University, St. Louis;

Breast Cancer Research in the Americas: New Partnerships In Breast Cancer Control And Prevention



Ramirez A.

University of Texas Health Sciences Center at San Antonio, Epidemiology and Biostatistics, San Antonio, USA

Breast cancer is one of the leading cancers in the world yet there is a paucity of data on Latinos and breast cancer. The majority of breast cancer research has been conducted in North America and Europe. Expanding the pool of researchers, patients and programs to other countries, especially those less developed, is increasingly seen the next critical step in the fight against breast cancer. The National Cancer Institute and the Susan G. Komen for the Cure Foundation have made significant financial and programmatic commitments in the Latin Americas to promote research, outreach and education about breast cancer control and prevention. Additionally, breast cancer control and prevention interventions in the US aimed at Latino populations are also under scrutiny for adaptation in Latin American settings. These efforts have resulted in several new and dynamic research partnerships among a wide variety of different stakeholders in public health in these nations. This symposia will present current efforts of the NCI, the SG Komen Foundation and US researchers that focus on reducing cancer health disparities among Latinos in the US and Latina America. Dr. Amelie Ramirez will chair the panel as well as describe a multi site study conducted among low income US Latinas to examined breast cancer ‘time to diagnosis’ disparities. Dr. Jorge Gomez will describe multi-national breast cancer genetics research and biospecimen repository development in Central and South America. Dr. Karla Unger will highlight the benefits of using promotoras to increase access to breast cancer screening services among low-income Mexican women. Dr. Catherine Olivaros will review several Komen research programs and unique partnerships currently underway in South America.

Keywords: Cancer Latino




Ramirez A.

University of Texas Health Sciences Center at San Antonio, Epidemiology and Biostatistics, San Antonio, USA

The study compared time from initial abnormal breast screen to definitive diagnosis between navigated and non-navigated patients among Latina women in 6 US cities. Subjects presented radiologic classification of initial abnormality (BIRADS) 3, 4, or 5 detected on a mammogram, clinical breast exam, magnetic resonance imaging, or ultrasound between. Navigated patients received assistance by locally trained navigators using a patient-centered model. Non-navigated patient data was obtained via retrospective medical chart review. Among 480 women follow-up data was available for 425 (88.5%). BIRADS status was the only significant predictor of timely diagnosis. More than 95% of subjects achieved definitive diagnosis within 180 days. Median time to definitive diagnosis was significantly reduced among navigated vs. non-navigated Latinas (20 days versus 27 days, hazard ratio [HR] 1.32, p = .007) yielding a 132% increase in rates of diagnosis among navigated women. This effect was primarily observed in women with an initial BIRADS 3 result, especially when adjusted for clinically directed waiting periods between initial and follow-up screening examinations. Among navigated patients, only between-BIRADS variation rather than sociodemographic characteristics, the number of barriers to care, insurance status or type or site-specific variables were associated with timely or time-to-diagnosis. Patient-centered navigation to assist Latina women with breast screening abnormalities reduces median time-to-diagnosis by approximately 25% when types of screening abnormality and barriers to care are addressed at patient level. Community-based interventions may be the most effective means to reduce cancer health disparities when addressing the needs of underserved populations.

Keywords: cancer Latinos




Gomez J.

National Cancer Institute, Office of Latin American Cancer Program Development (US-LACRN), Washington, USA

The United States-Latin America Cancer Research Network (US-LA CRN) launched its first breast cancer pilot study in 2010 in 20 hospitals and research facilities in Argentina, Brazil, Chile, Mexico, and Uruguay. The primary goal is to characterize molecular profile distribution (luminal A, luminal B, HER2-like, and basal) in Latin American women with non-metastatic stage II or III breast cancer. Molecular profiles are correlated with epidemiological, histological, and clinical data, including pathologic response to standard neoadjuvant chemotherapy. This prospective cohort study (1) will not dispense investigational drugs, (2) will characterize molecular profiles of breast cancer in Latin America and (3) will examine associations between response to neoadjuvant therapy and molecular profiles. Tissue samples for gene expression profiling will be collected during routine core biopsies or surgery. Core biopsies and surgical resection specimens will undergo histopathologic evaluation and tumor ER, PgR, HER2, and Ki67 status assessment. Next, patients will be sorted by hormone receptor and HER2 status and receive standard neoadjuvant chemotherapy. Tissue samples will be re-assessed for residual cancer burden for pathologic response to neoadjuvant treatment and gene expression. Five-year patient follow-up will determine associations between molecular profiles and disease evolution after standard treatment. Besides providing data on the effectiveness of standard chemotherapy in Latin American women, the study will establish biobanks in participating countries to conduct new clinical trials on complex genomic and pathologic biomarkers and investigational therapies. Studying the molecular profile of breast cancer in Latin America will improve diagnosis and treatment, correlate molecular subtypes with long-term survival and response to therapy, and identify indolent-disease subpopulations of cancer patients, perhaps enabling future personalized cancer management. Dr. Gomez will provide outcomes of the study to date and reflect on the implications of creating international biobanking repositories and gene studies in Latin America.

Keywords: cancer genetics




Ungar-Saldana K.

Fundacion Cimab, Science Advisory, Mexico City, Mexico

Cimab Foundation is a non-governmental, non-profit organization whose goal is to attack the problem of breast cancer from the root, which means the lack of information on breast cancer by educational campaigns about the methods of detection of this disease. Since 2010, a patient navigation project has worked to reduce barriers and improve access to breast cancer screening services among low-income women residing in communities in and around Monterrey, Mexico. Five social workers were trained as breast cancer awareness trainers and patient navigators. These trainers and patient navigators in turn educate female community members to become promoters of breast cancer screening in their communities. Additionally, we organize “community health brigades” where breast clinical exams done by specialists are offered without charge and free mammograms are scheduled for women aged 40 and older. Patient navigators accompany women to their mammograms, oversee that the interpreted studies get to the patients in a 2-week time frame and facilitate further diagnostic tests and admittance to a cancer hospital if needed. An evaluation of breast cancer awareness and screening practices is being conducted among a sample of participants to the “community health brigades”.

Keywords: cancer Latinos




Oliveras C.

Susan G. Komen for the Cure, Susan G. Komen Global Health Advocacy Alliance, Dallas, USA

The Susan G. Komen Global Health Advocacy Alliance is an international initiative to promote breast health advocacy and to increase awareness of and access to breast screening services, especially among the poor. One effort in Latino America partners Komen with non-governmental organizations (NGOs) to train advocates and conduct breast cancer education in concert with existing programs that are already testing for HIV/AIDS, tuberculosis and malaria. Another effort joins Komen with the NCI’s Office of Latin American Cancer Program Development, in 5 countries (Argentina, Brazil, Chile, Mexico and Uruguay) to support the development of programs for cancer research, clinical trials, training programs, technology and local advocacy capacity building. In Costa Rica, Brazil, Mexico and Peru, Komen is working with the World Health Organization to study cost effectiveness of breast cancer control interventions. Working with local Health Ministries, this project analyses existing health infrastructure, epidemiological data and cancer data to identify and develop culturally appropriate and cost feasible breast cancer outreach and education programs. Finally Komen has initiated a new 3 year partnership with the Caterpillar Foundation that will award grants to local NGOs in Sao Paulo, Brazil; Panama City, Panama and Monterrey, Mexico to establish comprehensive early detection programs, build local capacity, and provide financial support directly to community organizations. The presentation will discuss these programs, their outcomes to date and future plans for national and regional breast cancer control and prevention collaborations in Latin America.

Keywords: cancer Latinos


Social Context, Health Behavior and Childhood/Adolescent Health



Sacker A.1, Bartley M.2, Kelly Y.1, Cable N.2

1 University of Essex, Institute for Social & Economic Research, Colchester, United Kingdom

2 University College London, Epidemiology and Public Health, London, United Kingdom

Breastfeeding has been associated with higher cognitive scores, better test results and fewer socio-emotional problems in childhood. These outcomes in turn predict the probability of upward social mobility. This study examines the relationship between breastfeeding and inter-generational social mobility. We use data from two British birth cohorts to examine the hypotheses that breastfeeding increases the chances of upward social mobility and that it is more beneficial to less advantaged children. Rates of breastfeeding were higher in the 1958 National Child Development Study (43% breastfed for 1 month or more) than the 1970 British Birth Cohort (21% for 1 month or more). Breastfeeding was also more socially patterned by 1970, with more advantaged mothers being more likely to breastfeed – a situation which is still evident today. Total social mobility among men and women was broadly similar in the two cohorts. We used a propensity score matching approach to match breastfed and non-breastfed cohort members on a large range of characteristics to more effectively estimate the hypothesised causal effect of breastfeeding on social mobility. Social class of origin was based on father’s class. Both class of origin and own social class in adulthood were measured by the Registrar General’s social class (RGSC). We modelled the odds of upward social mobility for those in RGSC II-V and of downward social mobility for those in RGSC I-IV conditional on being breastfed for 1 month or more, social class of origin and the interactions between social class and breastfeeding categories. Results show that for the 1958 cohort, breastfeeding increased the odds of upward mobility in both men (1.25, 95% CI 1.04-1.51) and women (1.45, 95% CI 1.19-1.76), independent of social class of origin. Similarly breastfeeding reduced the odds of downward mobility for men (0.78, 95% CI 0.62-0.98) and women (0.81, 95% CI 0.66-1.00). Breastfeeding had the same effect among members of different social strata. Results for the 1970 cohort are compared with these findings for the 1958 cohort and implications drawn for children growing up today.

Keywords: Social class; Resilience; Longitudinal research; Health behaviors

CORRESPONDING AUTHOR: Sacker Amanda, University of Essex; Colchester;



Singh AS.1, Te Velde S.2, Chin A Paw MJM.1, Androutsos O.3, Brug J.2

1 VU University Medical Center, EMGO Institute for Health and Care Research, Department of Public and Occupational Health, Amsterdam, The Netherlands

2 VU University Medical Center, EMGO Institute for Health and Care Research, Department of Clinical Epidemiology and Biostatistics, Amsterdam, The Netherlands

3 Harokopio University, Department of Nutrition & Dietetics, Athens, Greece

Purpose: Knowledge about the potential correlates of energy balance-related behaviours (EBRBs) is essential to guide interventions. The aim of the present study was to assess personal and social environmental correlates of EBRBs among 10- to12-year-old children in Europe.

Methods: A school-based survey among 10-12 year old children was conducted in eight European countries using a standardized protocol. Children completed a self-administered questionnaire measuring EBRBs and personal and social environmental factors. Age-adjusted covariance analyses were carried out, for the full sample and for each country separately. Descriptive analyses were conducted, looking at differences according to country and gender.

Results: More than 7000 children participated in the study. Children reported a more positive general attitude towards fruit juices than towards soft drinks. They reported good availability for soft drinks and fruit juices and very good availability for breakfast products in their home environment. Children’s attitude with regard to physical activity (PA) was very positive; their attitude towards watching TV was rather neutral. Children are well aware of the recommendations with regard to PA and television watching.

Conclusions: Children’s knowledge and attitude towards some EBRBs is good, although attention is needed for fruit juices and TV watching. There is also room for improvement for creating a home environment that is less obesogenic, across all European countries.


This work is presented on behalf of the ENERGY-consortium. The ENERGY-project is funded by the Seventh Framework Programme (CORDIS FP7) of the European Commission, HEALTH (FP7-HEALTH-2007-B).

Keywords: correlates, children, physical activity, sedentary behavior, soft drink consumption, fruit juice consumption

CORRESPONDING AUTHOR: Singh Amika, VU University medical center;



Kamphuis CBM.1, Turrell G.2, Giskes K.2, Mackenbach JP.1, Lenthe, van FJ.1

1 Erasmus MC, University Medical Center, Department of Public Health, Rotterdam, The Netherlands

2 Queensland University of Technology, School of Public Health, Brisbane, Australia

Objective: To study the role of childhood socioeconomic conditions and adulthood risk factors for explaining socioeconomic inequalities in cardiovascular diseases (CVD) mortality in adulthood.

Design and setting: The prospective GLOBE study was carried out in the Netherlands, with baseline data from 1991 and linked with the cause of death register in 2007. At baseline, participants reported on adulthood socioeconomic position (SEP) (own educational level), childhood socioeconomic conditions (occupational level of respondent’s father), and adulthood risk factors (health behaviours, material circumstances, psychosocial factors). Analyses included 5,395 men and 6,306 women, and Cox proportional hazard ratios (HR) were calculated.

Main outcome measures CVD mortality.

Results: A low adulthood SEP was associated with increased CVD mortality for both men (HR 1.84; 95% CI: 1.41-2.39) and women (HR 1.80; 95% CI: 1.04-3.10). The largest contributor to adulthood CVD inequalities were material conditions for men (42%; 95% CI: -73 to -20) and behavioural factors for women (60%; 95% CI: -191 to -28). Simultaneous adjustment for adulthood risk factors and childhood socioeconomic conditions attenuated the HR for the lowest adulthood SEP to 1.31 (95% CI: 0.97-1.78) for men and 1.19 (95% CI: 0.65-2.15) for women.

Conclusions: Adulthood material, behavioural and psychosocial factors played a major role in the explanation of adulthood SEP inequalities in CVD mortality. Childhood socioeconomic circumstances made a modest contribution, mainly via their association with adulthood risk factors. Efforts to reduce health inequalities should consider the influence of socioeconomic circumstances across the life course and specifically target adulthood risk factors

Keywords: cardiovascular disease; socio-economic status; health behaviors

CORRESPONDING AUTHOR: Kamphuis Carlijn, Erasmus University, Rotterdam;



Salari R., Fängström K.

Uppsala University, Department of Women's and Children's Health, Uppsala, Sweden

We employed a population-based approach to evaluate the reach and effectiveness of low intensity levels of Triple P – Positive Parenting Program when delivered by professionally trained teachers at their respective preschools.

Twenty one preschools were randomly assigned to either dissemination of Triple P (levels 2 and 3) or to the waitlist control condition. Participants in the study were 324 mothers and 228 fathers of children aged 3 to 5 years. Parents completed a set of questionnaires, including measures of externalising and internalising problems in children, parenting practices, parental satisfaction, inter-parental relationship, and parental adjustment. All parents in the intervention preschools were offered the program, but they could choose to accept or refuse the invitation.

Of 213 mothers and 150 fathers in the intervention preschools, 63 mothers (29.6%) and 25 fathers (16.75%) participated in at least one Triple P session over the 18-month period. We compared baseline measures for parents in the intervention preschools who did and did not attend the program later. Mothers who attended the program reported higher levels of problem behaviours in their children and lower parental satisfaction and efficacy, compared to non-attenders. Fathers who attended the program reported higher level of emotional problems in their children and higher levels of depression in themselves, compared to non-attenders. A series of repeated measures ANOVAs were used to compare the outcome measures for the two conditions at 18 months after baseline. Compared to the parents in the waitlist preschools, parents in the intervention preschools reported significant improvement only on one of the measures. Compared to fathers in the waitlist condition, fathers in the intervention condition reported lower levels of inconsistent parenting (p < .01). At baseline, inconsistent parenting was shown to be associated with child behaviour problems. Improvements in parental sense of efficacy for both mothers and fathers approached the significance level (p < .10).

These results suggest that an at-risk population self-selected themselves into the preventive program. However, to address all their needs appropriately, we might need to offer more high intensity interventions (levels 4 and 5) alongside the low intensity options.

Keywords: Population health, randomized controlled trial, prevention, children

CORRESPONDING AUTHOR: Salari Raziye, Uppsala University, Uppsala;



Meshkova T.1, Mitina O. 2, Aleksandrova R.1, Kelina M.1, Nikolaeva N.1

1 Moscow State University of Psychology and Education, Department of Clinical Psychology and Special Education, Moscow, Russia

2 Lomonosov MSU, Moscow State University of Psychology and Education, Laboratory of quantitative psychology, Moscow, Russia

To reveal the risk factors of eating disorders a special questionnaire was constructed. It measures different aspects of eating behaviors, family relations and family attitudes towards eating and figure, relations with friends and teachers, social environment (fashion tendency etc.), personal traits, health problems. To make the results more reliable several other questionnaires were used: Eating Attitude Test (EAT-26), Russian version of “Children's Report of Parental Behavior Inventory” (CRPBI), self-esteem and level of aspirations. The subjects were 661 girls and young women between ages 12 and 23, high school and college students from Moscow and Ryazan (regional center of Russia). It was shown that factors preventing or ameliorating disorders differ from one age phase to another and in the capital and middle size city. At the age of 15 girls realized physical changes in their body, and if they fail to receive mental support from the family or significant others in the new status (having difficult emotional self-access and are not able to reduce emotional instability and depression), they fall back into former conditions (anorexic behavior, physical exercises). The girls in the later period having overcome the fear of becoming an adult (including first sexual experience) they usually do not want to return to adolescence. They feel more separation from the family and surrounding people, are more experienced in the emotional self-access and use eating as a tool of emotional regulation. In this period they try to be more independent. The protection factors which were outgoing from the family become weaker and opposite: negative factors which can produce family relations can be more powerful in that time. Comparing two subsamples according place of living we can say that age differences are more significant in the megalopolis than in the regional city. Since eating disorder is in most cases not a separate problem, but is included in the complex relations among different attitudes, motivations, preferences and social environment complex moderation and mediation analysis using structural equation modeling was used to reveal the relationships.

Keywords: adolescents, eating behaviors, risk factors, population health

CORRESPONDING AUTHOR: Meshkova Tatiana, MSUPE, Moscow;



Nikolaeva EI.1, Verenkova VS.2

1 Herzen State Pedagogical University, Child's Psychophysiology and Psychology Department, Saint-Petersburg, Russia

2 Eletz State University, Department of Psychophysiology and Psychology, Eletz, Russia

The purpose of the report was to understand how mothers’ emotional behavior could influence the possibility of child’s recovery after the birth. About 95% of newborn infants in Russia have received the diagnoses from birth. These disorders are caused by mothers’ pathology during pregnancy. By the end of their first year about 40% of children and by the end of the second year about 60% of children recover. We used emotional intelligence assessment test and mothers’ attachment assessment test. The study included 100 mothers with their 100 children of the first and second years. The following two sets of procedures were used to carry out the aim of the study. The first set of procedures involved describing the distinct features concerning the health of children in their first or second year of life. A comprehensive appraisal of the children’s health was conducted based on health criteria (Golubeva et al, 2002), information obtained from the individual medical records of the children, aged up to two years. The second set of procedures was aimed at examining the psychological features of the mothers with children up to two years old and included the following procedures: a questionnaire evaluating the attitude of a mother toward a child during its first two years of life (Vereshagina & Nikolaeva, 2009) and the questionnaire to evaluate emotional intelligence (Lyusin, 2004). The most common diagnoses given to children at birth were perinatal encephalopathy and motor disturbance syndrome. There is no difference between mothers of children in the first and second years of life with respect to levels of attachment: 54 percent of the mothers in each group have a low level of attachment, and 44 percent and 42 percent, respectively, have an average level. Only 2% and 4% of the mothers with children in the first and second years of life have a high level of attachment. No mothers were found to suffer from maternal deprivation. A positive prognosis in relation to the children’s health during the first year of life depends on the level of a mother’s acceptance of her child; the higher the rating on the acceptance--non-acceptance scale, the healthier the child. The probability of a child’s recovery during the first two years of life cannot be predicted based on the mother’s ratings for emotional intelligence.

The work is supported by grant RGNF12-16-48010

Keywords: Health, children's health, health behavior

CORRESPONDING AUTHOR: Nikolaeva Elena, Herzen University, Petersburg;

Health and Performance related to Workstress



Panagopoulou E.1, Tsigka E.2, Montogmery A.3

1 Aristotle University of Thessaloniki, Medicine, Thessaloniki, Greece

2 Aristotle University of Thessaloniki, Department of Family Medicine, Thessaloniki, Greece

3 University of Macedonia, Department of Educational Psychology and Health Psychology, Thessaloniki, Greece

Despite advancements in patient safety procedures medical errors continue to increase within hospital settings. Preliminary evidence has identified burnout as one risk factor for medical errors. However, very little information exists on the types of errors that are more likely to occur from physicians suffering from burnout.

Aim: This study is part of the ORCAB project, a multi-center project examining the effects of burnout on quality of care. The project is funded under the FP7th Research Framework. The aim of this study was to examine the associations between physician burnout and two different types of medical errors: omissions, referring mainly to memory lapses and attentional slips, and medical mistakes occurring as a result of false judgment, or violation of hospital procedures.

Methods: 510 surgeons, and internal medicine specialists from 12 different centers in 5 different countries participated in the study. Burnout was assessed using valid versions of the MBI for each participating country. Medical errors were assessed using a scale developed, and validated for the purposes of the study. Participants had to indicate in a visual analogue scale the frequency of occurrence of several types of omissions, or mistakes during the past six months.

Results: Controlling for the effects of gender, age, years of experience, burnout was predictive of medical omissions for both surgeons and internal medicine specialists (p < .01).

Conclusions: Results indicate that burnout does not influence clinical judgment. At the same time, it interferes with cognitive processes, such as memory and attention and can therefore endanger clinical practice.

Keywords: occupational health decision making

CORRESPONDING AUTHOR: Panagopoulou Efharis, Aristotle University;



Montgomery A.1, Georganta K.1, Tsiga E.2, Panagopoulou E.2

1 University of Macedonia, Department of Education and Social Policy, Thessaloniki, Greece

2 Aristotle Medical School, Lab of Hygeine, Thessaloniki, Greece

Aim: Burnout reduces the ability of healthcare professionals to provide the best quality of care possible and increases the risk that they will make mistakes. Moreover, healthcare professionals who deal directly with patients on a daily basis report even higher burnout levels. The well being of healthcare professionals has a direct impact on the quality of care delivered to patients. The aim of the following paper is to evaluate the relationship between job burnout, job engagement and sub-optimal care.

Method: Participants were healthcare professionals from university clinics from the city of Thessaloniki, Greece. Survey data were collected from a sample of 379 health care professionals. The sample included physicians (29%), nurses (38%) and medical residents (33%) working in both medical and surgical units of a University Hospital. Self-reported data on job burnout, job engagement, affectivity and reported sub-optimal care were collected.

Results: Controlling for affectivity, hours worked and work experience, within the total sample sub-optimal care was significantly associated with depersonalisation (beta = .31, p < .001), but not emotional exhaustion, vigour or dedication. In terms of mean differences, physicians, in comparison with residents, reported higher levels of both vigour (p < .001) and dedication (p < .001). Residents, in comparison with physicians reported higher levels of both emotional exhaustion (p < .05) and depersonalization (p < .05), while nurses also reported higher levels of emotional exhaustion (p < .05) in comparison with physicians.

Conclusions: The quality of care delivered to patients is crucial, and the well being of healthcare professionals is symbiotically connected with the care of the patients. The present study demonstrates that depersonalization is a key reason as to why patients may be receiving sub-optimal care. The data suggest that residents in particular are an at-risk group. The present study is cross-sectional thus it is difficult to infer causality. However, the results have important implications for both medical education and the organisational experience of healthcare professionals within hospitals.

Keywords: burnout, engagement, sub-optimal care

CORRESPONDING AUTHOR: Montgomery Anthony, University of Macedonia;



Spanu F.1, Baban A.1, Dumitrascu D.2, Bria M.1

1 Babes-Bolyai University, Department of Psychology, Cluj-Napoca, Romania

2 Iuliu Hatieganu University of Medicine and Pharmacy, Department of Internal Medicine, Cluj-Napoca, Romania

Aim: There is substantial evidence showing that burnout mediates between work demands and the quality of personal and working life among health professionals. Recent studies have shown that medical personnel experiencing high levels of burnout also report lower level of quality of care provided to their patients. The aim of our research was to investigate if perceived work demands impact the quality of care provided by health professionals, and whether this relationship is mediated by burnout.

Method: Survey data were collected from a sample of 311 health professionals in Romania, as part of the ORCAB European project. The sample included physicians (N = 74), nurses (N = 146) and residents (N = 91) working in both medical and surgical units of a University Hospital. Self-reported data on burnout (Maslach Burnout Inventory), suboptimal care and work demands (organizational demands, physical demands and emotional demands) were collected. All scales show good internal consistency coefficients. The mediation model was tested using Structural Equation Modeling, in AMOS. Bootstrapping was used in order to investigate whether the mediated path is significant.

Results: Fair support was found for the hypothesized model (χ2 = 49.159, df = 7, GFI = .953, CFI = .930, NFI = .918, RMSEA = .113). Significance test for the indirect effect showed that burnout mediates the impact of job demands on quality of care (β = .631, p = .001).

Conclusions: Our data revealed that job demands impact the quality of care provided to the patients and that health professionals’ burnout mediates this relationship. These results have implications for designing interventions aiming at improving quality of care. They show that efforts should start with improving the quality of the work experience in the medical field.

Keywords: Occupational health, Health outcomes

CORRESPONDING AUTHOR: Spanu Florina, Babes-Bolyai University, Cluj;



Suominen S.1, Koponen A.2, Virtanen M.3, Simonsen N.2, Vahtera J.1

1 University of Turku, Department of Public Health, Turku, Finland

2 Folkhälsan Research Center, Research program of Public Health, Helsinki, Finland

3 Finnish Institute of Occupational Health, Organization and management, Helsinki, Finland

Introduction: Previous studies suggest an association between favourable psychosocial work environment of the health care personnel and good treatment outcome within several patient groups.

Aim: The aim of the present study was to explore whether balance between perceived work demands and work control, i.e. work strain, among primary care health center (PCHC) personnel is associated with glycemic control of treated type 2 diabetes patients.

Material and methods: A survey of the psychosocial work environment of the personnel (doctors and nurses) in 18 PCHCs in 5 municipalities in Finland was carried out in 2006 as a part of the longitudinal Ten Town Study. Register data of work unit characteristics from 2006, as e. g. rate of sickness absence among personnel was gathered from the municipalities running the PCHCs and with appropriate consent linked to the survey data.

General population data on mean income in 2006 and unemployment rate in 2007 from the area the PCHC served was delivered by Statistics Finland.

Sex and age of patients (N = 8 975) with type 2 diabetes and their HbA1c values (<7% vs. > = 7%) on glycemic control were collected from the patient registries of the health care centers and made anonymous.

The individual personnel and patient data were linked on the level of the PCHC and analyzed with multi-variate multi-level logistic regression modeling using R software.

Results: Perceived high work stain (high demands, low control) among personnel associated significantly (OR 1.44, p < 0.01) with poor glycemic control among type 2 diabetes patients when variables describing work unit characteristics and population data at the area level were controlled for. Social support from the supervisor did not associate with glycemic control.

Conclusion: Developing psychosocial work environment by decreasing work strain can improve glycemic control of type 2 diabetes patients. Thus, it can be speculated that such measures could have positive effect on the outcome of treatment of several other public health problems.

Keywords: Managed care, Worksite heatlh, Effectiveness

CORRESPONDING AUTHOR: Suominen Sakari, University of Turku;



Alexandrova-Karamanova A.1, Dimitrova E.2, Panayotova Y.1, Naydenova V.3

1 Health Psychology Research Center, -, Sofia, Bulgaria

2 Institute for Population and Human Studies – Bulgarian Academy of Sciences, Department of Demography, Sofia, Bulgaria

3 Sofia University “St. Kliment Ohridski”, Department of Work, Social and Educational Psychology, Sofia, Bulgaria

Introduction: Work specifics of medical profession characterize it as stressful, demanding and with high level of responsibility, thus implying greater risk for health professionals’ health and well-being. Nevertheless, organizational culture in hospital settings and its impact on health and well-being of health professionals has rarely been in the focus of research, particularly in Bulgaria.

Aim of the study: To identify which aspects of organizational culture are relevant for health professionals’ risk, protective health behaviours and emotional well-being.

Methods & sample: The data is from a quantitative survey (part of the ORCAB project) conducted among doctors, nurses and residents in University hospitals in Sofia. By means of correlation and regression analyses we identify the organizational factors influencing health protective and health risk behaviours of hospital staff as well as their emotional well-being (positive & negative affectivity) at work. The predictors included in the models are: types of organizational culture (Clan, Market, Hierarchy and Adhocracy) and Physical, Emotional, Organizational and Cognitive work demands. We also control for hospital, staff position, weekly work hours and demographic characteristics.

Main findings: The results show that organizational culture types are predictors of negative affectivity and risk health behaviours; work demands are predictors of negative affectivity and both protective and risk health behaviours. Higher strength of the organizational culture and lower work demands are generally related to better emotional well-being, higher frequency of health protective behaviours and lower frequency of risk health behaviours.

Discussion & implications for practice: The findings reveal that hospital organizational culture has a significant impact on health professionals’ functioning, which may affect patient safety and quality of care patients receive. The results are relevant to the development of organizational change intervention at participating hospitals (next stage of the ORCAB project), allowing a focus on the change of specific aspects of organizational culture that bear higher risk for health professionals’ health and well-being.

Keywords: Occupational health, health behaviours, emotions

CORRESPONDING AUTHOR: Alexandrova-Karamanova Anna, Health Psychology Center, Sofia;



Van der Klink JJL., Koolhaas W., Groothoff JW., Brouwer S.

University Medical Center Groningen, Public Health, Groningen, The Netherlands

Aims: Many older workers face increased vulnerability to their work ability. Aims of this study were: a) to examine the association of coping and social support on work ability; and b) to determine the role of support in mediating the association of coping strategies with work ability.

Methods: Data of this cross-sectional study were obtained from workers older than 45 years (N = 14565). Work ability was measured by the Work Ability Index (WAI). The Utrecht Coping List was used to assess active, emotional and avoidance coping. Organisational, co-worker and community support were measured with a standardized scale. Effect of coping strategies and perceived support on work ability were investigated with linear regression analysis. Mediation of support on the relation between coping and work ability was tested using a multistage regression approach.

Results: Differences between a poor/moderate and good/excellent work ability were significant for all variables in the univariate analyses. In the multivariate model occupation, coping strategies and co- worker and community support remained significant (p < .001). On active coping, community support explained 12,5% of the variance in work ability (β = 0.349, p < .01), and together community support and active coping explained 13,7% or the variance in work ability (β = 0.265, p < .01). The effect on work ability was less with community support as a mediator but remained significant thus continuing to exert a direct effect on work ability. Also on emotional coping, community support predicted work ability (β = 0.349, p < .01), and the contribution of interference with emotional coping to work ability was reduced (β = -0.206, p < .01), indicating that community support partially mediated effects of emotional coping on work ability. On avoiding coping co-worker support contributed to the inverse prediction of work ability (β = -0.382, p < .01), and the contribution of interference with avoidance coping to work ability was reduced (β = -0.323, p < .01).

Discussion: Because the cross/sectional design only associations between coping styles, support and work ability can be established. Community support mediates the effects of active and emotional coping on work ability; co-worker support mediated the effects of avoidance coping.

Keywords: Coping, Social support, Work Ability

CORRESPONDING AUTHOR: van der Klink Jac, University MC Groningen;

Smoking Cessation: Novel Intervention Approaches



Turrell G.1, Hewitt B.2, Miller S.1

1 Queensland University of Technology, School of Public Health, Brisbane, Australia

2 University of Queensland, Institute of Social Science Research, Brisbane, Australia

Introduction and aims: Individual smokers from disadvantaged backgrounds are less likely to quit, which contributes to widening inequalities in smoking. Residents of disadvantaged neighbourhoods are more likely to smoke, and neighbourhood inequalities in smoking may also be widening because of neighbourhood differences in rates of cessation. This study examined the association between neighbourhood disadvantage and smoking cessation and its relationship with neighbourhood inequalities in smoking.

Design and methods: A multilevel longitudinal study of mid-aged (40-67 years) residents (n = 6915) of Brisbane, Australia, who lived in the same neighbourhoods (n = 200) in 2007 and 2009. Neighbourhood inequalities in cessation and smoking were analysed using multilevel logistic regression and Marko chain Monte Carlo simulation.

Results: After adjustment for individual-level socioeconomic factors, the probability of quitting smoking between 2007 and 2009 was lower for residents of disadvantaged neighbourhoods (9.0%-12.8%) than their counterparts in more advantaged neighbourhoods (20.7%-22.5%). These inequalities in cessation manifested in widening inequalities in smoking: in 2007 the between-neighbourhood variance in rates of smoking was 0.242 (p ≤ 0.001) and in 2009 it was 0.260 (p ≤ 0.001). In 2007, residents of the most disadvantaged neighbourhoods were 88% (OR 1.88, 95% CrI 1.41-2.49) more likely to smoke than residents in the least disadvantaged neighbourhoods: the corresponding difference in 2009 was 98% (OR 1.98 95% CrI 1.48-2.66).

Conclusion: Fundamentally, social and economic inequalities at the neighbourhood and individual-levels cause smoking and cessation inequalities. Reducing these inequalities will require comprehensive, well-funded, and targeted tobacco control efforts and equity based policies that address the social and economic determinants of smoking.

Keywords: Smoking, socio-economic status, longitudinal, tobacco control

CORRESPONDING AUTHOR: Turrell Gavin, QUT, Brisbane;



Meyer C.1, Ulbricht S.1, Grothues J.2, Rumpf H-J.2, John U.1

1 University of Greifswald, Institute of Epidemiology and Social Medicine, Greifswald, Germany

2 University of Lübeck, Department of Psychiatry and Psychotherapy, Lübeck, Germany

Aim: The research question was whether sufficiently large proportions among populations may be recruited for brief intervention using three approaches of recruitment. Each of them included two studies.

Methods: In the phone-based approach 1 for a first study a random sample of phone numbers had been drawn in Germany. In a second study all families with a child below 4 years were addressed. Approach 2 was a setting-approach. In a first study a random sample of general medical practices and in the second study a random sample of dental practices had been drawn. Each consecutive patient at age 18 to 70 was contacted. In the setting- and life-event-based approach 3 girls and women at age 14 to 25 were addressed in gynecological practices. The second study of approach 3 included the recruitment of women after having given birth on obstetric wards. The aim in the majority of the six studies was abstinence from tobacco smoking. Brief interventions were based on the Transtheoretical Model of Intentional Behavior Change and on Motivational Interviewing.

Findings: In approach 1, study 1, six thousand and seventy-three households that included smokers were contacted. Among the smokers, 50.3% participated in the intervention study. In study 2, among 1,287 contacted families with one or more smokers, 71.6% participated in the study. In approach 2, among 2,074 eligible patients in general medical practices 79.8% took part. Among 303 patients in dental practices, 77.3% were ready to participate in the study. In approach 3, among 869 eligible patients in gynecological practices 80.4% (study 1), and among 1,128 mothers on the obstetric wards 77.2% were recruited. All samples included a majority of smokers who did not intend to quit smoking in the next six months.

Conclusions: The proactive strategies implemented in the three approaches to recruit smokers for brief interventions provided promising proportions of participants.

Keywords: Population impact; Smoking cessation; Brief Interventions; Motivation Interviewing; Transtheoretical model

CORRESPONDING AUTHOR: Meyer Christian, University of Greifswald;



Bock B.1, Foster R.2, Deutsch C.2

1 Brown University, Psychiatry, Providence, USA

2 Live Inspired LLC, Providence, USA

There is growing interest in behavioral interventions delivered through mobile platforms. We conducted an 8-week smoking cessation program developed using recommendations from focus groups. The program was delivered primarily through SMS text messages and included social networking for peer support along with tailored messages based on user feedback. In a randomized pilot trial we compared this program (TXT) to a control condition (Mojo) of daily non-smoking-related motivational texts. Outcome variables include 24-hour (self-reported) and 7-day (cotinine verified) abstinence.

Adults smoking >3 cigarettes/day who used text messaging were eligible. Individuals (191) were screened for eligibility online (66%) or by phone (34%). Of those screened, 39% did not complete the online enrollment after screening, 12% did not wish to come to the in-person visit for orientation, 8% were declined to participate and 9% were ineligible.

Results: Enrolled participants (N = 60) averaged 32 years of age (range: 18-61), and were primarily non-Hispanic white (70%); Black (22%), or bi/multi-racial (6%); 20% were Hispanic. Most had completed 12 (21%), 14 (36%), or 16 (24%) years of education. The sample was evenly split between those who worked part time (<35 hrs/week) full time (35+ hrs/week), and those who were unemployed. Participants smoked an average of 16 cigarettes/day (SD = 8.4; range 4-40). Most (73%) had not made a serious quit attempt (>24 hrs) in the past year.

For 24-hour abstinence, intention to treat analyses showed that at the 8 week (end of treatment) assessment, 25.0% of TXT and 17.4% of Mojo groups reported abstinence (OR = 1.43). At the 3-month follow up 21.4% of TXT and 8.7% of Mojo group reported abstinence (OR = 2.46).

For 7-day abstinence, at the 8 week (end of treatment) assessment 21.4% of TXT and 13.0% of Mojo groups achieved abstinence (OR = 1.64). At the 3-month follow up 17.9% of TXT and 4.3% of Mojo group were abstinent (OR = 4.11).

These results indicate that mobile technology has significant potential for aiding smoking cessation in people’s everyday lives. Participants’ positive responses to the program’s social networking and tailored messaging capabilities suggest that these features warrant further study as tools for promoting smoking cessation.

Keywords: Smoking, Text Message, Mobile Health

CORRESPONDING AUTHOR: Bock Beth, Brown Medical School, Providence;



Van der Aalst C. M.1, Van Klaveren R. J.2, Willemsen M. C.3, De Koning H. J.1

1 Erasmus MC, University Medical Center, Department of Public Health, Rotterdam, Netherlands

2 Erasmus MC, University Medical Center, Rotterdam, Netherlands

3 CAPHRI School for Public Health and Primary Care, Maastricht University, Health Education & Promotion, Maastricht, Netherlands

Worldwide, the burden of cancer is still increasing, which is in a high degree due to an increased adaptation of (cancer related) risk-behaviour. Several cancer screening programmes are effective in reducing cancer mortality, but evidence about the impact of these programmes on future lifestyle is scarce. Our review showed that cancer screening might be a teachable moment, but a major concern is the potential health certificate effect (review 1). The impact of lung cancer screening was investigated amongst smokers of the Dutch-Belgian randomised controlled lung cancer screening (NELSON) trial (trial 1 and 2).

Two random samples were selected of 50-75 years old male smokers at high risk for developing lung cancer randomised to the screen (n = 641) or control arm (n = 643) of the NELSON trial. Smoking behavioural change was investigated at randomisation (T0), 2 years (T1, trial 1) and 4 years of follow-up (T2, trial 2). At T1, prolonged abstinence was reported in 14.5% of the screen arm smokers and 19.1% of the control arm smokers (p < 0.05). After 4 years, these rates were 24.3% (screen arm) and 29.3% (control arm) (p = 0.09). Multivariate analysis showed that lower baseline nicotine dependency and randomisation to the control arm increased the likelihood of being abstinent from smoking at follow-up. Multivariate analysis showed that the allocation to the control arm (T1, T2), the level of education (T1), the motivation to quit smoking (T1) and the level of nicotine dependency (T2) were predictors of smoking abstinence at follow-up (T1 and T2) (p < 0.05)

In conclusion, although all trial participants were inclined to quit smoking more than average, male smokers who received CT screening for lung cancer were statistically significant less likely to quit smoking, possibly due to a false feelings of reassurance caused by screening. Research is urgently needed to battle this effect and to increase the potential of cancer screening to reduce the burden of (lifestyle-related) cancer.

Keywords: smoking, tobacco use, cancer screening

CORRESPONDING AUTHOR: van der Aalst Carlijn, Erasmus MC;



Diviani N., Schulz P J.

University of Lugano, Institute of Communication and Health, Lugano, Switzerland

Background: People’s health is the result of a complex interaction of different determinants – e.g. the individuals’ socioeconomic status, the availability of social support or existing public policies. Disparities in smoking related to socioeconomic status, in particular to educational level, have been widely acknowledged by several studies worldwide and most of the efforts to reduce smoking and cancer disparities have relied on education. In Switzerland, smoking and cancer rates are higher than in other developed countries, but the country presents lower than average health inequalities related to socioeconomic status. The Swiss model of universal healthcare leads us to rule out a major impact of public policies as well, and to hypothesize that an important role in explaining smoking disparities in Switzerland is played by another determinant of health, namely the presence or absence of the support of a social network.

Methods: To assess the role of social support in predicting tobacco disparities in Switzerland, data on tobacco use, availability of a social network, and education collected in a representative sample of the Swiss population (N = 17,760) in the context of the 2007 Swiss Health Survey have been analyzed.

Results: Respondents with lower educational level (compulsory education or less) did not present higher smoking rates but, on the contrary, with a smoking rate of 23.1%, this group was the one with the lowest percentage of smokers (p < .001). As regards social support, respondents reporting not having a person with whom they can discuss about personal problems presented significantly higher smoking rates than the others (p < .001). Specifically, a particularly important role is played by the presence or absence of familiar support, with respondents reporting not having a reference person within the family or seeing family members only one a year or less presenting higher smoking rates (p < .001).

Discussion: Tobacco control interventions targeted to low-education groups that have been successful in other countries may not obtain the same results in Switzerland. Swiss policy makers should consider the possibility to develop new strategies aimed at providing people the social support they lack within their social and familiar environment.

Keywords: smoking; health disparities; social support

CORRESPONDING AUTHOR: Diviani Nicola, Università di Lugano, Lugano;

Models and Theory- based Interventions for Risk Reduction



Emmons K.M.1, Puleo E.2, Viswanath V.1, Gillman M.W.3, Bennett G.G.4, Haines J.5, Sprunck-Harrild K.1, Greaney M.1

1 Dana-Farber Cancer Institute, Medical Oncology, Boston, USA

2 University of Massachusetts, Amherst, School of Public Health, Amherst, MA, USA

3 Harvard School of Public Health, SPH Nutrtion;HMS Population, Boston, USA

4 Duke University, Psychology and Neuroscience, Durham, USA

5 University of Guelph, Family Relations and Applied Nutrition, Ontario, Canada

Effective and scalable interventions addressing multiple risk behaviors are needed. Healthy Directions-2 (HD2) was a theory-driven cluster RCT to promote improvement in five cancer risk factors in the context of primary care: smoking, physical activity (PA), and intakes of red meat (RM), fruits and vegetables (FV), and multi-vitamins (MV). The primary sampling unit was the provider, randomized to three arms: 1) usual care (UC); 2) web or print intervention materials (HD2); or 3) HD2 materials plus 2 brief coaching calls (HD2+). Secondary sampling units were patients within practice (n = 2,440); they were racially/ethnically diverse (46% non-white) with only 3.0% meeting all behavioral recommendations at baseline. Follow-ups were post 6-month intervention, and at 18 mos. Primary outcome was change in multiple risk factor (MRF) score. Change in individual risk factors was a secondary outcome.

HD2 and HD2+ led to improvements in MRF score, vs UC; 34% of UC participants had improved MRF scores at 6 mo., vs 49% and 50% in HD2 and HD2+ respectively (p < .0001), with similar results at 18 mo. (p < .003). Individual risk factor analyses focused on those participants with a specific risk factor at baseline. At 6 mo., HD2+ led to greater increases in the number of participants that met PA guidelines than either UC or HD (55%, 37%, and 37% respectively, p < .005), but there were no differences at 18 mo. Both HD2 and HD2+ led to increased MV use at 6 and 18 mo., (p’s < .0005), decreased RM intake at 18 mo. (p < .04), and marginally increased FV intake at 6 mo. (p < .08) vs UC. HD2 led to marginal increases in FV compared with either HD2+ or UC at 18 mo. (p < .08). There were no significant differences in smoking. Cost-effectiveness analyses are underway.

HD2 demonstrated that the two intervention conditions had equivalent levels of effect in reducing multiple risk factors in a large population of primary care patients, and equal impact on individual risk factors; an exception was physical activity, where the addition of coaching proved more effective. This study provides important information re the limited additional impact of counseling over materials-based interventions, for reduction of population risk for preventable disease.

Keywords: Cancer, Health Behavior Change

CORRESPONDING AUTHOR: Emmons Karen, Dana-Farber Cancer Inst, Boston;



Wu C-J., Chang A. M.

Queensland University of Technology, School of Nursing, Brisbane, Australia

While the literature demonstrates the lack of a theoretical base for many health intervention programs, some studies do refer to an underpinning theory, but provide little detail on how the theory is applied to interventions being tested for effectiveness. A theoretical framework is crucial to specifying the fundamental elements for guiding the development of intervention programs and selection of appropriate outcomes. Without explicitly knowing the theoretical basis for the intervention elements, it is difficult to replicate a particular intervention, thus reducing repeated testing of the effectiveness of an intervention. There is some research supporting the use of Bandura’s Social Cognitive Theory in health intervention programs for changing people’s individual health behaviours. Self-efficacy is a core construct of this theory, and strategies including mastery, vicarious experience, verbal persuasion and self-appraisal are advocated to promote patient’s adoption of self-management. This paper illustrates the application of using the self-efficacy construct and aims to demonstrate how a framework can be used in developing the main components of an intervention program and in the delivery of a peer-support based cardiac-diabetes self-management program. More explicit depiction of the theoretical components of such intervention programs would ensure meta-analyses of studies of self-management programs had greater homogeneity. Provisional findings indicate that a self-efficacy theory-based intervention program for those with chronic disease has the potential to improve effectiveness in managing their conditions.

Acknowledgements: The full study was supported by funding from the Department of Health & Ageing through the ‘Sharing Health Care Initiative’ Research Grant in Australia.

Keywords: peer support, self-management, theory, self-efficacy, cardiac, diabetes




Ramadas A.1, Quek KF.1, Oldenburg B.2, Chan CKY.1, Zanariah H.3

1 Monash University, Jeffrey Cheah School of Medicine and Health Sciences, Petaling Jaya, Malaysia

2 Monash University, School of Public Health and Preventive Medicine, Melbourne, Australia

3 Hospital Putrajaya, Department of Medicine, Putrajaya, Malaysia

Introduction: Despite the fact that the Internet is a convenient and effective intervention delivery medium, there are only a few successful web-based studies reported with type 2 diabetes mellitus (T2DM) patients. Furthermore, none of these interventions focused on dietary management of these patients.

Rationale & Objective: We designed a two-armed randomized-controlled trial (myDIDeA) to improve dietary knowledge, attitude and behavior (DKAB) the patients with uncontrolled HbA1c (>7.0) via a 6-month web-based dietary education program.

Methods: T2DM patients (n = 128) from the outpatient clinics at three public hospitals were recruited with informed consent, and then randomized into the e-intervention (n = 66) or the control (n = 62) group. The e-intervention group received an intensive six-month dietary intervention through the study website, which was developed based on various established guidelines and recommendations but personalized according to the participants’ dietary stages of change, in addition to the usual standard treatment at the outpatient clinics. In contrast, the control group continued their usual standard treatment for patients with T2DM in the hospitals. Data were collected at baseline, 6 months post-intervention and at 12 months follow-up using validated instruments. All data were analyzed with IBM® PASW® Statistics 17.0.

Results & Discussion: Despite within group analysis showing an increase in the mean DKAB in both groups (p < 0.001), Bonferroni post-hoc analysis between groups revealed significantly higher mean DKAB scores in e-intervention group at post-intervention (p < 0.01) and follow-up (p < 0.001), compared to baseline. Similar to the total DKAB score, those in the e-intervention group showed significantly higher dietary knowledge and attitude score compared to the control group (p < 0.01). However, only the participants in the e-intervention group have shown significant improvement in the dietary behavior score at post-intervention and follow-up (p < 0.001).

Conclusion: myDIDeA was found to be a successful intervention program to improve the overall DKAB score, due to the improvement in the knowledge and attitude sub-domains.

Keywords: Diet, Diabetes, Behavior Change, e-Health, Intervention, Randomized controlled trial

CORRESPONDING AUTHOR: Ramadas Amutha, Monash University, Sunway;



Meyer C.1, Ulbricht S.1, Rumpf H-J.2, John U.1

1 University of Greifswald, Institute of Epidemiology and Social Medicine, Greifswald, Germany

2 University of Lübeck, Department of Psychiatry and Psychotherapy, Lübeck, Germany

Background: Although brief physician-delivered advice to stop smoking is both effective and cost-effective, implementation in routine clinical practice is still insufficient. Computer-based interventions emerged as a time saving option that might help to exhaust the potential population impact of the general practice setting. The aim of the present study was to combine measures of efficacy used in clinical trial with other components determining population impact as described in the “Reach, Efficacy – Adoption, Implementation, Maintenance” (RE-AIM) framework developed by Glasgow and colleagues.

Method: 151 practices were randomly assigned to one of three intervention programs consisting in the delivery of: (1) brief advice by the practitioner; (2) individually tailored computer-generated letters; or (3) a combination of both interventions. We assessed three dimensions of population impact: (1) adoption, i.e., the rate of practices participating in the program; (2) reach, measured as the number of interventions provided within 7 months; (3) effectiveness, measured as smoking abstinence at 12-months follow-up.

Results: Among the practices, 70% adopted the program with no significant differences across study groups. Treatment was provided to 3086 adult smokers. Negative binomial regression analysis revealed that the number of interventions provided was higher in practices allocated to the tailored letter and combination intervention groups by 215% (p < .01) and 127% (p = .02), respectively, compared to the brief advice intervention group. Among the patients who received the combination of both intervention, the odds of point abstinence from smoking was increased by 65% (p = .02) and 32% (p = .01) compared to the brief advice and tailored letters intervention respectively. Comparing the number of abstinent patients at follow-up revealed that the tailored letter and combination interventions were superior to the brief advice intervention.

Conclusions: Computer-based interventions alone or in addition to conventional practitioner-delivered advice can foster the participation of general medical practices in tobacco control. The comprehensive evaluation of the different components determining the population impact revealed that the most relevant improvement can be attributed to “Reach”. Future methodological research should target the development of standards for research designs to assess the population impact.

Keywords: RE-AIM; Smoking Cessation; Primary medical care; Computer expert systems; Brief interventions

CORRESPONDING AUTHOR: Meyer Christian, University of Greifswald;



Esperat C.1, Inouy J.2, Gonzalez E.3, Feng D.4, Song H.1

1 Texas Tech University Health Sciences Center, School of Nursing, Lubbock, USA

2 University of Hawaii, School of Nursing and Dental Hygiene, Honolulu, Hawaii, USA

3 Drexel University, College of Nurisng & Health Professions, Philadelphia, USA

4 Texas Tech University, Human Development and Family Studies, Lubbock, USA

Purpose: The purpose of the study was to examine the effects of using community health workers on behavior change and clinical outcomes in under-served minority populations with chronic illness. The Transformation for Health conceptual framework, based on the work of Paulo Friere, a Brazilian philosopher, was used to guide this study, allowing integration of existing theories and constructs in explaining the process of transformational behavior.

Method: A Patient Navigation Program (PNP), using community health workers (Promotoras) for chronic disease self-management was implemented at a nurse-managed primary clinic in East Lubbock, Texas. Patients (N = 152) with diabetes, hypertension, asthma, and co-morbidities of obesity and/or depression participated in the study. Using community health workers, patients with chronic illness were followed for two years. HgA1c, blood pressure and lipid profiles were collected to monitor clinical outcomes. The Patient Health Questionnaire, Self Efficacy for Diabetes Management Survey (SED), Self Efficacy for Managing Chronic Disease (SEMCD) instrument and Summary of Diabetes Self Care Activities (SDSCA) Questionnaire were used to monitor behavioral changes. Descriptive statistics and paired t-tests were used to analyze clinical and behavior changes between baseline and at 24 months.

Results: The hospitalization rate of asthma patient (n = 27) was reduced significantly from 51.6% (12 months prior to TPS) to zero during navigation program (χ2 = 18.9, p < .001). Paired t-test shows an average reduction of 1.14% on HbA1c level in diabetes patients (n = 125), which was significantly reduced from average 9.1% to 7.8% (t124 = 7.49, p < .001). The average scores for SED, SEMCD and SDSCA were significantly improved 1.12 (t55 = -5.07, p < .001), 0.99 (t70 = -3.98, p < .001) and 0.77 (t53 = -4.59, p < .001), respectively after enrollment in the program. The mean score for the Opportunity for Nurturance subscale of the social provisions instrument was significantly decreased 0.58 (t77 = 2.35, p < .05) after enrollment in the PNP. Overall, these findings provide support for the effectiveness of community health workers in facilitating clinical and behavioral changes among the patients of the Patient navigation program.

Keywords: Chronic illness, Community intervention, Health behavior change

CORRESPONDING AUTHOR: Esperat Christina, Texas Tech University, Texas;



Hagger M.1, Lonsdale A.2, Hein V.3, Koka A.3, Pasi H.4, Lintunen T.4, Lindwall M.5, Rudolfsson L.5, Chatzisarantis N.6

1 Curtin University, School of Psychology and Speech Pathology, Perth, Australia

2 Oxford Brookes University, Department of Psychology, Oxford, United Kingdom

3 Tartu University, Faculty of Exercise and Sports Sciences, Tartu, Estonia

4 University of Jyvaskyla, Department of Physical Education, Jyvaskyla, Finland

5 University of Gothenberg, Department of Psychology, Gothenburg, Sweden

6 National Institute of Education, Physical Education and Sports Science, Singapore, Singapore

This study tested an integrated model of the psychosocial determinants of alcohol-related behaviour among company employees from four nations. A motivational sequence was proposed in which motivational orientations from self-determination theory influenced intentions to consume alcohol within guideline limits and alcohol-related behaviour via the mediation of the theory of planned behaviour variables of attitude, subjective norms, and perceived behavioural control (PBC). A three-wave prospective design using self-reported psychological and behavioural measures. Company employees (N = 486, males = 225, females = 261; M age = 30.41, SD = 8.31) from four nations (Estonia, Finland, Sweden, and UK) completed measures of autonomous and controlled motivation from self-determination theory, attitudes, subjective norms, PBC, and intentions from the theory of planned behaviour, and self-reported measures of past alcohol consumption and binge-drinking occasions at the first time point (time 1). Follow-up psychological and behavioural measures were taken one month later (time 2) and follow-up behavioural measures taken a further 2 months later (time 3). Path analyses supported the motivational sequence with identified regulation (time 1) predicting intentions (time 1), and alcohol units consumed (time 2). The effects were indirect via the mediation of attitudes and PBC (time 1). A similar pattern of effects was found for the effect of time 2 psychological variables on time 3 units of alcohol consumed. There was little support for the effects of the psychological variables on binge drinking behaviour. Findings provide new information on the psychosocial determinants of alcohol behaviour in company employees and the processes involved. Results may provide impetus for the development of interventions to reduce alcohol consumption.

Keywords: alcohol, binge drinking, intentions, identified regulation, autonomous motivation

CORRESPONDING AUTHOR: Hagger Martin, Curtin University, Perth;

Behavioral Medicine in China - Prospects and Challenges



Oldenburg B.

Monash University, Public Health, Melbourne, Australia

Chair: Carina Chan, Malaysia


Xuefeng Zhong: Peer Support interventions for Diabetes and Community Health Centers in China

Ding Ding: Preventing smoking initiation among rural-to-urban migrant women in China

Joseph Lau: The role of behavioral medicine research in HIV research in China

Discussant: Brian Oldenburg

China will have a population of almost 1.5 billion people by 2030. Although life expectancy has improved remarkably over the past 20 years, many public health challenges remain, including rising non-communicable diseases (NCDs), emerging infectious diseases and environmental issues. Recent times have also seen the rapid rise of the same lifestyle risk factors that are driving the NCD epidemic in other countries.

Behavioural medicine can play an important role in disease prevention and health promotion. However, the professional and research disciplines that contribute to the inter-disciplinary field of behavioral medicine in other countries do not have the same traditions in China, e.g, very few universities in China offer any health psychology training and there is also a lack of interdisciplinary research in public health and related fields.

Three examples of behavioral medicine research in China will be presented and each presenter will discuss how s/he undertook the study and the challenges and issues that confronted them. Zhong Xuefeng will present on the development and evaluation of a novel peer-support intervention for diabetes that was conducted in community health centers. Ding Ding will present on smoking prevention among rural-to-urban migrant women and potential policy strategies in mainland China. Joseph Lau will illustrate the opportunities and challenges of applying behavioural medicine research approaches in HIV-related research in China. The discussion will focus on the uniqueness of behavioral medicine research in China due to its cultural traditions and health care system. Further discussion will address the opportunities and challenges in establishing stronger behavioural medicine traditions in China for the future.

Keywords: public health, multiple risk factors, health policy

CORRESPONDING AUTHOR: Oldenburg Brian, Monash University;



Xuefeng Z.

Anhui Provincial Center for Disease Control and Prevention, Health Education, Hefei city, China

Chinese government policy directs that services of Community Health Centers (CHCs) are organized around neighborhoods and housing complexes. Accordingly, CHC professional teams serve specific sites to provide basic clinical and preventive services including chronic disease management. In collaboration with the Center for Disease Control & Prevention (CDC) in Anhui Province, peer supporters were trained by CHC and CDC teams, co-led monthly peer support meetings with CHC professionals, and organized activities (e.g., morning walking, Tai Chi, food shopping) as well as providing individual support to neighbors. A community randomized control trial design was used to evaluate the effectiveness of the community-based peer-led support program (PLSP) in improving self-management practices among individuals with diabetes. Six sub-communities were randomly sampled from seventeen cities. Three sub-communities were assigned randomly to experimental groups and others to comparison groups. Total 726 volunteer diabetes patients were recruited and were assigned randomly to experimental (n = 365) and comparison (n = 361) groups. Both quantitative and qualitative methods were employed to evaluate the effectiveness and feasibility of the program implementation during July 2009 to August 2010. The results indicated that the PLSP for diabetes self-management can improve diabetes diet and physical activities significantly by increasing the level of knowledge about SM, self-efficacy on SM, and perceived social support. It can also significantly improve participants' fasting plasma glucose (FPG), two-hour postprandial plasma glucose (2hrPPG), and moderately improve health status. Peer supporters report the cooperation with the CHCs as a key strength of their program. Despite the close relationship with the CHCs, peer supporters and their neighbors see their activities as very much part of their neighborhoods. In contrast to western images of Chinese culture discouraging the sharing of emotions, peer support provided opportunities for emotional exchange. This is because cultural norms against burdening one’s family with negative feelings are lessened with non-family peers with diabetes.

Keywords: Health Behaviour change Diabetes Public Health

CORRESPONDING AUTHOR: Zhong Xuefeng, Institute of Health Education;



Ding D.1, Wan X.2, Shin S.3, Raymond H.4, Liu H.2, Yang G.2, Novotny T.3

1 University of California San Diego, Family Preventive Medicine, La Jolla, USA

2 Peking Union Medical College, School of Basic Medicine, Beijing, China

3 San Diego State University, Graduate School of Public Health, San Diego, USA

4 San Francisco Department of Public Health, San Francisco, USA

China is the world’s largest producer and consumer of tobacco. Although the current smoking prevalence among women is low (2.4%), an increase is expected as a result of change in cultural norms and tobacco marketing campaigns directed towards women. The subgroup that is particularly at risk is the 105 million rural-to-urban migrant women, as they experience more stress in daily living and are more vulnerable to a range of risk behaviours. In summer 2011, we conducted a survey study of 2229 migrant women from 10 provincial capitals in China through local CDC offices. The study included several key steps: 1) developing and programming a handheld computer data collection (HCDC) system, 2) training Chinese collaborators to use the HCDC system for data collection and data transfer, 3) pilot testing the HCDC system, 4) data collection, 5) data analyses, 6) disseminating research findings through a policy meeting. Findings from the study suggested that migration and associated social stressors (e.g. discrimination) were associated with higher susceptibility to smoking. To prevent smoking onset of migrant women in China, several specific policies and other strategies were proposed at the policy meeting, such as regulations of cigarette marketing and worksite surveillance. This study is an example of public health research in China using a novel data collection method and a translational behavioural medicine component.

Keywords: Smoking, Tobacco Control, Research to practice translation, Research method




Lau TF.

The Chinese University of Hong Kong, Centre for Health Behaviours Research, School of Public Health and Primary Care, Hong Kong, China

HIV research and care work require interdisciplinary input, as pointed out by a number of researchers. Behavioral medicine is however, a relatively new topic in China and historically, social sciences departments were separated from medical universities. In this presentation, we shall consider the published evidence concerning the prevention and control of HIV in China over the last 20 years in order to identify the proportion of them 1) using behavioral theories (e.g. Health Belief Model, Theory of Planned Behaviors) to explain risk behaviors, 2) using behavioral theories to guide design of interventions, 3) using mental health variables to explain risk behaviors and 4) involving first author and co-authors coming from social sciences departments (e.g. psychology and sociology) in China and overseas. The second part of the presentation will consider the presenters' behavioral research into HIV prevention among female sex workers who are injecting drug users and methadone users, to illustrate opportunities and potentials, as well as difficulties in applying behavioral theories and approaches in developing effective and sustainable interventions. The presentation will identify some of the barriers of translational research versus efficacy studies in this field in China.

Keywords: HIV, Health Behaviors, Theory, Interdisciplinarity, and Research to practice translation

CORRESPONDING AUTHOR: Lau Joseph, Chinese University of Hong Kong;

Translation of Research into Policy and Practice



DeJoy D.1, Padilla H.1, Vandenberg R.2, Wilson M.1

1 The University of Georgia, Department of Health Promotion and Behavior, Athens, USA

2 The University of Georgia, Department of Management, Athens, USA

Obesity has reached epidemic proportions in the U.S. and this has prompted many employers to initiate or expand efforts to help employees manage their weight. Progress has been hampered, however, by the lack of evidence-based interventions suitable for work settings. This presentation summarizes formative research and pilot study findings from a worksite translation of the Diabetes Prevention Program (DPP). Union Pacific Railroad provided the setting for this research at one of their locomotive maintenance facilities. There were 167 employees at this site (predominately white, middle-aged males). Formative data were collected through stakeholder interviews, focus groups, and observation of the work environment using a validated assessment tool. Major adaptations of DPP included converting intervention materials to a self-study format and replacing lifestyle coaches with an occupational health nurse and peer coaches. Key concepts of the DPP Lifestyle Balance manual were retained, with formatting, graphics, and modifications to make the manual more reader-friendly and suitable for self-study. The pilot study was a single-group design with three data collection points: baseline, 6 months (core intervention), and 12 months (maintenance). Sixty-seven employees were recruited into the pilot study. At baseline, the mean BMI and body weight for the sample were 32.1 ± 5.3 and 99.6 ± 19.6 kg, respectively. As with the original DPP, participants were expected to complete 16 lessons in 24 weeks, and the first session included supervised height and weight measurement and individual consultation with a dietitian or health educator to set personal weight loss and physical activity goals. Attrition was relatively low from baseline to 6 months (repeat participation rate = 88%) and 40 participants completed all three data collection points. Paired sample t-tests were used to compare BMI and body weight between groups. There was a significant reduction in BMI after the core intervention (31.8 ± 5.3 vs. 31.5 ± 5.3; p < 0.05) and this change was maintained for an additional 6 months. Overall, mean weight loss among participants was 1.4 kg (p < 0.05). Results are discussed in terms of population health and the challenges of translation research.

Keywords: Worksite Health, Research to Practice Translation, Obesity

Corresponding author: Padilla Heather, The University of Georgia;



Aro AR.1, Fredsgaard M.1, Viehbeck S.2, Edwards N.2

1 University of Southern Denmark, Unit for Health Promotion Research, Esbjerg, Denmark

2 University of Ottawa, Institute of Population and Public Health, Ottawa, Canada

Ethical guidelines in many European countries were designed for individually-oriented biomedical health research. In many countries, current guidelines are inappropriate for health policy and public health research, with its societal focus. Furthermore, the practice of ethics reviews of health policy research varies considerably across countries. This poses challenges for international health policy research. The aim is to show first results and challenges of ethical clearance of an international translational health policy research program. The setting is the 7-country, 5-year European Commission (EC)-funded research program REPOPA (Research into Policy to enhance Physical Activity, Denmark (DK), Canada (CS), Finland (FI), Italy (IT), The Netherlands (NL), Romania (RO) and U.K. are collaborators. REPOPA maps use of research evidence in policy making both via documents and expert interviews; carries out interventions among policy makers and academics to enhance cross-sector policy making; validates best practices and tools and evaluates the REPOPA process and its products. EC requires documentation about ethics clearance before research can start. The practice of ethical clearance in the countries was mapped by internet-survey, in-depth discussions among the partners and with ethics offices, and by a review of existing national ethics guidelines. DK, IT, RO and NL require no ethical clearance for this kind research and consequently have no agency to provide review and clearance. However, CA and UK require clearance for all parts of the program, from all partner countries. FI requires clearance for interviews and interventions with which it is involved. As the coordinating country, DK is expected to carry out an overall ethical clearance for the whole REPOPA program. This is a challenge, since DK has no agency to do this; the solution might be an ad hoc committee. Clearly this kind of international health policy research needs ethics guidelines development on the international level. This should be done in collaboration with different disciplines including health, political and social sciences and, ethics and legal experts as well as relevant ethics review boards with relevant expertise and experience.

Keywords: ethical issues, research to practice translation, health policy

CORRESPONDING AUTHOR: Aro Arja R., University of Southern Denmark;



Setswe G.

School of Public Health and Preventive Medicine, Monash University Australia, Department of Health Sciences, Melbourne, South Africa

This presentation examines the relationship between behavioural HIV prevention research, policy development and implementation. The presentation starts by exploring whether we are getting the evidence from randomised controlled trials of interventions for reducing the risk of HIV and AIDS. It also explores whether research findings are adequately translated into prevention policies and whether HIV research findings are being made available to the research subjects and communities and whether research is being conducted in their interests or other interests.

With reference to some of the HIV prevention policies adopted by the African countries, or by member states, the presentation is asking whether these policies are ‘evidence based’ (i.e. rooted in research), or not. The presentation looks at barriers to implementation of HIV/AIDS programmes and examines ways of bridging the gap between research, policy and implementation.

Finally, this presentation examines whether there is sufficient coordination and dissemination of the research that is being initiated by different academic or research bodies within countries and within regions. It looks at whether there is a balance between academic freedom and the need – in the context of a devastating HIV/AIDS epidemic - to ensure that resources are not wasted via duplication or on research which cannot be translated into HIV prevention policies or programs.

Keywords: Policy; Research to practice translation

CORRESPONDING AUTHOR: Setswe Geoffrey, Monash University, Johannesburg;



Stauder A., Cserháti Z.

Semmelweis University, Institute of Behavioural Sciences, Budapest, Hungary

Background: The efficiency of an intervention is not only reflected by its effectiveness in a controlled research setting, but also by its sustainability and implementation in real life setting.

Aim: We report our experiences with the implementation of a complex, standardized stress management intervention, the internationally used, Williams Life Skills (WLS) program in Hungary.

Methods and results: The components of this 16 hours small group intervention are awareness of stressors, cognitive techniques to deal with negative thoughts and negative emotions, short relaxation techniques, problem solving, communication and interpersonal skills practice. After translation and some minor cultural adaptation of the program originally developed in the US, it was implemented among various target groups to improve their stress management skills. Questionnaire based follow-up studies showed significant (ps < 0,01) reduction of perceived stress (PSS10), anxiety (STAI-T), depression (BDI) and subjective somatic symptom (PHQ15) scores among distressed individuals, healthy employees and medical students after the training as well as at 6 or 12 month follow-up. In parallel, the training of professionals for facilitating WLS training has been started. In total 146 professionals started, and 94 have obtained the facilitator diploma until now. During the 7 years period over 2500 persons participated in the intervention, and there is still a raising interest in different settings, partly as a health promotion program, partly as a therapeutic intervention, with the involvement of various financial resources. The Hungarian version of the video based self-help version of the WLS program has also been available since 2008.

Conclusion: Besides scientific evidence, important components of the sustainability of this behavioral intervention are the satisfaction of the professionals who are delivering the program, the satisfaction of the participants, its standardized format and that the WLS program can be implemented within the existing system without extra resources.

Thanks to Virginia Williams and Redford Williams for the development of the program, and to the Hungarian Lifeskills Team (see for their high quality work.

Keywords: stress, multilevel intervention

CORRESPONDING AUTHOR: Stauder Adrienne, Semmelweis University, Budapest;



Huijg JM.1, Van der Zouwe N.2, Gebhardt WA.1, Crone MR.3, Verheijden MW.4, Middelkoop BJC.3

1 Leiden University, Clinical, Health and Neuropsychology, Leiden, The Netherlands

2 Regional Public Health Service Hollands Midden, -, Leiden, The Netherlands

3 Leiden University Medical Center, Department of Public Health and Primary Care, Leiden, The Netherlands

4 TNO, Leiden, The Netherlands

Introduction: For an effective introduction of efficacious physical activity (PA) interventions in primary health care (PHC), it is important to know which factors influence the process. The aim of this qualitative study was to identify factors influencing the introduction (i.e., adoption, implementation, and continuation) of PA interventions in PHC, as perceived by stakeholders.

Methods: 28 semi-structured interviews were held with 6 intervention owners, 4 healthcare advisors, and 18 professionals involved in five PA interventions delivered in PHC in the Netherlands. Factors influencing the adoption, implementation, and continuation of these interventions were addressed. All interviews were audio-recorded and transcribed. Data were analyzed by means of Atlas.ti using grounded theory principles.

Results: Stakeholders reported a multitude of factors influencing the introduction of PA interventions in PHC. Factors were related to the 1. socio-political context (i.e., policy, financial support), 2 organization (i.e., management support, team work), 3. adopting person (i.e., knowledge and skills, perceptions on the intervention), 4. patient (i.e., perceptions on the intervention, experience with the intervention), 5. innovation (i.e., success, relative advantage), and 6. innovation strategy (i.e., training, research). Furthermore, some factors appeared to be particularly important to one of the distinct stages of the introduction process. For the adoption of PA interventions, professionals’ motivation and their perceptions on patients’ cognitions, motivation, behavior, and characteristics play a prominent role. Professionals’ knowledge and skills and the presence of facilities and resources have a strong influence on PA interventions’ implementation. Finally, factors most important to the continuation of PA interventions are typically related to governmental policies about PA promotion and financial support.

Conclusions: This study provides an overview of factors that are perceived by stakeholders to influence the introduction of PA interventions in PHC. Therefore this study provides new insights with regard to the design of effective implementation strategies, with special attention to the distinct stages of the process.

Keywords: Research to practice translation; Dissemination; Primary care; Physical activity; Intervention; Prevention

CORRESPONDING AUTHOR: Huijg Johanna, Leiden University;



Varga G.

Uppsala University, Department of Women's and Children's Health, Uppsala, Sweden

Background: The Swedish National Institute of Public Health has financed several practice-based studies in the municipalities, connecting them to universities over the last few years. These projects, like numerous other scientific programs in municipalities, typically have a short life. In this environment it is a difficult task to ensure that the know-how and research methodologies collected and worked out in a project are reused in subsequent projects. In order to assure sustainability and a well-functioning partnership between the municipality and the researchers, a few research groups have involved representatives from the municipalities in the project work both as leaders and as research staff partly from university budget. The aim of this study was to gain insights from the local research assistants on how they perceived the work with the universities.

Method: We conducted individual interviews with four assistants and asked them to tell their perceptions on the partnership. The material was analysed with narrative method combining thematic and structural analysis.

Results: The main topics the local research assistants recounted were the challenges of splitting the project responsibilities between the municipality and the university; the workload distribution between the research and their regular job; managing barriers through regular dialogues with politicians, practitioners and researchers; implementing changes to the project based on lessons learnt; and the benefits of the cooperation with researchers in their professional life, in their personal development, and furthermore for the general public.

Discussion: The ability of local research assistants in succeeding in combining the scientific requirements and the municipalities' obligations depend on their work experience and their level of prior research experience. All assistants described that their knowledge about research increased; two of the assistants reported significant personal development, the others obtained great insights about the key ingredients of successful cooperation with different stakeholders.

Conclusion: This study identified that proper stakeholder management, regular coaching of project assistants, and openness to changes in the project contribute the most to successful municipality-university partnership.

Keywords: Research to practice translation, Community intervention

Corresponding author: Varga Gabriella, Uppsala University, Uppsala;

Changing gender roles as social determinants of health



Kopp M.1, Bobrova N.2, Ádám SZ.1, Balog P.1

1 Semmelweis University, Institute of Behavioural Sciences, Budapest, Hungary

2 University College London, Department of Epidemiology and Public Health, London, United Kingdom

Background: Among the social determinants of health the ways of coping with changing gender roles seem to be of central importance. For strengthening gender equity in health it is fundamental to find new forms of combining the work and family life of women and men in a harmonious way. The disturbances in these processes are important risk factors of the premature morbidity and mortality, first of all among men and of impoverished mental health among women. Family and working place might enhance each other, but for this aim it is necessary to establish new forms of gender roles to be able to fulfil these parallel vocations for healthy and competent life.

The presenters of the symposium and the titles of the abstracts are:

Szilvia Ádám, PhD, Hungary: The role of gender in health.

Bobrova, Natalia, PhD, Russia, UK: Gender roles and hazardous drinking in Russia

Piroska Balog, PhD, Hungary: Gender differences in the health consequences of marital stress

Prof Maria Kopp, MD, PhD: Social support, marital status and premature mortality in the Hungarian population

Conclusion: the four speakers will discuss the connection between changing gender roles and health behaviour and health on the basis of epidemiological surveys in the suddenly changing societies of Russia and Hungary.

Keywords: gender, alcohol, family, premature mortality, social support

CORRESPONDING AUTHOR: Kopp Maria, Semmelweis University; Budapest;



Ádám SZ., Győrffy ZS., Cserháti Z.

Semmelweis University, Institute of Behavioural Sciences, Budapest, Hungary

Background: Mounting gender role pressures and increased participation of women in the medical profession may lead to high prevalence of work-family conflict (WFC), a specific form of stress, among female physicians. However, little is known about the manifestation and gender-specific stressors of WFC as well as its impact on the physicians’ health in a traditional cultural setting.

Aim: To explore the manifestation and potential sources of WFC and investigate its predictive role in adverse health outcomes among physicians in Hungary.

Methods: The prevalence of WFC were assessed by questionnaires (N = 420). The direction, type, and potential sources of WFC were explored by content analyses of semi-structured in-depth interviews (N = 123) using the demand-control-support model of stress.

Results: Female physicians (N = 219) reported significantly higher mean level and prevalence of WFC compared to men (N = 201). The predominant form of WFC was work-to-family conflict among physicians; however, significantly more female physicians experienced family-to-work conflict and strain-based WFC than men (39% vs. 18% and 68% vs. 20%, respectively). Significantly more male physicians experienced time-based work-family conflict than women. In regression analyses, high job demands, job strain, high workload and number of children, younger age, and lack of support in the workplace predicted WFC best (R2 0.59). Content analyses of interview data (N = 123) revealed significant gender differences in the provision of social support to physicians. Female physicians lacking parental, peer (i.e., access to same-sex professional role models/mentors, gender equity), or organizational support (i.e., family-friendly policies) experienced significantly higher WFC compared to appropriate control. Significantly more female physicians reported allergy. Female physicians scored significantly higher on the emotional exhaustion subscale of the MBI and significantly more female physicians experienced high levels of emotional exhaustion compared to male physicians. WFC emerged as a significant predictor of somatic as well as psychological morbidity including hypertension, neoplasms, burnout, and depression among female physicians.

Conclusions: These findings suggest that lack of social support may function as an antecedent to WFC experienced by female physicians. Furthermore, these results imply a potential path from WFC to poor somatic and psychological health in a scarcely researched population of physicians, and among female physicians, in particular, and provide further data for cross-cultural occupational stress research in a traditional cultural setting.

Keywords: work-family conflict, physicians, social support, antecedents, gender differences

CORRESPONDING AUTHOR: Ádám Szilvia, Semmelweis University, Budapest;



Bobrova N.

University College London, Epidemiology and Public Health, London, United Kingdom

Gender differences in drinking patterns and the reasons behind them were investigated in the Russian city of Novosibirsk using a mixed method design. The quantitative study was based on the Health, Alcohol and Psychosocial factors In Eastern Europe cohort and included 9363 men and women aged 45-69 years. In addition, 44 semi-structured qualitative interviews were conducted from a sub-sample of the cohort to explore in-depth a variety of drinking occasions and practices and to assist in explaining and interpreting the findings of a quantitative study.

The quantitative data revealed a large gender differences in drinking between men and women, with men consuming alcohol more frequently and in larger amounts, and a significantly larger proportion of men drinking in hazardous ways. For example, 34.5% of men and only 1.4% of women reported drinking five drinks (100 g) or more on a single occasion at least once a month. Having ten drinks (200 g) or more on one occasion at least once a month was reported by 13.9% of men and 0.3% of women.

Qualitative interviews have shown that these differences were largely related to gender roles and perceived gender identity: “a real woman” is supposed to drink a minimum amount of alcohol; by contrary “a real man” pursuing a traditional masculinity model can drink a lot. Women’s multiple responsibilities at home were leaving them little time to drink, hence, protecting them from hazardous drinking, whereas men’s total withdrawal from domestic responsibilities provided them more opportunities for leisure - which was often spent drinking. These differences were also reflected in occupational cultures and drinking patterns: women reported no drinking at the workplace, and no drinking after work with colleagues. Men, on the other hand, had quite a few drinking experiences related to their jobs which were triggered by access to ethanol at work, working away from home in exclusively male company, management that was tolerant of drinking at work, and work related-stresses. Finally, qualitative accounts revealed different gender role-related responses by men and women to stressful situations, especially during economic hardships.

Keywords: gender roles, alcohol, Russia

CORRESPONDING AUTHOR: Bobrova Natalia, University College London;



Balog P.1, Falger P.2, Szabó G.3, Kopp M.1

1 Semmelweis University, Institute of Behavioural Sciences, Budapest, Hungary

2 Maastricht University, Social Psychiatry, Maastricht, The Netherlands

3 Semmelweis University, Institute of Health Sciences, Budapest, Hungary

Background: In post-modern society, marital distress may be a core factor in predicting adverse mental, physical, and social health outcomes in adulthood, including exhaustion and depression, addictive behaviour, absenteeism, divorce, and cardiovascular and other morbidity and mortality. Marital distress (Shortened Marital Stress Scale) most likely is associated with personality traits and may confer different health risks for men and women.

Method: Analysis of cross-sectional and follow-up data from representative national epidemiological panels in Hungary (2002-2006; total N = 12,680). We analysed data on all men and women younger than age 65 who were married/cohabitating and economically active at examination. Most hierarchical regression analyses were adjusted for age, education, SES, BMI, physical activity, and lifestyle factors and performed separately for men and women.

Results, Cross-Sectional: In men and women, marital distress was associated with hostility, low self-efficacy, low purpose in life, binge drinking, sleep complaints, anxiety, and vital exhaustion and depression (BDI). In men, but not in women, marital distress was also associated with smoking, alcoholism and current treatment for hypertension, the latter mediated through depressive symptoms. In women, but not in men, marital distress was associated with current treatment for depression.

Results, Follow-Up: In men and women, younger age, higher education, and marital distress contributed independently to divorce during follow-up, whereas subjective economic status and parental divorce were marginally associated. Moreover, marital distress was also conducive to elevated depression during follow-up. In separate analyses, vital exhaustion and depression in both men and women predicted CVD (hypertension, ischemia, myocardial infarction, and stroke) during follow-up. Since marital distress was associated with exhaustion and depression in the above cross-sectional analyses, future analysis will focus on marital distress as predictor of CVD endpoints.

Discussion: In these analyses, marital distress was associated with serious adverse mental and physical health outcomes, in particular hypertension in men and depression in women.

Keywords: gender, health, stress

CORRESPONDING AUTHOR: Balog Piroska, Semmelweis University, Budapest;



Kopp M., Székely A., Ádám SZ.

Semmelweis University, Institute of Behavioural Sciences, Budapest, Hungary

Background: Gender differences in premature mortality rates are extremely high in Hungary. The question is the possible role of changing gender roles in these health related differences.

Aim: We aimed to quantify the relationships between family related social support characteristics and premature mortality among men and women separately in the Hungarian population.

Methods: Men (n = 1130) and women (n = 1529), aged 40-69 years, participants in the Hungarian Epidemiological Panel (2002) were followed for 3.5 years for total mortality. Cox-proportional hazard models were used to evaluate the association between family arrangements and family related social support measures and mortality.

Results: During the follow-up, 99 men (8.8%) and 53 women (3.5%) died. Each measure of family related social support characteristics was more deleterious in men compared to women, but the strength of this interaction was different for different social support measures. Singlehood, high marital stress and low social support from child/children were more important risk factors among men than among women.

Conclusion: In Hungary there are huge differences between the male and female gender roles. Middle-aged Hungarian men seem to be considerably more vulnerable to the chronic stress of low family related social support than women.

Keywords: Risk factors, social support, family, epidemiology, gender, premature mortality

CORRESPONDING AUTHOR: Kopp Maria, Semmelweis University, Budapest;



Csoboth C., Susanszky E., Kopp M.

Semmelweis University, Behavioural Science Institute, Budapest, Hungary

Introduction: The number of single parents is increasing world wide. Nevertheless only a few studies analyze how the health of single parents is affected by being the sole caregiver of their children. Some findings indicate that lone parents experience a higher incidence of health problems than partnered parents. The objective of our presentation is to discuss data published regarding this important societal issue and to present data from our own research conducted in Hungary.

Methods: We analyzed data of a national representative cross-sectional survey (Hungarostudy 2006) of the Hungarian population. The survey contained sociodemographic questions and questionnaires measuring physical and mental health and associated psychosocial risk factors.

Results: Of the 1563 persons who declared to have young children in their household, almost one-tenth (9%) reported to be raising their child/children alone. Most of these single parents were mothers. 48% of single-parents evaluated their socioeconomic state far below the national average. These single parents also described their health significantly worse compared to parents rearing their children in a relationship (11% vs. 5%). A higher frequency of single parents complained of exhaustion and fatigue (21% vs. 15%) and reported more psychiatric disturbances (13% vs. 5%). Severe depression was more prevalent among single parents (10% vs. 6%) as was suicidal ideation (25% vs. 15%) and suicide attempt (13% vs. 5%).

Discussion: Our results suggest that both the physical and mental health of parents who raise their child/children by themselves can be worse compared to those parents who are raising their children in a relationship. Health policy makers need to pay attention more to this increasingly large group of adults who are at risk for poorer physical and mental health.

Keywords: single parents, physical and mental health, socioeconomic status

CORRESPONDING AUTHOR: Csoboth Csilla, Semmelweis University;

The impact of disasters on health: what do we know? What do we need to know?



La Greca A.

University of Miami, Psychology, Coral Gables, USA

Disasters occur worldwide and can be very devastating, contributing to substantial property damage, loss of life, and major life disruption. In fact, in just the first six months of the year, natural disasters across the globe made 2011 the most costly on record, with over $265 billion in property damage. This economic cost is in addition to substantial loss of life, with over 15,000 disaster-related deaths and thousands of individuals who remain missing. Some of the disasters contributing to this record-breaking year include the earthquake and tsunami in Japan, the earthquake in New Zealand, flooding in Australia, multiple events in the US (tornados, flooding, fires, earthquakes), and typhoons in the Philippines and Japan, among others. Although substantial work has documented the impact of disasters on individuals, families, and communities (Bonanno, Brewin, Kaniasty, & La Greca, 2010; Norris, 2002), much greater attention has been devoted to the psychological consequences of disasters than to their physical health impacts. Yet, disasters can contribute to physical health difficulties both through direct physical injury as well as through chronically stressful conditions that indirectly lead to physical health problems. This symposium will highlight approaches to understanding disasters’ impact on the physical health of children, adults, and/or communities. Across the presentations, a range of disasters (technological and natural disasters, terrorist events) and a range of physical outcomes (chronic illness, pain and medication use, somatic concerns, health-risk behaviors) will be addressed. The presentations also address implications for future research as well as for planning postdisaster interventions.

Natural Disasters’ Impact on Children: Does It Affect Health and Health Behaviors?

A.M. La Greca, B. Lai, and W. Herge

Beyond PTSD: Pain and Medication Use in Children Affected by Trauma

G. Dybe

Impacts of Technological Disasters on Physical and Behavioral Health: \Lessons from the Exxon Valdez Disaster

LA. Palinkas

Keywords: trauma, disasters, PTSD, disease, somatic symptoms, health behaviors

CORRESPONDING AUTHOR: La Greca Annette, University of Miami;



La Greca A., Lai B., Herge W.

University of Miami, Psychology, Coral Gables, USA

Children are a vulnerable population in disasters, as disasters not only disrupt children’s lives but also adversely affect their primary support systems. Over 20 years of research documents the psychological impacts of disasters on children. Across diverse events, findings reveal that disasters contribute to children’s symptoms of anxiety, depression, and posttraumatic stress (PTS). Yet, little is known about disasters’ impact on children’s health, despite the fact that acute and chronic stress, which are often present postdisaster, can contribute to poor physical health and disease. This presentation draws on two prospective studies of children in the aftermath of destructive disasters, Hurricanes Charley (n = 384) and Ike (n = 328), which examined the disasters’ impact on somatic complaints and health risk behaviors. Using a conceptual model of risk and resilience, we examined the impact of child characteristics, disaster-exposure, recovery stressors, and social support on children’s somatic symptoms. We found a dose-response association between disaster-exposure and children’s somatic symptoms, both concurrently and prospectively. Moreover, children’s PTS reactions mediated the association between stressors and somatic concerns. Following Hurricane Ike, we also examined children’s health behavior outcomes, finding that disaster-exposure predicted more sedentary behaviors in children. These findings point to the need for further research on the health impacts of disasters on youth, and suggest that postdisaster interventions should target both physical and mental health issues. Implications for disaster preparedness will also be discussed.

Keywords: trauma, disasters, health behaviors, somatic symptoms, PTSD

CORRESPONDING AUTHOR: La Greca Annette , University of Miami;



Dyb G.

University of Oslo, Dept. of Clinical Medicine, Oslo, Norway

Studies of disasters and other traumatic events in children and adolescents have documented a wide range of negative psychological consequences, such as anxiety, depression and PTSD. For example, following the tsunami disaster in Southeast Asia in 2004, we found that Norwegian children and adolescents with greater disaster exposure reported more symptoms of PTSD, and that this effect was stronger for youth whose parents were also distressed. However, less attention has been paid to associations between disaster events and children’s physical health and pain. Yet, studies suggest that pain is a common problem reported by individuals with PTSD, regardless of the type of traumatic event experienced. Here we report on our studies of Norwegian youth exposed to violence and sexual abuse. In our own studies of 16,000 adolescents, 6.1% of the girls and 1.6% of the boys in 10th grade reported being sexually abused the past year. Sexually abused youth reported significantly more pain (headache, back/neck pain, stomach pain) than non-abused peers. Moreover, the trauma-exposed youth reported using more pain killers and tranquillizers, suggesting that not only pain but also distress may trigger medication use. These findings suggest several avenues for further research on children postdisaster, and have implications for postdisaster intervention efforts.

Keywords: Children's health, Pain, Medication

CORRESPONDING AUTHOR: Dyb Grete, University of Oslo, Oslo;



Palinkas L.

University of Southern California, School of Social Work, Los Angeles, USA

This presentation introduces a conceptual framework for understanding the physical and behavioral health impacts of technological disasters based on the experience of the Exxon Valdez oil spill in 1989. Research conducted in the aftermath of that event documented significant associations between exposure to the oil and subsequent cleanup efforts and increased rates of generalized anxiety disorder, posttraumatic stress disorder, and depressive disorder; reports of alcohol and drug abuse and domestic violence; and use of mental health services. Spill cleanup workers, Alaska Natives, and families and children were especially vulnerable to these impacts. Adverse behavioral health outcomes were also found to be associated with patterns of spill-related social conflict, prolonged litigation over compensation for damages, cultural displacement, and reduced social support. However, exposure to the oil spill was also associated with significant increases in self-reports and physician-verified reports of heart disease, high blood pressure, diabetes, thyroid problem, cancer, asthma, ulcer, bronchitis, chronic cough and skin rashes. Cleanup workers were especially vulnerable to these physical health impacts. Drawing from the concept of corrosive communities and its relationship to theories of conservation of resources, cognitive activation, and risk and resilience, the conceptual model identifies three levels or tiers of impacts: biopsychosocial impacts that are direct consequences of the contamination of the physical environment; interpersonal impacts that are direct consequences of the biopsychosocial impacts; and physical and behavioral health impacts that are consequences of both the biopsychosocial and the interpersonal impacts. The conceptual framework may be used to anticipate and plan for long-term physical health impacts of other technological disasters, including the Deepwater Horizon oil spill in the Gulf of Mexico and the nuclear power plant disaster in Fukushima, Japan.

Keywords: disasters, stress, behavioral health, physical health

Corresponding author: Palinkas Lawrence, Univ. of Southern California;

Behavioral and Psychosocial Processes in CVD



Lundgren O.1, Garvin P.2, Kristenson M. 2

1 Linköping University, Department of Public Health and Community Medicine, Linköping, Sweden

2 Linköping University, Department of Public Health and Caring Sciences, Linköping, Sweden

Background: A large body of scientific data has revealed a clear association between psychological factors and the risk for ischemic heart disease. The vast majority of these studies have been focused on psychological risk factors, such as depression, anxiety, hostility and perceived stress. Surprisingly little interest has been offered to the other side of the coin; if psychological resources constitutes protection against ischemic heart disease. In large cross-sectional studies, a significant protective effect has been revealed (e.g. in INTERHEART), but there are only a handful of prospective studies with conflicting results.

Material & Methods: At baseline, data for traditional cardiovascular risk factors and questionnaire data for psychological resources and risk factors were obtained from a normal population of 1007 men and women, aged 45-69 years. Psychological resources were measured with the questionnaires Self-Esteem, Mastery, Sense of Coherence and Perceived Control. Psychological risk factors were Depression, Cynicism, Hostility, Hopelessness and Vital Exhaustion. At a six-year follow up, data of incidence or death in myocardial infarction, as well as interventions for instable angina pectoris, ware obtained from a registry from the Swedish ministry of health care.

Results: After adjusting for effects from lifestyle (smoking, diet, alcohol and physical activity) and known risk factors (age, sex, BMI, blood pressure, lipid levels), our analyses showed an independent protective effect of Self-Esteem (OR/SD in scale sum; 0.91, p = 0.007), Mastery (OR: 0.85, p = 0.001), Sense of Coherence (OR = 0.97, p = 0.04) on the risk of incidence in myocardial infarction. As expected, the psychological risk factors constituted a significant increase in disease risk.

Discussion: This is one of the first prospective studies to show that psychological resources have independent protective effects on the risk of myocardial infarction incidence. This knowledge is of importance for primary, as well as secondary preventive efforts in health care. It might also be informative for national and global public health initiatives.

Keywords: Coping Coronary artery disease

CORRESPONDING AUTHOR: Kristenson Margareta, Linköping University; Sweden;



Freedland K E.1, Burg MM.2, Chait S.3, Steinmeyer BC.1

1 Washington University School of Medicine, Department of Psychiatry, St. Louis, USA

2 Yale University School of Medicine, Section of Cardiovascular Medicine, New Haven, USA

3 VA Boston Healthcare System, -, Boston, USA

Background: Nonadherence to cardiac medications and antidepressants may help to explain how depression and low perceived social support (LPSS) increase the risk of mortality after acute myocardial infarction (MI). We hypothesized that depression and LPSS during the first few weeks after an MI, and persistent depression and LPSS over the first 18 months after an MI, predict nonadherence to medications. Methods: Data on depression, LPSS, and self-reported adherence to aspirin, beta-blockers, calcium channel blockers, hypolipidemics, and antidepressants were collected at baseline (within one month of the index MI) and at 6- and 18-month follow-ups from 2,481 participants in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial. The Beck Depression Inventory (BDI) was used to assess depression, and the ENRICHD Social Support Instrument (ESSI) was used to assess LPSS. Multiple imputation was used to analyze incomplete data. A linear mixed model was fitted to examine the time-dependent effects of depression and LPSS on adherence during the follow-up period, adjusting for sociodemographic variables, the ENRICHD medical risk score, the number of medications prescribed at baseline, and the participant’s group assignment (treatment vs. control). Results: In the fully-adjusted model, the time-dependent (i.e., 6- and 18-month) BDI (β = -0.24, p < .001) and ESSI (β = 0.22, p < .01) scores predicted adherence. In contrast, the baseline BDI and ESSI scores were not predictive. Other significant predictors included the number of drugs prescribed (β = 0.80, p < .001) and Caucasian race (β = 3.30, p < .001). Discussion: These findings suggest that both persistent depression and persistent LPSS predict nonadherence to cardiac and antidepressant medications over the first 18 months after an acute myocardial infarction. Further research is needed to determine whether nonadherence mediates the effects of persistent depression and LPSS on post-MI morbidity and mortality.

Keywords: Adherence; Coronary heart disease; Depression; Social support

Corresponding author: Freedland Kenneth, Washington University, St. Louis;



Gulliksson M.1, Burell G. 1, Vessby B.1, Lundin L.2, Toss H.2, Svärdsudd K.1

1 Uppsala University, Public Health and Clinical Medicine, Uppsala, Sweden

2 Uppsala University, Department of Medicine, Uppsala, Sweden

Background: Psychosocial factors are independently associated with increased risk of cardiovascular disease (CVD) morbidity and mortality, but the effects on CVD of psychosocial factor intervention is uncertain. We therefore performed a randomized controlled clinical trial of cognitive behavioural therapy (CBT) on CVD recurrence.

Methods: 362 women and men, aged 75 or less, discharged from hospital after a coronary heart disease (CHD) event within the past 12 months, were randomized to traditional care (reference group, n = 170) or to traditional care plus a CBT program (intervention group, n = 192), focused on stress management, with 20 two-hour sessions during one year, focusing on stress management. Median attendance to the CBT program was 85% per session. Outcome variables were all cause mortality, hospital admission for recurrent CVD, or recurrent acute myocardial infarction (AMI).

Results: During a mean 94 months of follow up the intervention group had 41% less fatal and non-fatal first recurrent CVD rate (HR 0.59, 95%CI 0.42-0.83, p = 0.003), 45% less recurrent AMI rate (HR 0.55, 95%CI 0.36-0.85, p = 0.007), and a non-significant 28% less all cause mortality (HR 0.72, 95%CI 0.40-1.30, p = 0.28) than the reference group after adjustment for other outcome affecting variables. In the CBT group there was a strong dose-response effect between intervention group attendance and outcome. During the first 2 years of follow-up there were no significant group differences in traditional risk factors.

Conclusions: The CBT intervention program decreased the risk of recurrent CVD and recurrent AMI. This may have implications for secondary preventive programs in CHD patients.

Keywords: cardiovascular disease, stress

CORRESPONDING AUTHOR: Burell Gunilla, Uppsala University, Uppsala;



Ginting H.1, Näring G.2, Becker E S.2

1 Maranatha Christian University, Faculty of Psychology, Bandung, Indonesia

2 Radboud University, Behavioural Science Institute, Nijmegen, The Netherlands

This study investigated the impact of information about heart disease on anxiety among patients with CHD. A group of 150 patients with CHD was randomly assigned to either a control group, or one of two experimental groups. The participants in the experimental groups watched a videotape containing comprehensive information about heart disease. Development of the intervention and scenario of the videotape were taken from the Myth and the Truth about heart disease (Furze, 2007). Participants in one experimental group additionally had an opportunity to ask questions to a general practitioner at the first viewing of the videotape. The participants in both of the experimental groups continued to watch the videotape at home for two weeks, once every two days. Before, right after the first viewing, and after two weeks, the participants completed the Heart Threat Related Word Stroop Task (HTRW Stroop), had their heart rate and their blood pressure measured and filled in the York Cardiac Beliefs Questionnaire (YCBQ) and the State Anxiety Inventory (STAI). Results indicated that right after watching the videotape with or without time for questions and after two weeks watching the videotape, the participants’ beliefs about heart disease were significantly more adaptive (p < .001 and p = .003) and their levels of anxiety were significantly lower (p = .021 and p = .01) than that of the control group. Furthermore, patients in the experimental groups had significantly lower heart rate (p = .004 and p = .033) and lower blood pressure (both systolic; p = .006 and p = .035 and diastolic; p = .007 and p = .009) than the control group after the intervention and their reaction time in HTRW Stroop was significantly faster (p = .003 and p = .01). This study provides strong evidence that delivering information about the disease to patients with CHD can lead the patients to adjust their beliefs about the disease and reduces the level of anxiety as is indicated by both explicit and implicit measures.

Keywords: coronary heart disease, information, videotape, beliefs, anxiety

CORRESPONDING AUTHOR: Ginting Henndy, Radboud University, Nijmegen;



Mortensen OS.1, LaFontaine A.2, Gyntelberg F.1, Suadicani P.1

1 Bispebjerg Hospital, Department of Occupational Medicine, Copenhagen, Denmark

2 Georgia Health Sciences Hospital, Department of Family Medicine, Augusta, USA

Background: Cycling to work is very common in Denmark and more so among the lower social classes. The long-term health consequences of cycling to work are only sparsely studied. We examined the association of cycling to work on coronary heart disease- and all-cause mortality. We also examined if the association was equal in all social classes.

Methods: 30-year follow-up in the Copenhagen Male Study of 5,249 gainfully employed men aged 40-59 years. 274 men with cardiovascular disease at baseline and 59 men unable to ride a bike or with missing answers on the question on daily cycling were excluded, leaving 4,916 for the incidence study.

Information on daily amount of cycling and cycling to work was obtained from questionnaire items. Social class was measured according to Svalastoga and was modified into five classes (in analyses collapsed to high and low). Physical fitness (maximal oxygen consumption, VO2Max) was estimated using the Åstrand bicycle ergometer test, and information on death diagnoses was obtained from official national registers.

Results: In the 30-year follow-up period 580 men (11.8%) died from coronary heart disease and 2,644 (53.8%) died in total. Cox analyses adjusted for age, smoking, leisure time physical activity and physical fitness showed that there were only minor differences in total mortality between those who ride a bike to work and those who don’t HR 0.95 [0.87-1.03] and in coronary mortality HR 0.99[0.82-1.19]. However, when stratified on social classes there was a significant protective effect on all-cause mortality from cycling to work in the higher social classes HR 0.81 [0.70-0.94] but not in the lower social classes HR 1.04[0.93-1.15]. The same trends were found for coronary mortality HR 0.84 in the higher social classes and HR 1.07 in the lower social classes without reaching statistical significance.

Conclusion: The strength of the association of cycling to work and mortality depended on social class with more benefit found in higher social classes. In the higher social classes cycling to work is a choice as part of a healthy lifestyle, in the low social class cycling to work may reflect necessity.

Keywords: coronary heart disease, social class, physical activity

CORRESPONDING AUTHOR: Mortensen Ole, Bispebjerg University Hospital;



Janssen I.1, Powell L H.1, Matthews K A.2, Sutton-Tyrrell K.3, Jasielec M S.1, Hollenberg SM.4, Everson-Rose S A.5

1 Rush University Medical Center, Preventive Medicine, Chicago, USA

2 University of Pittsburgh, Psychiatry, Pittsburgh, USA

3 University of Pittsburgh, Epidemiology, Pittsburgh, USA

4 Cooper University Hospital, Cardiology, Camden, USA

5 University of Minnesota, Medicine, Minneapolis, USA

Background: Studies of protective psychosocial factors for women focus mainly on factors such as social support and optimism. Little attention has been directed toward the impact of life engagement on physical health.

Methods: To examine the link between life engagement and progression of coronary calcification (CAC) among women at midlife, psychosocial assessments and CT scans were compared as part of the Study of Women's Health Across the Nation (SWAN) Heart ancillary study conducted from 2001-2005 in Chicago, IL and Pittsburgh, PA. Data from 338 women (33% black, 67% white; mean age, 50.8 ± 2.8) years) with 2 assessments an average of 2.3 years apart were analyzed. Life engagement was assessed as the sum of the 6-item purpose of life scale with each item rated on a 5-point scale from 1 to 5 with higher values indicating more purpose. CAC was assessed via electron beam computed tomography; progression was defined as an increase in CAC of >10 Agatston units and analyzed using log-binomial relative risk (RR) regression.

Results: Life engagement was high (mean 25.0 ± 3.3). In a multivariable model adjusted for baseline calcium, age, time between CT scans, race, menopausal status, HT use, education, systolic blood pressure, BMI, HDL cholesterol, and statin use, life engagement significantly predicted CAC progression. Each 1-SD higher life engagement was associated with decreased relative risk of CAC progression [RR = 0.84 (95%CI = 0.75-0.95) p = .006]. The effect did not differ by race and was independent of depression and social support.

Conclusions: Life engagement may be a novel and independent protective factor for subclinical disease progression in midlife women. More attention to this protective factor is needed. Supported by NIH/DHHS (grants AG012505, AG012546, HL065581, HL065591, HL089862).

Keywords: coronary artery disease, longitudinal research, resilience

CORRESPONDING AUTHOR: Janssen Imke, Rush University MC, Chicago;

Stress Reducing Interventions in Medical Settings



Golm D.1, Schmidt-Samoa C.2, Dechent P.2, Kröner-Herwig B.1

1 University of Göttingen, Clinical Psychology and Psychotherapy, Göttingen, Germany

2 University Medicine , Department of Cognitive Neurology, Göttingen, Germany

Tinnitus describes the perception of sound in the absence of external noise. About 5% of the population is affected by chronic tinnitus. About 20% of the tinnitus afflicted individuals experience severe distress due to the phantom noise. Negative cognitive emotional evaluation of tinnitus and its assumed consequences are commonly believed to be a major factor determining tinnitus-related distress. Models of tinnitus distress and recently conducted research propose a fronto-parietal-cingulate network to be more active in highly distressed tinnitus patients. The aim of the study was to identify brain regions, which are more active in highly distressed tinnitus patients during the processing of tinnitus-related stimuli in comparison to low distressed tinnitus patients and healthy controls. We examined three groups of age and sex matched participants; highly distressed tinnitus patients (n = 16; mean age: 53.38; SD = 12.33), low distressed tinnitus patients (n = 16; mean age: 52.25; SD = 11.73) and healthy controls (n = 16; mean age: 52.75; SD = 9.40) by the means of functional magnetic resonance imaging (fMRI). The participants underwent fMRI while performing an emotional Stroop task, which consisted of colored tinnitus-related words and neutral words. The participants had to name the color of each presented word via button press on a four-button-response pad. A subgroup of the highly distressed tinnitus patients received a cognitive-behavioral training, which aimed to reduce tinnitus-related distress. Responders to the training and age and sex matched low distressed tinnitus patients underwent the emotional Stroop task for a second time. The final results will be presented.

Keywords: FMRI, Emotions, Stress

CORRESPONDING AUTHOR: Golm Dennis, University of Göttingen;



Weise C.1, Kleinstäuber M.2, Andersson G.3

1 University of Marburg, Department of Clinical Psychology and Psychotherapy, Marburg, Germany

2 University of Mainz, Department of Clinical Psychology and Psychotherapy, Mainz, Germany

3 Linköping University, Department of Behavioural Sciences, Linköping, Sweden

Objectives: Tinnitus is a considerable problem for about 2-4% of the adult population. Cognitive behavioural treatments (CBT) have been shown to be effective in reducing tinnitus distress, however, the availability of individual counselling is limited. Therefore Internet-based CBT-approaches (iCBT) have been developed and showed promising results. The aim of our study was to investigate the efficacy of an iCBT to reduce tinnitus distress.

Methods: 124 patients with distressing chronic tinnitus were randomly assigned to either an Internet-based CBT (n = 62) or an online discussion group (n = 62), both lasting for 10 weeks. The iCBT group works on a self-help program including different tools to improve tinnitus coping. Patients receive individual weekly e-mail feedback. In the online discussion group, patients discuss different topics related to tinnitus, however not to tinnitus coping. Primary and secondary outcome were assessed pre and post treatment and 6 months after the end of the treatment.

Results: Significant interactions (time x group) in favour of the iCBT were found. Medium to large between-group effect sizes (Hedges' g) support these findings. After the end of the treatment, patients of the iCBT group reported significantly reduced tinnitus distress (F(1,117) = 43.28, p < .001; g = .88), increased tinnitus acceptance (F(1,117) = 37.83, p < .001; g = .80) and fewer depressive symptoms (F(1,117) = 22.92, p < .001; g = .43). Results of patients participating in the online discussion group were also improved, however significantly less articulated than in the iCBT group. Follow-up results indicated the stability of the improvements over 6 months.

Conclusion: The guided iCBT was highly accepted and led to significant and long-term stable improvements in tinnitus distress and associated variables. The efficacy of the iCBT was superior to the efficacy of the discussion group. Due to the use of an Internet-based approach, the treatment was available for patients situated all over the country. Thus, implementing Internet-based treatments might partially compensate for the lack of face-to-face treatments to reduce tinnitus distress. Further research is needed to investigate which factors influence the efficacy of Internet-based treatments.

Keywords: e-health, CBT, chronic disease, treatment

CORRESPONDING AUTHOR: Weise Cornelia, Philipps-University, Marburg;



Friebel L., Netterstrom B.

Bispebjerg Hospital, Department of Occupational and Environmental Medicine, Copenhagen, Denmark

Background: Increasing numbers of patients are being referred to the medical sector with stress symptoms, and the number of employees being on sick leave due to persistent stress symptoms has increased rapidly in the last two decades having high costs both for the individual and society. Hence, we find a need for evidence based stress treatment programmes in general medical practice.

The aim of this study was to evaluate the effect of a multidisciplinary stress treatment programme on reduction in symptom levels and return to work (RTW) rate.

Methods: General Practitioners within the capital region of Denmark were invited to refer patients with persistent work related stress symptoms to the project. Inclusion criteria were being employed and on sick leave. Exclusion criteria were major psychiatric or somatic disease or abuse. 238 patients were referred and a total of 198 were included in the project. Using a randomized wait list control design, the participants were randomized into three groups: intervention group (69 participants), treatment as usual (TAU) group (71 participants) or wait list control (WLC) group (58 participants).

The stress treatment programme consisted of: Nine one-hour sessions aiming at: 1. Identification of relevant stressors. 2. Changing the coping strategies of the participants. 3. Changing workload and tasks. 4. Workplace dialogue. Each participant also attended a Mindfulness meditation course (2 hours a week in 8 weeks).

Treatment in the intervention group and TAU group lasted approx. 3 months.

Self-reported data on psychological symptom levels (MDI and SCL-92) were obtained at baseline, and at 3, 6 (only WLC group), and 12 months follow-up. Data on RTW were obtained by the therapists/occupational physicians in charge of the treatment.

Results: Reductions in symptom levels were significantly larger in the intervention group and TAU group compared to the WLC group (P = 0.001). Regarding RTW, 67 % of the participants in the intervention group had returned to work/the labor market full time after three month. This was significantly higher than in the TAU (36%) and WLC group (22%) (P < 0.001).

Conclusion: The stress treatment programme shows significant effects on reductions in symptom levels and return to work rate compared to a wait-list control group.

Keywords: Stress, Treatment, Occupational health, Rehabilitation, Randomized controlled trial

CORRESPONDING AUTHOR: Friebel Lene, Bispebjerg Uni. Hospital, Cph;



Kekecs Z.1, Jakubovits E.1, Gombos K.2, Janecskó M.3, Varga K.1

1 Eotvos University, Faculty of Education and Psychology, Department of Affective Psychology, Budapest, Hungary

2 Saint János Hospital and North Buda Unified Hospitals, Department of Ophthalmology, Budapest, Hungary

3 Semmelweis University, Clinic for Anaesthesiology and Intensive Therapy, Budapest, Hungary

Interventions using therapeutic suggestions in the perioperative period are extensively discussed in the literature, however, most of the studies are conducted on surgical procedures involving general anaesthesia.

In our current study we investigate the effectiveness of a complex intervention containing suggestion and relaxation techniques on the wellbeing, anxiety, perioperative parameters and recovery of patients undergoing cataract surgery. In this ophthalmic operation only topical anaesthesia is used, the patients are awake and have to cooperate with the surgeon during the procedure.

This was a randomized controlled study involving 84 patients enlisted for cataract surgery. The intervention group listened to a sound recording with positive suggestions and relaxation techniques, the control group got the regular ophthalmological treatment only, with no sound recording.

Intervention group subjects had better subjective wellbeing (p = 0,019), were more calm and relaxed during the procedure (p = 0,029) and were more cooperative with the surgeon in the operating theatre (p = 0,004). Physiological measures like heart rate (p = 0,045) and blood pressure (p = 0,034) data support the subjective measure findings too. We also found that patients in the intervention group had better visual acuity at the first control visit (the day after the surgery) (p = 0,035).

These findings suggest that using therapeutic suggestion techniques during the preparation for cataract surgery provides valuable benefits for patients and surgeons alike.

Keywords: Surgery, Clinical application, Anxiety, Relaxation

CORRESPONDING AUTHOR: Kekecs Zoltán, ELTE, Budapest;



Brosschot JF.1, Van der Togt SAM.2, Verkuil B.1

1 Leiden University, Psychology, Leiden, The Netherlands

2 Leiden University Medical Center, Psychology, Leiden, The Netherlands

Objectives: The present study was conducted to investigate if a positive psychology intervention would lead to enhanced happiness and diminished symptoms of depression. Our goal was to replicate the findings of Seligman, Steen, Park and Peterson (2005) that showed that the positive psychology intervention “Three Good Things” (a week long focusing on positive events) resulted in increased happiness and decreased depressive symptoms up to six months follow-up. We tried to extend these results in two ways: (1) by measuring perseverative cognition (PC) and subjective health complaints (SHC), (2) and by measuring implicit affective variables: implicit positive (I-PA) and negative affect (I-NA) and implicit happiness (I-Happiness). We hypothesized that the “Three Good Things” intervention would lead to higher happiness and lower depression (replication Seligman et al., 2005), lower PC and SHC. In addition we expected decreases in I-NA and increases in I-PA and I-Happiness. We used a control intervention that was more similar in structure and time window (focusing on impressive things) than Seligman et al.’s (2005) control condition (focusing on childhood events).

Methods: A convenience sample of 282 participants was randomly assigned to the experimental condition “Three Good Things” and the control condition “Three Impressive Things”. Measurements were done at five subsequent time points: baseline, immediate posttest, one week posttest, one month posttest and three months posttest. Manipulation checks were administered at all four follow-up time points. A repeated measures design with intervention (condition) as ‘between-subjects factor’ and measurement (time) as ‘within-subjects factor’ was used.

Results: Participants in the “Three Good Things” intervention showed no increased happiness or decreased depressive symptoms across time. We also failed to show that PC and SHC diminished. However, we did find proof that the “Three Good Things” intervention leads to significantly lower I-NA and higher I-PA and I-Happiness across time. Moreover, participants that carried on the interventions and/or kept thinking about it, had decreased subjective health complaints (SHC)

Conclusion: Summarizing, on the one hand we failed to replicate the findings of Seligman et al. (2005). On the other hand we extend previous studies by showing that a positive psychology intervention has impact on implicit mood variables and SHC. This finding is in line with the ‘extended perseverative cognition hypothesis’, which proposes the existence of unconscious negative emotions (stress) and its influence on health.

Keywords: positive psychology; subjective health complaints, implicit emotions

CORRESPONDING AUTHOR: Brosschot Jos, Leiden University, Leiden;

Decision Making and Ethics



Turnbull D.1, Oster C.1, Flight I.2, Zajac I.2, Wilson C.3

1 University of Adelaide, School of Psychology, Adelaide, Australia

2 Commonwealth Scientific and Industrial Research Organisation, Colorectal Cancer and Gut Health, Preventative Health Research Flagship, Adelaide, Australia

3 Flinders University of South Australia, School of Medicine, Adelaide, Australia

Colorectal cancer is an ideal target for early detection and prevention through cancer screening. This presentation will report on the results of an Australian qualitative study exploring the decision-making of screeners and non-screeners, who were involved in a randomized controlled trial of a decision support system for colorectal cancer screening. Using a maximum variability sampling frame, we conducted 4 focus groups and 30 telephone interviews. The presentation will focus on why people who were offered the Faecal Occult Blood Test (FOBT) decided to screen or not to screen, and what influenced them to take action and complete the test. We identified the main reason for respondents deciding to screen for CRC as ‘wanting to know’ their CRC status. However, wanting to know was not a simple ‘either-or’ decision, but functioned on a continuum ranging from wanting to know, through varying degrees of ambivalence, to not wanting to know. The majority of respondents expressed ambivalence with regard to CRC screening, and the main cue to action was the opportunity to screen without being too inconvenienced. Implications of the findings for the provision of screening opportunities for at-risk populations will be discussed.

Keywords: Cancer screening; decision making

CORRESPONDING AUTHOR: Oster Candice, University of Adelaide, Adelaide;



Huijg J. M.1, Gebhardt W. A.1, Crone M. R.2, Verheijden M. W.3, Van der Zouwe N.4, Middelkoop B. J. C.2

1 Leiden University, Clinical, Health and Neuropsychology, Leiden, The Netherlands

2 Leiden University Medical Center, Department of Public Health and Primary Care, Leiden, The Netherlands

3 TNO, -, Leiden, The Netherlands

4 Regional Public Health Service Hollands Midden, -, Leiden, The Netherlands

Introduction: For an effective introduction of efficacious physical activity (PA) interventions in primary health care (PHC), it is important to know which factors influence the three main stages (i.e., adoption, implementation, and continuation) of this process. The aim of this two-round Delphi study was to achieve consensus among a group of experts on the relevance (i.e., importance and changeability) of factors that may impact the introduction, as identified from a systematic literature review and a qualitative study.

Methods: In the first round, 44 experts completed an electronic questionnaire in which they scored each potential factor on their importance for each stage of the introduction process, and their changeability. In the second round, a questionnaire based on the first round results was sent to the experts, in which they were asked to indicate their top-10 of most important factors to the different stages and to re-rate the changeability of the factors.

Results: Results showed experts agreed on the importance of various determinants to a specific stage. The presence of a public health problem, support of health insurance companies, support for the intervention and presence of intervention champions within the organization, and professionals’ positive perception regarding PA, the intervention’s effectiveness, and its fit with the target group were important to the adoption stage. Professionals’ skills, knowledge and experience of intervention effectiveness were important to the implementation stage. The presence of a network between PHC and local resources for PA practice, the availability of a list of those resources, and the interventions’ prospects were important to the continuation stage. Factors were not always stage-specific, e.g., the interventions’ financial feasibility, coverage of intervention costs for patients, and time to deliver the intervention were identified as important to all three stages. The results further indicated a lack of consensus on the changeability of the factors.

Discussion: This study suggests general and stage-specific factors that could be taken into account when designing appropriate strategies to introduce PA interventions in PHC. This is worthy of further examination in longitudinal and experimental studies.

Keywords: Research to practice translation; Dissemination; Primary care; Physical activity; Intervention; Prevention

CORRESPONDING AUTHOR: Huijg Johanna, Leiden University;



Grilo A. M.1, Santos MC. 1, Santos-Rita J.1, Gomes A. I.1, French M.2

1 Instituto Politécnico do Lisboa, Department of Human Science, Lisbon, Portugal

2 Faculty of Medicine, Pilsen, General Medicine, Prague, Czech Republic

The importance of patient-centred care has recently been more emphasized by health educators. There is enough evidence that patient-centred care leads to better health outcomes, such as adherence to health treatments, patient satisfaction and general health status. According to international studies, female health care professionals are more patient-centred than male professionals. There is no consensus about the effect of clinical experience on patient-centred orientation, during the under-graduate course. The present study aims at assessing the role orientations in female medical and nursing students, in Portugal, according to their pre-clinical and clinical experience.

Medical students (n = 410) and nursing students (n = 444)from Portuguese Public Medicine and Nursing Schools filled in the Patient-Practitioner Orientation Scale (PPOS), an instrument developed by Krupat et al. (2000) that measures the role orientations of the doctor-patient relationship, ranging from patient-centred, to doctor or disease-centred. The scale was translated to Portuguese by French (2008) and adapted for this study. Subjects also filled in two six-point Likert scales, focused on the students’ view of their competence in clinical and communication situations. To compare medical students and nursing students, we considered two subgroups: pre-clinical and clinical clerkship.

The total PPOS score was significantly different (p < 0.001) among medical and nursing students. The pre-clinical and clinical clerkship medical students scored lower than the nursing students. Perception on the communication competence is very high (mean > 4) in pre-clinical groups. Only in nursing students, the total PPOS score and the perception on the communication competence increase with clinical experience.

In spite of the international movement toward communication as a core clinical skill, the culture of healthcare and the curricula of Portuguese traditional Medical Schools neglect patient-centred attitudes, which attempts to share information and respect for the totally and individuality of the patients.

Keywords: gender, population health

CORRESPONDING AUTHOR: Grilo Ana, Instituto Politecnico, Lisbon;



Brown M.

University of California, Public Health, Merced, USA

Discrete choice experiments (DCEs) are an increasing popular way of identifying the factors that people take into consideration when making decisions about their health or health care, and the relative importance of each factor. This study uses DCEs to examine the preferences for pre-birth testing for genetic conditions. 205 participants completed a DCE asking whether they or their partner would be willing to have a pre-birth genetic test. Based on extensive initial consultations, the factors identified as important for decision making included the type of condition being tested (e.g., diabetes), the likelihood of the condition being expressed (penetrance) and the age of expression, the cost of the test, and the conditions of the test (wait till results, pain and distance to the test site). The results indicating that people show greater interest and willingness to pay for genetic tests for positive traits, lower waiting times, less pain, and increased penetrance of the tests, with WTP estimates the lowest when there is pain involved with the tests and highest for positive traits with high penetrance. The results from this analysis help identify the factors important to people when considering genetic tests. In addition, the study also illustrates how DCEs can identify the relative importance of each of the aspects. The discussion highlights the usefulness and challenges with using DCEs for health research.

Keywords: genetics, economics




Raaijmakers LGM.1, Bagchus C.2, Martens MK.2, De Vries NK.3, Kremers SPJ.1

1 Maastricht University Medical Centre, Department of Health Promotion, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht, The Netherlands

2 ResCon, Research & Consultancy, Amsterdam, The Netherlands

3 Maastricht University Medical Centre, Caphri, School for Primary Care and Public Health, Maastricht, The Netherlands

Objective: The main aim of this study was to obtain insight in the perceptions of health care professionals regarding the Netherlands Diabetes Federation Health Care Standard (HCS) for type diabetes and the hindering factors that play a role.

Methods: A cross-sectional questionnaire study was conducted among health care professionals (N = 1547) between June and November 2010.

Results: Of the health care professionals (N = 1302) 39.2% was in possession of the health care standard for type 2 diabetes, while 17% was unfamiliar with the HCS. Only 13.8% of the professionals that were somehow familiar with the HCS perceived themselves as working completely in accordance with the HCS. Professionals perceived the guidelines from their own professional group more as the norm for high quality diabetes care than they perceived the HCS to be the norm (mean = 4.0 SD 0.5; mean = 2.9 SD 1.3). The majority (72.8%) thought the HCS contributes to a large extent to insuring the quality of care and the feasibility of working in accordance with the HCS was judged considerably positive (mean = 3.9 SD 0.7).

We identified several differences in appreciation of the HCS between health care professionals. General practitioners most often perceived themselves as working in accordance with the HCS, while internists worked relatively less in accordance with the HCS. Diabetes nurses perceived the HCS less as the norm for high quality diabetes care compared to GP’s and internists. GP’s were more positive about the feasibility of working in accordance with the HCS in comparison to diabetes nurses and internists. Internists were the least positive about the contribution of the HCS to insuring quality of care.

The most important hindering factor professionals perceived was the lack of (access to) effective lifestyle interventions to guide people with (a higher risk of) diabetes.

Discussion: Professionals should be further educated about the content of the HCS and especially its additional value to the guidelines of the own professional group. In order to deal with the main perceived barrier, the familiarity with and access to lifestyle programs should be increased since programs that meet the conditions for cost-effective lifestyle programs are developed in the Netherlands and implemented in several pilot locations in primary care. Furthermore effectiveness and implementation trials are needed to ensure the quality of these programs.

Keywords: Diabetes, adherence

CORRESPONDING AUTHOR: Raaijmakers Lieke, Maastricht University Maastricht;



Solyom A. E.

Centra Health, Department of Psychiatry, Lynchburg VA, USA

For more than 60 years, the USA has stood alone among developed nations in failing to provide universal health care for her citizens – except for those who became eligible for the government provided Medicaid, Medicare and Veterans Administration services over the past 40 years. In all, Congress has been responsible for inexcusable deaths, chronic diseases, disabilities and suffering of millions by acting as if the right of insurance companies to profiteer from people's diseases and disabilities was more important than the right of people to health care. The medical profession also shares the responsibility by failing to confront the fundamental moral problem of unrealized rights and unattained justice.

The new law (PPACA and HCERA, 2010) extends health insurance to 95 percent of the population, increases patient safety, establishes coordinated patient centered care with payment for quality, supports primary and rural health care providers, expands community health centers and promotes preventive and public health services. It also provides multiple opportunities and challenges for the creative contributions by physicians in the implementation of its many parts, such as reducing wasteful redundant and unnecessary services by integrated patient care.

The law reduces the moral plight of millions lacking health insurance and improves patient safety and quality of care. Yet, it is ethically inadequate due to political and business constraints: 1. it still leaves about 15 million people (5 percent) without health insurance, 2. it allows the profiteering by insurance companies from people’s diseases and disabilities, i.e., it continues to view health care as a commodity not as a right.

The reform law represents an opportunity for a more just and higher quality health care system, but that cannot materialize without the moral and professional commitment and leadership of physicians, who have to affirm that: 1. the practice of medicine is a moral activity, 2. adequate physical and mental health is a prerequisite to basic human rights, 3. health care is not a commodity but a basic right, and should be provided to individuals and society by a non-for-profit system with equal access to quality services for everybody, 4. people’s health care needs are relative and flexible, and fair distribution of services includes appropriate variations, 5. care for people’s health entails reciprocity between individuals and society, i.e., the promotion of healthy lifestyle and the adherence to it by individuals and families are part of health care.

Keywords: Ethical issues, Health policy

CORRESPONDING AUTHOR: Solyom Antal, Lynchburg, VA, USA;

Psychosocial Interventions in Cancer: Strategies for Cancer Prevention and Control



Tercyak K.1, Patenaude A.2

1 Georgetown University, Department of Oncology, Washington, USA

2 Dana-Farber Cancer Institute, Department of Pediatric Oncology, Boston, USA

Genetic counseling and testing for BRCA1/2 mutations is a well-established part of the identification and management of hereditary breast/ovarian cancer risk. Thus, increasing numbers of women are confronting complex decisions about whether and how to communicate cancer risk information to their potentially at-risk relatives, including their minor-age children. To date, little research has been conducted on ways to support parental decisions about communicating cancer risk information to the family. In light of this, we developed a decision-support intervention and conducted a multisite randomized controlled trial to assess the impact of our decision support intervention on maternal disclosure of BRCA1/2 test results to children and related outcomes. Following pre-test genetic counseling, 100 mothers (M age = 44) completed a baseline telephone survey and were randomized to either a decision support intervention (DSI) or standard care (SC) group. Before receipt of their cancer genetic test results, mothers in the DSI group self-paced through a multistep decision guide based on the Ottawa Decision Support Framework, while mothers in the SC group accessed an educational booklet. An outcome survey was re-administered 1-month following post-test genetic counseling, and included child communication and intervention satisfaction assessments. The overall prevalence of disclosure of maternal cancer genetic test results to children (M age = 12) was 62%. Child disclosure was significantly higher in the DSI group (73%) vs. SC group (52%), X2 (1) = 4.67, p = .03. After adjusting for the effects of child age and maternal BRCA1/2 status, mothers in the DSI group remained more likely to communicate to children than those in SC, OR = 2.75, 95% CI = 1.01, 7.47: intervention satisfaction was significantly higher among DSI vs. SC mothers, t = 2.43, p = 0.02. Our results suggest that theory-based, self-paced decision support increases communication among mothers and their children about hereditary breast/ovarian cancer risk and is associated with greater satisfaction. We will discuss the implications of these findings for promoting and maintaining child and family health in the era of personalized medicine for the prevention and treatment of adult-onset cancer. We will also discuss the implications of our research for children's psychosocial quality of life and well-being in the context of identifying and managing familial cancer risks through clinical and population-based approaches.

Keywords: Decision making, Genetics, Children, Family

CORRESPONDING AUTHOR: Tercyak Kenneth, Georgetown University, Washington;



Zajac I.1, Wilson C.2, Flight I.1, Turnbull D.3, Young G.2, Cole S.2, Gregory T.3

1 Commonwealth Scientific and Industrial Research Organisation, Preventative Health, Adelaide, Australia

2 Flinders University of South Australia, School of Medicine, Adelaide, Australia

3 The University of Adelaide, School of Psychology, Adelaide, Australia

Objective: Colorectal cancer (CRC) is a major public health problem in Australia. It is the second leading cause of cancer-related death and the most frequently diagnosed internal cancer. Despite the significant impact of this disease, population screening uptake using faecal occult blood test (FOBT) remains sub optimal. Therefore, this study explored the effectiveness of a web-based Personalised Decision Support (PDS) tool in terms of improving participation in this important preventive health behaviour.

Methods: Three-thousand four-hundred and eight (3,408) participants were recruited into this randomised controlled trial (RCT) and assigned to one of three trial conditions: Tailored PDS; Non-Tailored PDS; or Control (paper-based). Participants were asked to visit the web-based PDS tool to complete a questionnaire or complete a paper-based questionnaire in accordance with the condition they had been assigned to. The questionnaire addressed factors relating to FOBT participation, based on the Preventive Health Model. Those in the Tailored PDS condition received feedback tailored to their responses and stage of decision to screen. Participants who visited the PDS tool or who returned a completed paper-based questionnaire subsequently received an invitation to screen via FOBT that was consistent with Australia’s National Bowel Cancer Screening Program. This invitation was accompanied by either paper-based bowel cancer information (Control group only), or access to online information via the PDS.

Results: Analysis at the conclusion of the RCT revealed a statistically significant difference in participation between the three trial conditions [χ2 (2) = 14.93, p < .001]. FOBT participation rates were 78%, 84.8% and 84.1% for Control, Non-tailored and Tailored conditions, respectively.

Conclusion: Web-based Personalised Decision Support appears to have a positive impact on FOBT participation rates in Australia. However, there was no apparent additional effect of tailoring the content delivered to users based on our studies results as FOBT participation was essentially equal across PDS conditions. Tailoring is complex and costly and may not be necessary if the aim is simply to improve participation in a once-off screening invitation.

Keywords: Cancer Screening, Prevention




Janda M.1, Youl P.2, Baade P.2, Neale R.3

1 Queensland University of Technology, School of Public Health, Brisbane, Australia

2 Cancer Council Queensland, Brisbane, Australia

3 Queensland Institute of Medical Research, Brisbane, Australia

Aim: Men 50 years of older are at high risk to develop thick melanomas and die from melanoma. Using data from a randomised trial of a behavioural intervention (n = 930), we assessed baseline clinical, attitudinal and behavioural factors associated with visiting a doctor for a clinical skin examination (CSE).

Methods: A video-based intervention was designed (n = 469) and compared to brochures-only control (n = 461) to increase whole-body CSE in Queensland, Australia. The effects of baseline clinical factors (such as number of moles), attitudes, including perceived risk of developing skin cancer, and baseline behaviours including attending health checks in general, self- and clinical skin examination practices were explored in relation to likelihood of having at least one CSE during the 13-month study follow-up period using uni- and multivariable logistic regression analyses.

Results: Overall, 64% of men reported having had a CSE during the study follow-up period. Multivariable analysis showed that patients who were concerned about a spot or mole at baseline, or strongly agreed with seeing their doctor if they found anything suspicious on their skin were more willing to see a doctor for CSE. Baseline behaviours such as regularly visiting their doctor for health checks, having checked their own skin in the past 6 months and having their doctor ever deliberately check any part of their body for early signs of skin cancer also increased likelihood of a CSE. Baseline clinical factors such as having some or many moles, or having had a skin spot or mole removed in the past also increased willingness to have a CSE. Receiving the video-delivered intervention appeared to be more effective than receiving the control intervention in increasing uptake of CSE at the 7-month follow-up visit, but not the 13 months visit.

Conclusion: Our findings indicate that in addition to clinical factors such as previous removal of skin lesions and number of moles, men’s perceived risk of skin cancer, willingness to see a doctor for general health checks, and previous treatments for skin spots, were associated with uptake of CSE. Doctors’ visits for general health checks present an opportunity to discuss skin health with patients, especially those at high risk of melanoma.

Keywords: Screening, cancer, sun safety, behavior change, population health

CORRESPONDING AUTHOR: Janda Monika, QUT, Brisbane;



Labelle L.1, Campbell T.1, Carlson L. 2

1 University of Calgary, Psychology, Calgary, AB, Canada

2 University of Calgary, Department of Oncology, Calgary, AB, Canada

Objective: This longitudinal waitlist controlled study of MBSR explored the timing of MBSR-related changes in mindfulness, emotion regulation, and psychological outcome variables (symptoms of stress and mood disturbance), in cancer patients. The study also assessed temporal precedence of change in putative mediator variables, consistent with current models of the mechanisms of MBSR.

Methods: Patients were recruited from the MBSR program waitlist and were either registered for immediate participation (n = 135), or were waiting for the next program (n = 76). Participants completed questionnaires pre-, mid- and post-MBSR or waiting period. Piecewise hierarchical linear modeling was employed to assess changes over time as a function of condition (MBSR vs. waitlist) within the first and second halves of the intervention. Cross-lagged correlations and linear regression analyses were conducted to test for a group difference in the prediction of (1) later emotion regulation and outcome variable change from earlier mindfulness change, and (2) later outcome variable change from earlier emotion regulation change.

Results: An effect of MBSR on present-focused attention/awareness and nonjudgmental acceptance emerged early in the program (t = 4.22, p < .001; t = 2.47, p < .05). Negative perseverative thinking (rumination and worry) also changed early (t = -2.16, p < .05; t = -3.00, p < .01). The tendency to label emotions, act with present-focused awareness and nonreactivity developed later (t = 3.22, p < .01; t = 3.21, p < .01; t = 3.46, p < .01), as did changes in experiential avoidance (t = -2.80, p < .01), symptoms of stress (t = -3.63, p < .01) and mood disturbance (t = -2.25, p < .05). Early increases in nonjudgmental awareness correlated with subsequent decreases in worry (r = -.26, p < .05); this correlation was stronger in the MBSR group (t = -2.81, p < .01). However, early changes in rumination and worry also correlated with later changes in mindfulness, suggesting bi-directional relationships.

Conclusions: This is the first controlled study to examine the timing of changes during MBSR. Evidence that early increases in mindfulness lead to improved psychological functioning was weak. More detailed analyses of MBSR-related change will strengthen conclusions that can be drawn regarding mechanisms of MBSR.

Keywords: Mindfulness-based Stress Reduction; cancer

Corresponding author: Carlson Linda, University of Calgary, Calgary;



Zimmermann T.1, Heinrichs N.2

1 University of Braunschweig, Institute of Psychology, Braunschweig, Germany

2 University of Bielefeld, Institute for Psychology, Bielefeld, Germany

The cancer diagnosis is a stressful event that poses formidable and enduring challenges, not just to the women themselves, but also to their intimate partners. A conjoint process of mutual support has been suggested to be an effective coping strategy for patients who are married or in committed relationships. There are few interventions for couples facing cancer, although both partners maybe affected by the disease of one partner. The primary aim of this study was to gather data on the potential benefits of a brief psychological intervention (“Side by Side”) designed to assist women and their partners to cope with breast cancer.

Ninety couples were randomly assigned to either the couples’ component (“Side by Side”), or an information component containing the same educational materials, but no relationship focus. In addition to pre, post, 6 month follow-up and 12 month follow-up self-report measures, observational data on mutual supportive behavior when communicating about a cancer-related topic were collected.

Multi-level analyses suggest that females receiving Side by Side showed larger reductions in cancer-related distress and fear of progression post-intervention compared to women in control group. Furthermore, couples in the Side by Side intervention showed less avoidance in dealing with the cancer, more posttraumatic growth, and better communication skills and dyadic coping relative to the control group. Short-term changes in cancer-related functioning may be improved by enhancing couples’ dyadic coping skills during acute medical treatment of the disease. The findings highlighted the importance of helping both, the woman and her partner, to effectively cope with cancer in a couple’s context.

Keywords: cancer, couple-focused

CORRESPONDING AUTHOR: Zimmermann Tanja, University of Braunschweig;



Antoni M.1, Lutgendorf S.2, Blomberg B.3, Carver C.1, Lechner S.4, Arevalo J.5, Cole S.5

1 University of Miami, Department of Psychology, Coral Gables, USA

2 University of Iowa, Department of Psychology, Iowa City, USA

3 University of Miami, Department of Microbiology and Immunology, Miami, USA

4 University of Miami, Department of Psychiatry, Miami, USA

5 UCLA, Department of Medicine, Los Angeles, USA

Background: Negative affect states are associated with pro-inflammatory transcriptional profiles in circulating leukocytes, and it follows that psychosocial interventions that decrease negative affect may alter leukocyte gene expression associated with inflammation. Such interventions may be particularly relevant in the context of cancer treatment, since inflammation may delay recovery and promote disease progression. This study tested whether a group-based Cognitive-Behavioral Stress Management (CBSM) intervention targeting negative affect and cognition might modulate distress-related transcriptional alterations in women undergoing treatment for non-metastatic breast cancer.

Methods: Women (N = 79) undergoing primary treatment of Stage 0-III breast cancer were randomized to a 10-week CBSM protocol (N = 45) or an active control condition (N = 34) completed the Affect Balance Scale (ABS) and provided peripheral blood leukocyte samples for genome-wide transcriptional profiling and bioinformatic analyses at baseline, 6-, and 12-month follow-ups.

Results: Mixed Model group X time analyses controlling for patient age, race, disease stage, hormone receptor status, and treatment, tested whether changes over time (from baseline to 6 mo to 12 month follow-up) are significantly different in women assigned to CBSM vs controls. Women assigned to CBSM showed increased ABS positive affect (p < .01), decreased negative affect (p < .001), and increased composite positive-negative affect balance scores (p < .0001), whereas controls showed negligible change over time on each dimension. We found 62 transcripts showed significantly greater than 50% down-regulation of genes associated with inflammation over time in CBSM-treated patients relative to controls, including genes encoding pro-inflammatory cytokines (IL1a, IL1b, IL6), the prostaglandin-synthesis enzyme COX2 (PTGS2), and inflammatory chemokines and their receptors (CCL2, CCL3, CCL3L1, CCL3L3, CCL4L1, CCL4L2, CCL7, CXCL1, CXCL2, CXCR7). We also found greater down-regulation of genes associated with cancer promotion in CBSM vs controls including those involved in tissue remodeling and epithelial-mesenchymal transition (G0S2, LMNA, MMP9, OSM). By the 12-month follow-up women assigned to CBSM continued to show only about half the gene expression for many inflammation genes and cancer promotion genes compared to controls. Gene Ontology analyses confirmed that CBSM down-regulated genes were characterized by involvement in pro-inflammatory cytokine activity (GO:0006954;GO:0005125; both p < .0001) and wound healing (GO:0009611; p < .0001). RT-PCR analysis confirmed microarray-indicated group differences in the relative abundance of 12 of 12 transcripts audited (all p’s < .0001). Promoter-based bioinformatic analyses implicated decreased activity of NF-kB/Rel and GATA family transcription factors and increased glucocorticoid receptor activity as potential mediators of CBSM-induced transcriptional alterations.

Conclusion: A 10-week group-based CBSM intervention can reduce negative affect, and increase positive affect in parallel with altering the profile of leukocyte gene expression in ways that may facilitate better recovery from treatment for breast cancer. Women assigned to CBSM showed less gene expression for inflammation and cancer-promoting cell-signaling which together might relate to hastened recovery from treatment and could influence longer-term outcomes. Since prior work has shown that these forms of psychosocial intervention are associated with increased survival and reduced disease recurrence over the subsequent decade in breast cancer patients, the present work may provide insights into how these interventions facilitate recovery in the first year after surgery, which may influence the trajectory of disease over the future.

Keywords: threat/anxiety, cognitive-behavioral stress management, gene expression, immune system, inflammation, cancer, stress

CORRESPONDING AUTHOR: Antoni Michael, University of Miami;

Conflict of Interest: Dr. Antoni reports receiving publication royalties from a book and related training materials that he has authored on CBSM treatments in health psychology.

Neuromodulation of health and disease



Gidron Y.1, Hall P.2

1 VUB, Department of Medicine, Brussels, Belgium

2 University of Waterloo, Department of Applied Psychology, Salomons, Waterloo, Canada

The relevance of brain-immune communication for diseases has received little scientific consideration. This symposium will address neuromodulation of health and diseases. Ohira will present work on brain regions (OFC, DLPFC) which respond to peripheral immune changes (NK cells) during stress. Furthermore, he will present findings showing in people low on vagal nerve activity (indexed by heart-rate variability – HRV), that peripheral NK cell changes during stress correlate with brain stem activity, while in people high on HRV, ‘higher’ CNS levels (cingulate, medial prefrontal cortex) were associated with NK-cell changes. Thus, the vagus may influence recruitment of basic versus executive brain resources for immune-modulation during stress. Hall’s team will present studies on effects of executive control resources (ECR) on dietary behavior. The first talk will present results of an observational study where tests of ECR inversely predicted rates of fatty-food consumption, independent of confounders. The second talk will present findings of an experimental study testing the effects of brain stimulation of the left dorsolateral prefrontal cortex, to enhance ECR, on dietary behavior. This may be the first study testing causal relations between ECR and fatty food consumption in people. Gidron’s team will then present two studies on neuromodulation of diseases. First, the relation between hemispheric lateralization (HL) and onset of colds was tested in Argentinian students. Results revealed that only a factor named “strategic planning” (reflecting left-HL functions) significantly predicted reduced risk of colds, independent of confounders (e.g., gender, vaccination, health behavior, neuroticism). The second talk will present studies on vagal nerve activity (HRV) and prognosis in cancer. Results show that HRV significantly inversely predicts the tumor marker PSA in prostate cancer, and significantly positively predicts survival time in pancreatic cancer, independent of confounders. HRV also moderated effects of tumor stage on three tumor markers, supporting a hypothesized protective role of this nerve in cancer. Finally, effects of two non-invasive methods to activate vagal activity were tested, and only HRV-biofeedback, but not transcutaneous vagal nerve stimulation, increased HRV. Together, these studies advance our knowledge of neuromodulation of health and disease.

Keywords: Psychoneuroimmunology, Neuroregulation, Cancer, obesity, Immune function

CORRESPONDING AUTHOR: Gidron Yori, Free Univ. of Brussels (VUB);



Ohira H.

Nagoya University, Department of Psychology, Nagoya, Japan

Psychological acute stress increases numbers of natural killer (NK) cells, which plays a critical role in innate immunity, in peripheral circulation within several minutes. This phenomenon is called redistribution of NK cells and has been thought to reflect facilitation of preventive defense in acute stress situations. The redistribution of NK cells is not a stereotyped response but is sensitive to psychological characteristics of stressors, thus is thought under control by the brain. We have explored neural mechanisms of such top-down regulation of NK cell distribution by the brain using simultaneous measurement of brain activity by positron emission tomography (PET) and numbers of NK cells in blood during cognitive acute stress tasks.

An uncontrollable stressor manipulated in a mental arithmetic task with significantly reduced redistribution of NK cells, compared to a controllable stressor. PET revealed that activation in the orbitofrontal cortex (OFC) and dorsolateral cortex (DLPFC) correlated with changes of numbers of NK cells, suggesting that these brain regions which are involved in cognitive appraisal of stressor controllability can regulate the redistribution of NK cells. The numbers of NK cells decreased gradually as participants acquired adaptive strategies in a stochastic learning task (habituation), however, the number of NK cells turned to increase when the contingency between options and outcomes changed (re-mobilization). Again, activation in the OFC and DLPFC, as well as the dorsal striatum showed correlation with the number of NK cells.

Some psychological and biological factors modulate such relationships between brain activity and NK cells. Participants with high chronic stress showed blunted brain activity in the OFC, DLPFC, and striatum in the learning task, and additionally showed lack of correlations between activation in such brain regions and NK cells. Furthermore participants with lower vagal tone thus lower regulating ability reflected by lower heart rate variability also showed similar pattern with participants with high chronic stress; blunted activation in the brain and lack of brain-NK cells association. Dysfunction of the top-down regulation of NK cells by the brain might be a risk factor of several illnesses.

Keywords: Neuroregulation, immune function

CORRESPONDING AUTHOR: Ohira Hideki, Nagoya University;



Hall P.

University of Waterloo, Public Health, Waterloo, Canada

Contemporary models of health behavior increasingly describe self-regulatory processes as central. The act of self-regulation (i.e., striving toward one’s intentions or goals in an active way that involves subordination of non-compatible sub-goals, and avoidance of distractions) is more than a social construction. In fact, decades of research link the act of self-regulation with the operation of the frontal lobe, and specifically with the operation of the prefrontal cortex and associated structures. The modulatory relationship between the prefrontal areas of the brain and older areas governing appetitive responses serves as a primary rationale for positing that executive control resources (ECRs) are a central resource that assists with health behaviors that require resisting temptations. To the extent that such resources ensure successful execution of dietary behaviors, including the avoidance of appetitive foods that humans are wired by evolution to prefer, there should be some association between performance on executive function tasks and dietary behaviors. It should be the case, moreover, that performance on such tasks should selectively predict consumption of fatty foods and not necessarily consumption of non-fatty foods (which presumably do not require self-control to resist). The purpose of the present study was to examine: 1) the extent to which ECRs predict consumption of fatty foods, 2) the extent to which such prediction varies by age group, and 3) the selectiveness of the effect (for fatty foods vs. food in general). It was hypothesized that performance on tasks known to draw on ECRs would predict the frequency with which participants consumed fatty foods (but not non-fatty foods), and that this association may be slightly stronger among older adults than younger adults. To test this hypothesis, we recruited an age-stratified community sample of healthy adults between the ages of 18 and 90 (N = 208), and administered two well-established tests of ECR at baseline (the Stroop task and the Go-NoGo task). Participants subsequently completed the NCI Fat Screener at two time points, spanning two weeks of dietary behavior. We found that quicker reaction times on the Go-NoGo (β = .230, p = .001) and higher % correct on the Stroop (β = -.166, p = .021) both predicted reduced frequency of fatty food consumption (but not non-fatty food consumption) over the follow-up interval. The effects of ECR on fatty food consumption were robust to adjustment for demographics, BMI, and IQ. Finally, further analysis revealed no significant ECR x age interaction, suggesting that the effects of ECR on frequency of fatty food consumption were invariant by age group.

Keywords: health behaviors; cognitive factors

CORRESPONDING AUTHOR: Hall Peter, University of Waterloo, Waterloo;



De Couck M.1, De Greve J.2, Marechal R.2, Van Laethem JC.2, Gidron Y. 2

1 VUB, Department of Medicine, Brussels, Belgium

2 VUB, Faculty of Medicine, Brussels, Belgium

Introduction: The role of microenvironmental factors (e.g., inflammation) and neural factors (e.g., sympathetic activity) in promotion of tumors has been recently shown. We developed a model proposing that the vagus nerve could possibly slow down tumors due to its inhibition of inflammation, sympathetic activity and oxidative stress. The present lecture presents results of several studies testing the relationship between vagal nerve activity and prognosis in several cancers. Finally, we present preliminary results on the ability to activate the vagus nerve non-invasively.

Methods & Results: In a sample of 72 colon cancer patients, heart-rate variability (HRV), a vagal nerve index, was derived from presurgical EGCs. HRV significantly predicted levels of the tumor marker CEA one year later, independent of tumor stage and treatment (r = -.43, p = .006). In a study on 113 prostate cancer patients, HRV significantly predicted the tumor marker PSA at 6 months, independent of confounders (r = -.363, p < .05). In stage 2 pancreatic cancer, HRV significantly predicted survival days (r = .356, p < .05). In several studies, we show that vagal activity moderates the effects of tumor stage on tumor markers. Finally, we tested the effects of two forms of deep breathing versus resting and versus watching a nature film on HRV. The two forms of deep breathing significantly increased HRV parameters better than the film and resting.

Conclusions: Our results, observed in several cancers, demonstrate that vagal never activity at diagnosis may predict various outcomes, independent of confounders, and may moderate the effects of tumor stage on prognosis. The experimental study shows that deep paced breathing can systematically increase HRV. These results support our model of the protective role of the vagus nerve in cancer. Future studies will test the effects and mechanisms of activating the vagus in cancer.

Keywords: Cancer, Neuroregulation, Psychoneuroimmunology

CORRESPONDING AUTHOR: Gidron Yori, Free Univ. of Brussels (VUB);



Killianova T.1, Fabre B.2, Berg G.2, Gidron Y.1

1 VUB, Faculty of Medicine, Brussels, Belgium

2 University of Buenos Aires, Faculty of Medicine and Biomedical Sciences, Buenos Aires, Argentina

Introduction: Hemispheric lateralization (HL) relates to a relatively stable tendency to activate or utilize functions associated with one cerebral hemisphere. Left-HL has been related to immune potentiation while right-HL to immune suppression. Only one study tested and found that right-HL predicted upper-respiratory infections (URI), however, it did not include objective immune outcomes. The present study aimed to replicate and extend that study by measuring HL with multiple tools and URI via self-report and a relevant immune marker.

Methods: N = 108 Argentinian university students took part in this study. At baseline, they completed the Zenhousern HL questionnaire, the line-bisection test and a verbal versus visual memory test, to measure HL. During 8 weeks, they were followed for development of URI, assessed by self-report and corroborated by salivary secretory Immunoglobulin A (SIgA) levels. Confounders including health behavior and neuroticism were considered as well.

Results: N = 25 people developed colds during follow-up. Left-HL measured by the line bisection test significantly correlated with baseline SIgA (r = .22, p < .05). Of all HL measures, only the Zenhousern factor of “strategic planning” (inversely) predicted risk of URI, independent of gender, health behavior, neuroticism, and chronic diseases, only in non-vaccinated people (p = .01), not in non-vaccinated ones.

Conclusions: This study partly confirms the role of left-HL (strategic planning) in predicting reduced risk of URI. Future studies need to examine whether activating the left hemisphere reduces the risk of URI, which could be of scientific and clinical importance to public health.

Keywords: Infection, Psychoneuroimmunology

CORRESPONDING AUTHOR: Gidron Yori, Free Univ. of Brussels (VUB);

Sleep and Health



Sivertsen B.

Norwegian Institute of Public Health, Division of Mental Health, Bergen, Norway

Objective: Depression and insomnia are closely linked, yet our understanding of their prospective relationships remains limited. The aim of the current study was to investigate the directionality of association between depression and insomnia.

Methods: Data were collected from a prospective population-based study comprising the most recent waves of the Nord-Trøndelag Health Study (the HUNT2 in 1995-1997 and HUNT3 in 2006-2008). 24 715 persons provided valid responses on the relevant questionnaires from both surveys. Study outcomes were onset of depression or insomnia at HUNT3 in persons not reporting the other disorder in HUNT2.

Results: Both insomnia and depression significantly predicted the onset of the other disorder. Participants who did not have depression in HUNT2 but who had insomnia in both HUNT2 and HUNT3 had an odds ratio of 6.2 of developing depression at HUNT3. Participants who did not have insomnia in HUNT2 but who had depression in both HUNT2- and HUNT3 had an odds ratio of 6.7 of developing insomnia at HUNT3. ORs were only slightly attenuated when adjusting for potential confounding factors.

Conclusions: The results support a bidirectional relationship between insomnia and depression. This finding stands in contrast to the previous studies, which have mainly focused on insomnia as a risk factor for onset of depression.

Keywords: insomnia, depression, longitudinal, epidemiology

CORRESPONDING AUTHOR: Sivertsen Børge, Norwegian Institute of Public Health, Division of Mental Health, Bergen;



Canivet C.1, Östergren P-O.1, Staland Nyman C.2, Lindeberg S I.1

1 Lund University, Department of Social Medicine, Lund, Sweden

2 Gothenburg University, Department of Public Health and Community Medicine, Gothenburg, Sweden

Several studies have found insomnia and long sleep duration to be independently associated with subsequent disability pension. However, the issue of a possible gender-based pattern in this context has received little attention. The aim of the present study was to assess the impact of different sleeping problems and sleep duration on the rate of disability pension during a 12-year follow-up period.

The cohort was recruited by random invitations from the general population of Malmö, Sweden, aged 45–65 years in 1992; the participation rate was 41% (n = 14,555). The participants in this study were the 2,254 men and 2,065 women who were healthy and working at least 30 hours per week at baseline. Baseline data included sociodemographic factors, lifestyle, body mass index, the Job Content Questionnaire, social support and participation, ‘stress outside work’, self-rated health and an instrument assessing sleep quality and duration. Information on disability pension was obtained through record linkage from the National Health Insurance Register.

Disability pensions were granted to 9% of the men and 15% of the women during the follow-up period. Affirming moderate or very large problems with any of ‘initiating sleep’, ‘waking up during the night’, ‘waking up too early’, and ‘not feeling rested by sleep’ was defined as ‘problems with sleep’, and this was present in 33% of the women and 41% of the men. The age-adjusted hazard ratios for problems with sleep and subsequent disability pension were in men 1.8 (95% CI 1.4 to 2.4) and in women 1.6 (95% CI 1.3 to 2.0). In the full model, after adjustment for sleep duration and for potential confounders and/or mediators, these HRs decreased to 1.4 (95% CI 1.1 to 2.0) in men and 1.4 (95% CI 1.1 to 1.7) in women.

Short sleep duration, i.e. ≤6 hours/night on weekdays, was associated with having problems with sleep, long sleep duration was not. Only two percent of the population slept ≥9 hours/night. In women, but not in men, long sleep duration was strongly associated with the subsequent granting of a disability pension; the HR was 2.8 (1.7 to 4.6).

In conclusion, sleeping problems seem to be a significant risk-factor for disability pension in the middle-aged working population. There were also clear gender differences in the pattern regarding which type of sleeping problems that were most linked to disability pension.

Keywords: sleep disorders; gender; disability pension

CORRESPONDING AUTHOR: Canivet Catarina, Lund University;



Bøe T.

Uni Research, Uni Health, Bergen, Norway

Objective: This study explored the association between familial socioeconomic status, parental health, family structure and childhood sleep problems, and investigated the role of sleep problems as a mediator between familial socioeconomic status (SES) and childhood mental health problems.

Methods: Participants were 5,784 11-13 years old children from the Bergen Child Study. Data were collected on family economy and parental education levels, and on children’s difficulties initiating and/or maintaining sleep (DIMS), time in bed (TIB) and self-reported mental health problems.

Results: Sleep problems were significantly more common in children from lower SES families. Children from families with Poor and Average family economy had significantly higher odds of reporting DIMS compared to children from families with Very good economy (ORs = 3.5 and 1.7, respectively). The odds were reduced by 12-36% when adjusting for poor parental health and single parenting, but remained significant. Children from families with a Poor economy had increased odds of a short TIB, both in the crude model (OR = 1.9) and when adjusting for parental characteristics (OR = 2.2). Maternal education level was significantly associated with short TIB. Path analysis was conducted to investigate the potential mediating role of DIMS in the relationship between SES and mental health. The significant direct association between family economy and SDQ total problems score was found to be partially mediated by a significant indirect effect of sleep problems.

Conclusions: Sleep problems are common amongst children from families with a lower SES and may be a potential mechanism through which low SES is translated into mental health problems.

Keywords: Socio-economic status, Abnormal sleep , Children's health, Mental health

CORRESPONDING AUTHOR: Bøe Tormod, Uni Health, Uni Research;



Sloan E. P.

University of Toronto, Mount Sinai Hospital, Department of Psychiatry, Toronto, Canada

The effects of sleep deprivation, both acute and prolonged, are manifold. Marked transient physiological changes, including neurological, autonomic, immunolgic have been reported.

Pregnancy is a time when the majority of women experience some disruption to their sleep. In the first trimester, frequent urination and hyperemesis can be problematic. In the third trimester, gastric reflux, nasal congestion and discomfort due to increased fetal size play a role. During the post-partum months, care of the neonate results in a significant reduction in the total amount of sleep. While the majority of women accommodate to the reduction in the amount of sleep, for certain women, sleep deprivation can result in significant and potentially serious compromise in mental well-being. In this presentation, changes in sleep across pregnancy and in the post partum period are highlighted. The role of sleep deprivation in the pathogenesis of post-partum mental illness is discussed. Possible mechanisms, and in particular the role of the hypothalamic-pituitary-axis (HPA) will be presented. An approach to improving sleep quality and quantity in the immediate post partum period which we are currently researching will be presented.

Keywords: sleep deprivation, postpartum

CORRESPONDING AUTHOR: Sloan Eileen P., University of Toronto;



Mucsi I.1,2, Novák M.1,3

1Semmelweis University, Institute of Behavioural Sciences, Budapest

2McGill University Health Centre, Division of Nephrology, Montreal, Canada

3University of Toronto, Department of Psychiatry, Toronto, Canada

Chronic Kidney Disease (CKD) is a progressive condition with shortened survival and severely impaired quality of life (QoL) of patients. When the kidneys fail (end-stage renal disease), dialysis or transplantation (TX) is required. Both are intrusive, and psychologically, psychosocially demanding treatments. Successful kidney TX provides better survival and also better health related quality of life.

Sleep disorders are considered complex and multicausal in this population, and might be caused by biological/medical, psychological, social and lifestyle factors. Insomnia, sleep apnea syndrome and restless legs syndrome, are common both in patients on dialysis and TX patients but there is only limited data available about the association between sleep problems, quality of life and clinical outcomes in this patient population. Despite of the significant improvement in overall health after TX, still a significant proportion of kidney transplant recipients suffer from sleep disorders which negatively impact mental health and QoL. As we have shown earlier, the prevalence of both insomnia and restless legs syndrome is reduced in TX patients compared to patients on dialysis and it is similar to the prevalence observed in the general population. The prevalence of sleep apnea, however, is very high around 30% and likely contributes to the cardiovascular mortality of patients. In this talk we will review the impact of sleep problems, which are potentially treatable, on QoL and other clinical outcomes in patients with CKD. We suggest that diagnosis and management of sleep disorders may improve QoL, mental health and potentially, even impact survival in this population.

Keywords: chronic kidney disease, dialysis, kidney transplantation, sleep disorders, quality of life

CORRESPONDING AUTHOR: Novák Márta, Semmelweis University, Budapest;



Kubota K.1, Shimazu A.1, Kawakami N.1, Takahashi M.2

1 The University of Tokyo Graduate School of Medicine, Department of Mental Health, Tokyo, Japan

2 National Institute of Occupational Safety and Health, Kanagawa, Japan

Previous studies reported association of workaholism (i.e., working excessively hard in a compulsive fashion) with poor sleep quality. However, these studies utilized mostly a cross-sectional design, which precludes causal inferences. Additionally, participants of previous studies were limited to nurses recruited only from hospitals in Japan. Therefore, the present study aimed to demonstrate the prospective association of workaholism with sleep quality among Japanese employees from various occupations.

A web-based prospective survey was conducted among registered monitors of a survey company. The questionnaire included workaholism, sleep quality (Pittsburgh Sleep Quality Index), job characteristics, and demographics. Overall, 13,564 monitors were invited to complete the first-wave survey (October 2010). Recruitment for the survey was stopped when the number of respondents exceeded 2,500. The first-wave respondents (n = 2,520) were invited to the second-wave survey (May 2011) and 2,061 answered.

A total of 378 respondents were excluded because of changes in job or employment during follow-up (n = 364) and missing values (n = 14), resulting in 1683 respondents for analysis (859 males and 824 females). Analysis of covariance (ANCOVA) was conducted to compare sleep quality (7 components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleep medication, and daytime dysfunction) at follow-up among workaholism groups (low, middle, and high). Covariates included demographics and baseline levels of sleep quality and job characteristics.

ANCOVA showed that high-workaholic group had significantly longer sleep latency at follow-up compared to low- and middle-workaholic groups (F = 4.69, p < 0.05). High-workaholic group also had significantly higher levels of daytime dysfunction compared to low-workaholic group (F = 5.02, p < 0.01). However, no significant differences were found among workaholic groups in overall sleep quality, sleep duration, habitual sleep efficiency, sleep disturbance, and use of sleep medication.

In conclusion, workaholism was associated with poor sleep quality at seven-month follow-up in terms of sleep latency and daytime dysfunction.

Keywords: Mental health, Sleep disorders, Stress

CORRESPONDING AUTHOR: Kubota Kazumi, The University of Tokyo, Tokyo;

Conflict of Interest: Grant-in-Aid for Scientific Research on Innovative Areas (Research in a Proposed Research Area) 2010 and 2011 (No. 4102 - 21119003) from the Ministry of Education, Culture, Sports, Science and Technology, Japan, supported the present study.

Using e-Health Technologies to Improve Psychological Wellbeing in Cancer Patients



Prins JB.

Radboud University Nijmegen Medical Center, Department of Medical Psychology, Nijmegen, The Netherlands

How can e-Health technologies improve the quality of life during and after cancer treatment? This question will be addressed in a symposium that brings together experts in the field of developing, evaluating and implementing e-Health interventions for cancer patients. A broad overview will be offered with different types of interventions, ranging from non-guided fixed-structured interventions for adults, to virtual engagement for young cancer patients. First scientific results will be combined with an impression of these interventions and the challenges of conducting E-health research.

Chair of the symposium

Prof. dr. Judith [P.B.] Prins, Professor and chair of Medical Psychology


1. Prof. dr. Irma [I.M.] Verdonck-de Leeuw - “Integrating e-Health in psychosocial care in cancer patients: shared decision making, screening, self-help, and stepped care”

2. Annemarie [A.M.J.] Braamse, MSc - “Online self-management for psychological distress in hematological cancer patients treated with autologous stem cell transplantation”

3. Sanne [S.W.] van den Berg, MSc -“The BREATH intervention: Online self-management to facilitate adjustment after curative breast cancer. Study protocol and pilot evaluation of usage”

4. Dr. Mette [M.T.] Høybye, PhD - “Virtual engagement. Reflections from an early pilot-testing of a virtual intervention for young cancer patients – thoughts on design, presence and usability of e-health interventions to promote well-being.”

Keywords: e-Health, Cancer, Intervention

CORRESPONDING AUTHOR: Prins Judith, Radboud University, Nijmegen;



Verdonck-de Leeuw M.

VU University, Clinical Psychology, Amsterdam, The Netherlands

Cancer patients have to deal with various physical and psychological side effects of cancer and cancer treatment. Specific stressors as fear of death, interruption of life plans, and changes in body image and self-esteem lead to emotional distress in 25-30% of the patients. Therefore, it is important to monitor quality of life in a structured manner in clinical practice enabling to provide adequate supportive care in an early stage. In the Netherlands, government policy statements and national guidelines reflect broad scientific and social support for a structured, integrated approach to supportive care in cancer patients.

E-health applications including computerized decision support can be used as helpful tools in shared decision making and careful monitoring quality of life and outcome. However, it is important to integrate such e-health tools into supportive cancer care according to self management and stepped care principles in which several evidence-based interventions are offered in a structured way. This approach has the potential to improve the efficiency of supportive cancer care.

In this presentation, an overview will be given of running projects at VU University Medical Center, Amsterdam, The Netherlands, including the OncoCompass, a web-based knowledge and decision support system; OncoQuest, a touch screen computer system for monitoring quality of life in clinical practice; and various randomized controlled trials on innovative (stepped) care strategies including on-line interventions targeting symptoms and quality of life aspects in cancer patients.

The bottom line of these approaches is healthier patients, more satisfied care providers, and cost savings by empowering both professionals and patients.

Keywords: e-health cancer self management self-efficacy quality of life effectiveness cancer survivorship depression anxiety

CORRESPONDING AUTHOR: Verdonck-de Leeuw Irma, VU University Medical Center;



Braamse AMJ.1, Van Meijel B.2, Visser O.3, Van Oppen P.1, Boenink AD.1, Eeltink C.3, Cuijpers P.4, Huijgens PC.3, Beekman ATF.1, Dekker J.5

1 VU University Medical Center, Department of Psychiatry, Amsterdam, The Netherlands

2 INHolland University of Applied Sciences, Mental Health Nursing, Amsterdam, The Netherlands

3 VU University Medical Center, Hematology, Amsterdam, The Netherlands

4 VU University , Clinical Psychology, Amsterdam, The Netherlands

5 VU University Medical Center, Rehabilitation Medicine, Amsterdam, The Netherlands

Background: Autologous stem cell transplantation following high-dose chemotherapy is acknowledged as one of the most stressful treatments in modern cancer care. Psychological distress (i.e. depression and anxiety) is a strong predictor of functional status and other aspects of quality of life in these patients. Psychological treatment is hypothesized to improve psychological distress, functional status and other aspects of quality of life. We offer treatment consisting of a stepped care program, including an internet self-help intervention.

Purpose: To present our experiences, possibilities and limitations of online therapy in hematological cancer patients treated with autologous stem cell transplantation.

Methods: In the context of a randomized controlled trial, 29 patients who underwent autologous stem cell transplantation were offered treatment with the online self-management intervention ‘Stress under control’.

Results: Of the 21 patients who chose to start with the intervention, 12 quit after lesson 1 or 2. The other 9 patients completed the whole intervention successfully; preliminary evaluation showed a reduction of psychological distress in this group. Reasons for the patients to quit treatment varied from experiencing little psychological distress to having too many psychological problems, and being unwilling to deal with psychological problems.

Discussion: In the treatment of psychological distress, internet therapy seems to be a valuable option for patients with hematological malignancies undergoing autologous stem cell transplantation. However, not all patients judge this treatment type to be helpful. Detailed assessment of the need for psychological treatment, in a face to face contact, seems to be important in this intensively treated patient group. Patients’ need for treatment should be assessed, and intensity of treatment (online therapy or immediate referral for more intensive treatment) should be tailored to the specific needs of the individual patient.

Keywords: e-Health; Cancer; Mental health; Intervention; Quality of life

CORRESPONDING AUTHOR: Braamse Annemarie, VUmc, Amsterdam;



Van den Berg SW .1, Gielissen MFM.1, Ottevanger PB.2, Prins JB.1

1 Radboud University Nijmegen Medical Center, Department of Medical Psychology, Nijmegen, The Netherlands

2 Raboud University Nijmegen Medical Center, Department of Medical Oncology, Nijmegen, The Netherlands

Background: After completion of curative treatment, breast patients are faced with a broad range of survivorship topics concerning physical, emotional and social recovery. The universality of these topics motivated the BREATH [BREAst cancer e-healTH] study to develop and evaluate an easily accessible self-management intervention to facilitate adjustment for all breast cancer patients. Because the actual usage of the intervention is possibly related to its effect, a pilot study was conducted to gain more insight in usage variables.

Methods: The non-guided self-management BREATH intervention guides patients chronologically through universal survivorship topics. The effectiveness of the BREATH intervention compared to usual care is currently being investigated in a multicenter randomized controlled trial. Both sample size calculation and intervention target are based on two primary outcomes: Decreasing the psychological impact of breast cancer (distress) and improving patients own strengths (empowerment). The intervention protocol has a fixed structure that covers four months, representing four different phases of recovery after breast cancer. The content of the intervention is based on breast cancer specific knowledge combined with techniques from cognitive behavioral therapy.

Results: An explorative pilot-study on usage of the intervention was conducted for a sample of 38 non-metastatic breast cancer patients (mean age 42.3 years) who completed primary treatment 3 months earlier in 5 hospitals in the Netherlands. Data were obtained from the ongoing BREATH trail. All patients were randomly allocated to the intervention group and completed the four-month BREATH intervention. Multiple usage variables were tracked (including frequency, duration of visits, activity) and linked to baseline patient characteristics (age, education, distress) in order to explore subgroups of usage. Results of descriptive statistics and regression analyses will be presented at the congress.

Conclusions: With the use of e-Health technologies, the BREATH intervention provides a non-traditional psychological self-management approach to promote well-being in all breast cancer survivors. Because the intervention is offered to a heterogeneous group of patients (both distressed and non-distressed), usage variables provide objective measures about the intervention uptake and need to be considered in the analyses of effectiveness.

Keywords: Cancer, e-Health, Intervention

CORRESPONDING AUTHOR: van den Berg Sanne, Radboud University, Nijmegen;



Hoybye M T.

University of Southern Denmark, National Institute of Public Health, Copenhagen, Denmark

Introduction: One of the reasons being discussed for the disparity in survival between adolescents and young adults with cancer to children is suboptimal adherence to treatment among the elder group.

New social media and computer games may have a particular potential to positively affect the behaviour of young cancer patients and increase their adherence to treatment through increased knowledge about cancer and increased self-efficacy.

This project seeks to promote treatment adherence and alleviate social isolation through a supportive and engaging behavioural intervention in an online real-time multi-player 3D-platform.

Methods and material: The project developed a web-based online 3D-environment. In February and March 2011, 12 young Danish cancer patients were recruited from the Oncology Department at Aarhus University Hospital to pilot test the feasibility of the prototype of the online environment. They answered a brief online survey and received introduction to the virtual environment.

Results: We learned that 100% of the participants used the internet, 60% used it daily. Main use of the internet was communication in online social networks (80%). None of the participants however participated in internet discussion groups on cancer.

The young patients tested basic features of the virtual environment, such as logging in, moving around their avatar and chatting with other patients. To test the creation of a small virtual community we had asked the young patients to connect with each other and the research team within the environment at four specific times, from where they might physically be present. However, these virtual meet-ups weren’t successful.

Discussion: Young patients are very engaged with online media and see the potential of an online platform. However, the intervention failed to integrate with the online spaces where the young patients are already present and interact. This is a major area of development for this application and intervention.

Taking outset in these reflections the challenges of online interventions in cancer support, to create real-life impact on patient outcomes, will be discussed, relating issues concerning design, presence and usability of e-health intervention to defined research endpoints and actual outcomes.

Keywords: Cancer, Adolescent, e-Health, Internet, Adherence, Health behavior

CORRESPONDING AUTHOR: Hoybye Mette Terp, University of Southern Denmark;

Self-rated Health: Evidence for its Validity, Limits to its Validity, and Uses as a Measure of General Health



Benyamini Y.

Tel Aviv University, Bob Shapell School of Social Work, Tel-Aviv, Israel

Consistent evidence for the intriguing findings relating self-rated health (SRH) to future morbidity and mortality has raised continued interest in the possible uses of this measure, the reasons underlying its validity as well as the limits to its validity. This symposium spans four presentations that contribute innovative answers to these questions, followed by a discussion session. The first presentation, based on a National study from Hungary, shows that SRH reflects the effects of the financial situation on perceived health, at the personal and National level, and particularly the major political changes in 1990. The second presentation, based on a National study of midlife women in Israel, compares the majority population group to immigrant and minority groups and calls to question the role of socioeconomic versus cultural factors that affect health perceptions. The third presentation extends the evidence for the validity of SRH to nonagenarians from Finland, showing that although SRH is often rated as good, even at this old age SRH is related to diseases and functioning and is sensitive to changes in such measures. The fourth presentation, based on a study of middle-aged and old adults in Israel, shows that better health perceptions are associated with greater adherence to screening recommendations, an association that can partly explain the validity of SRH as a predictor of future morbidity. Together, the four studies describe a variety of uses for SRH and support its validity, at least within culture, throughout the entire span of adult years, yet also raise questions regarding the limits to its validity.


Presenters and titles

Tamás MARTOS, Hungary

Economic growth, income and self-rated health in Hungary: trends between 1991-2010

Yael BENYAMINI, Israel

Health, Cultural and Socio-economic Factors Underlying Differences in Self-ratings of Health among Long-term Residents, Immigrants, and Arab Women in Midlife in Israel

Henrike GALENKAMP, the Netherlands and Finland

Is self-rated health among nonagenarians still sensitive for changes in disease and functioning?

Efrat NETER, Israel

Self rated health is prospectively associated with screening for the early detection of colorectal cancer (CRC)

Dorly J.H. DEEG, the Netherlands


Keywords: Health, Measurement

CORRESPONDING AUTHOR: Benyamini Yael, Tel Aviv University, Tel Aviv;



Martos T.1, Kopp M.2

1 Semmelweis University, Institute of Mental Health, Budapest, Hungary

2 Semmelweis University, Institute of Behavioural Sciences, Budapest, Hungary

Individual variations in quality of life and more specifically, in self-rated health are often connected to income, income inequality and social status. Based on these findings, we make an attempt to describe the long term trend of self-rated health of the Hungarian population from the political changes in 1990 to the present days. Moreover, on the national level we connect these trends to the change of gross domestic product (GDP) of Hungary in the same time period and individual differences in net household income o the personal level. We analyze data from ten surveys (Hungarostudy, European Values Study, European Social Survey, total N = 27774 respondents) that assessed several important characteristics of well-being in Hungary in the last 20 years. On the whole results indicate the following important associations. (1) The years after political changes in 1990 proved to be a nadir regarding self-rated health in the Hungarian society. In the following years a significant increase may be hypothesized while this was followed by signs of stagnation and decrease up to the present. (2) On the national level, self-rated health is closely associated with the GDP (r = 0,6) and (3) on the personal level, the association of self-rated health with the net household income is relatively stable. Results indicate that economic conditions of living represent an important cultural factor for self-rated health in the Hungarian society.

Keywords: Self-rated health, Economics, Income, Hungary, Population health

CORRESPONDING AUTHOR: Martos Tamás, Semmelweis University, Budapest;



Benyamini Y.1, Boyko V.2, Blumstein T.2, Lerner-Geva L.2

1 Tel Aviv University, Bob Shapell School of Social Work, Tel-Aviv, Israel

2 Sheba Medical Center, The Gertner Institute for Epidemiology and Health Policy Research, Tel HaShomer, Israel

Background: Self-ratings of health (SRH) have been consistently reported to predict mortality and morbidity, even after controlling for a wide variety of health-related measures. They have also been reported to differ by ethnicity, race, and socioeconomic status (SES). Our objective was to assess differences in SRH between three groups of midlife women and investigate possible explanations for these differences.

Methods: A representative sample of Israeli women ages 45-64 was selected from the following groups: Jewish long-term residents (n = 540), Immigrants from the former Soviet Union after 1989 (n = 151), and Arab women (n = 123). Women were interviewed in their homes, in Hebrew/Russian/Arabic respectively. All measures were self-reported and included a single-item assessing SRH as well as diseases, medication use, functional limitation, health care utilization, symptoms, depression, health behaviors, psychosocial measures, socioeconomic measures and socio-demographic information.

Results: The three groups greatly differed in most study measures. Poorest health was reported by Immigrants, followed by Arabs and least by long-term residents. These differences remained after controlling for: (1) age and marital status; (2) health and functioning; (3) health behaviors; (4) psychosocial measures and life events. Only after controlling for education and income, the difference between Arab women and long-term residents was eliminated and the difference between immigrants and long-term residents was somewhat reduced. When SES measures were adjusted for in the first step, along with the socio-demographic measures, the difference between Arab women and long-term residents was eliminated at this step.

Conclusions: The results underscore the complexity of comparing SRH across cultures and understanding its underlying bases: Though the groups vastly differ in health status, this does not fully account for the differences in their SRH, which therefore seem to be related to social and cultural factors. Adjusting for SES may result in overlooking important cultural differences and differences in life events and may thus underestimate the cultural sensitivity of SRH, and vice versa: Adjusting for social and cultural factors, may lead to underestimating the role of SES.

Keywords: Health disparities, ethnic differences, measurement

CORRESPONDING AUTHOR: Benyamini Yael, Tel Aviv University, Tel Aviv;



Galenkamp H.1, Deeg DJH.1, Huisman M.1, Braam AW.2, Jylhä M.3

1 VU University Medical Center, Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, Amsterdam, The Netherlands

2 Altrecht Mental Health Care, Department of Emergency Psychiatry, Utrecht, The Netherlands

3 University of Tampere, Tampere School of Health Sciences, Tampere, Finland

Introduction: With age, there is an increasing gap between self-rated health (SRH) and actual health status. It is unknown if SRH is still a sensitive measure for health status among the very old. This study investigates whether SRH among nonagenarians changes over time, and examines its susceptibility for changes in measures of disease and functioning.

Methods: In the Vitality 90+ Study, questionnaires were sent in 2001, 2003, 2007 and 2010 to all people aged 90 years and over living in Tampere, Finland. Three hundred thirty four nonagenarians (community-dwelling and institutionalized) filled in the questionnaire in 2001 and had at least one follow-up measurement. Self-rated health, the presence of eight chronic conditions and functioning in five activities were assessed. GEE analyses were applied to examine longitudinal change in SRH and the predictive value of number of diseases and functional status. In addition, moderating effects of depression and living situation were examined.

Results: Most nonagenarians rated their health as average (48.5%). Good SRH (36.5%) was more prevalent than poor SRH (15.0%). On average, no change in SRH occurred within two years follow-up, but declined SRH (22.3%) was associated with poorer baseline functioning and declined functioning. After six and nine years, clear declines in SRH were apparent, and were associated with increased diseases and declined functioning. The impact of diseases and functioning was smaller among institutionalized people (diseases OR = 0.90, p = 0.532; functioning OR = 1.18, p < 0.001) than among community-dwelling people (diseases OR = 1.30, p = 0.022; functioning OR = 1.44, p < 0.001). In addition, the detrimental effect of functioning on SRH was stronger in those without depression (OR = 1.33, p < 0.001) than in those with depression (OR = 1.17, p = 0.002)

Conclusions: Even in nonagenarians, SRH reflects declines in functioning and increases in number of diseases. In particular in community-dwelling and people without depression, poor health affects SRH. These results provide support for the usefulness of SRH as a measure of health among the oldest olds.

Keywords: Older adults, Health, Disability, Chronic illness, Assessment

CORRESPONDING AUTHOR: Galenkamp Henrike, VUmc, Amsterdam;



Neter E.1, Stein N.2, Rennert G.3, Hagoel L.3

1 Ruppin Academic Center, Behavioral science, Emeq Hefer, Israel

2 Carmel Medical Center, Department of Epidemiology and Community Medicine, Haifa, Israel

3 Technion, Department of Epidemiology and Community Medicine, Haifa, Israel

Background: Perceived health is a consistent predictor of mortality and other health outcomes. One of the mechanisms hypothesized to explain its validity as a predictor is that SRH affects the adoption of health behaviors, yet most relevant evidence is cross sectional. The present study focuses on the performance of the recommended CRC screening test (Fecal Occult Blood Test, FOBT) in a CRC early detection program. SRH was measured before the behavior was enacted and allows examining the association between SRH and this health behavior in a longitudinal design. The paper also examined if CRC risk perception and attitudes, efficacy and intentions to perform the screening test varied as a function of SRH.

Methods: 2200 men and women aged 50-74, eligible for CRC screening and who have underwent the test a year before, were mailed a test-kit. Half were interviewed by telephone, 1-2 weeks following mailing of the test-kit, and the other half two months later. The latter timing assessed the interviews' 'mere measurement' effect on performing the test.

Results: Participants who rated their health as better than others' performed the screening test 2 months (and 6 months) following invitation, more often than those who rated their health as similar to or lower than that of others' (60.5%, 58%, and 48.2%, respectively, χ2 = 10.58, p < .01), even though these participants' perceived CRC risk was significantly lower than that of those who rated their health as comparable or lower than others' (p < .05). Intentions, perceived efficacy for performing the test and attitudes towards the test did not vary significantly by SRH. CRC knowledge of those who perceived their health as better or similar to others' was higher than those who rated their health as lower than others'. Participants who rated their health as better than others' were more often men, single, and had a higher education.

A hierarchical multivariate analysis of CRC screening behavior was performed. It included demographic variables in the first step, knowledge, SRH and risk perception in the second step, and the interaction between SRH and risk perception in the third step. Age, education and gender were significant predictors, and so was SRH. The interaction between SRH and risk perception was non-significant.

Conclusions: Self rated health contributes to predicting CRC screening, better than other cognitive variables, after accounting for demographic variables.

Keywords: cancer screening, health behaviors

CORRESPONDING AUTHOR: Neter Efrat, Ruppin Academic Center;

Behavioral Aspects of Chronic Diseases



Gillespie MW.

University of Alberta, Department of Sociology, Edmonton, Alberta , Canada

This paper describes the results of a Cox regression analysis of a subsample (n = 601) of respondents drawn from a University of Michigan study of the quality of life of Michigan patients suffering from end state renal disease (ESRD). The sample was selected from the Michigan kidney registry. The subsample consists of those patients for whom mortality status as of Nov. 30, 1986, along with the death date of the 13.5% who had died, was determined from the registry. These patients were interviewed in the summer months of either 1984 (n = 101) or 1985 (n = 400). My secondary analysis of these data focuses on the possible effects of emotional valence and arousal on mortality. I use the three-category ten item Bradburn Affect-Balance Scale to measure both valence and arousal. (The categories are never = 0, sometimes = 1, and often = 2.) Valence equals the difference between the sum of the responses to the five positive items and the sum of the five negative items. Arousal equals the sum of the responses to all ten items.

The main findings of my analysis are no relation between valence and mortality but a curvilinear relationship between emotional arousal and mortality. The nature of this curvilinear relation is that the mortality hazard ratio decreases with arousal at low levels of arousal and then increases with arousal at high levels. (HR = .37 & 1.05 for the linear and quadratic terms, respectively; p < .001, 2-tail test, for both estimates.) This curvilinear relation occurs when the regression is stratified by the respondent’s kidney transplant status. It also is unaffected by the inclusion of three control variables in the regression equation: the respondent’s bmi (HR = 1.05), a dummy variable that indexes diabetes as the cause of the respondent’s ESRD (HR = 1.70), and a three-item index that combines additional measures of feelings (HR = .50): self-reported health, high feelings of energy during the past month, and low feelings of sadness also during the past month. (The estimates for the three control variables are marginally significant at p < .05, 1-tail.) Finally, the curvilinear relation stands up when a plethora of other demographic, psycho-social, and health-related variables are tried. None of these controls is included in the final regression equation, however, because none significantly affects mortality (p < .05, 1-tail).My discussion of these results focuses on three contentious premises that underlie the existence and interpretation of this curvilinear relationship: (1) Valence and arousal, typically the first two principal components of a factor analysis of self-reported emotions, better represent the structure that underlies these reports than positive and negative affect, the two factors that typically result from the rotation of the principal components to simple structure. (2) Emotional arousal is the psychological manifestation of stress as defined by Selye as the “non-specific response to change.” (3) Calabrese’s use of the Yerkes-Dodson “law” to place the relation between stress and cognition in a hormetic framework can be extended to encompass the relation between emotion and morality, at least in the case of ESRD patients.

Keywords: emotions, renal/urological disorders

CORRESPONDING AUTHOR: Gillespie Michael, University of Alberta Edmonton;



Sainsbury K.1, Mullan B.2, Sharpe L.1

1 University of Sydney, Clinical Psychology, Sydney, Australia

2 University of Sydney, Psychology, Sydney, Australia

Coeliac disease (CD) is a chronic autoimmune disorder, which when not adequately treated with a strict gluten free diet (GFD), is associated with serious long term health complications including intestinal and bowel cancers, osteoporosis, and infertility. Depression and anxiety, as well as reduced quality of life (QOL) are more common in this population than in healthy controls. In addition, emerging literature suggests that eating disorder pathology and coping behaviour may also impact on dietary adherence and QOL. Although a number of studies have examined QOL in CD the majority have been limited to correlations and have focused on a reduced number of potentially significant variables, meaning a comprehensive understanding of the interactions between mental health and disease characteristics in CD, and the consequent impact on QOL, is lacking. Measures of QOL, depression, anxiety, eating pathology, and coping skills, as well as demographic and disease information were completed by 390 participants with biopsy confirmed CD. Correlations and hierarchical regression analysis were used to determine the nature of the relationships between QOL, psychological and disease factors. Demographic and disease variables including the number of symptoms prior to diagnosis, time to improvement after initiation of a GFD, and additional food intolerances accounted for 14.1% of the variance in QOL, F (6, 341) = 9.3, p < .001. Psychological variables added an additional 26.9% to the model, F (11, 336) = 21.2, p < .001, although only depression made a significant independent contribution. Poorer QOL was associated with both a higher incidence of psychological and CD symptoms. The combination of disease characteristics and psychological difficulties within CD in this study allowed for a more comprehensive examination of the factors influencing QOL than has previously been undertaken. The negative impact of psychological problems on QOL suggests that targeted interventions should include the provision of psychological coping skills as well as purely dietetic based strategies to improve physical symptoms and management of CD.

Keywords: Quality of Life, Mental Health

CORRESPONDING AUTHOR: Sainsbury Kirby, The University of Sydney;



Saboonchi F.1, Jäghult S.2, Wellander R.3, Wettersjö A.4

1 Red Cross University College, Stockholm, Sweden

2 Karolinska Institutet, Department of Clinical Science, Stockholm, Sweden

3 Stockholm University, Institute for Psychology, Stockholm, Sweden

4 Stockholm University, Institute of Psychology, Stockholm, Sweden

Background: According to Leventhal’s common sense model of self regulation (CSM), the patients’ perception of illness functions as an antecedent to patient’s coping efforts. Coping strategies, in turn, are widely assumed to influence health outcomes and determine the emotional sequel of living with a chronic illness. Anxiety is a major psychological distress associated with the onset and escalation of Inflammatory Bowel Diseases (IBD), asserting a negative impact on quality of life and subjective health of the patients. A main domain of illness perception, perception of lack of control, is a potentially important predictor of anxiety. On the other hand, acceptance coping, which denotes that the individual accepts the events and experiences that are beyond his or her control, has been suggested to relieve emotional distress. The present study, thus, examined the effect of perception of control and acceptance coping on anxiety and subjective health in a small community sample of patients with IBD.

Methods: 32 patients diagnosed with IBD (19 Crohn’s diseases, 13 ulcerative colitis) completed a battery of questionnaires including Brief Illness Perception Questionnaire (B-IPQ), Short Health Scale (SHS), Brief COPE; and Hospital Anxiety and Depression Scale (HADS).

Results: Path analysis revealed a direct effect of perception of lack control on self-reported anxiety (Standardized Beta = 0.24 p < 0.05), Perception of lack of control also was shown to significantly and adversely influence subjective health (Standardized Beta = - 0.35 p < 0.01). Furthermore, acceptance coping was shown to predict lower degree of anxiety (Standardized Beta = -0.42 p < 0.01), and improved subjective health (Standardized Beta = 0.29 p < 0.05). The analysis also indicated partial mediation of acceptance coping on the effects of perception of lack of control on anxiety and subjective health.

Conclusions: The findings of the present study suggest that while perception of personal and treatment control of the disease constitutes an important determinant of subjective health and lower degrees of anxiety, the acceptance based coping skills, i.e. to learn to accept what lays beyond one’s control, is an equally important target variable in efforts to improve the IBD patients’ subjective wellbeing.

Keywords: Anxiety, Coping, Inflammatory Bowel diseases, Illness perception

CORRESPONDING AUTHOR: Saboonchi Fredrik, Sophiahemmet, Stockholm;



Engelund G., Møller Hansen U., Willaing I.

Steno Health Promotion Center, Patient Education , Gentofte, Denmark

Aims: In Danish municipalities responsible for the delivery of patient education the volume of patients is not always large enough for disease-specific patient education. Instead the education must apply to people with different diseases typically type 2 diabetes, COLD, and heart disease. Many studies of life with a chronic illness focus only on one disease or on a particular aspect of chronic illness and thereby overlook common patient experiences across chronic diseases.

The aim of this study was therefore to explore and describe shared experiences and perceptions of life with a chronic illness among patients with Type 2 diabetes, COLD, and heart disease.

Methods: The study was based on qualitative data from four highly active workshops with 25 patients with a chronic illness. Three workshops were conducted with patients with type 2 diabetes, COLD, and heart disease respectively whereas the last one had participants with one of the three diseases. Each workshop lasted four hours and different types of probes were used to gather data through participation, dialogue and reflective exercises about life with chronic illness. Data were obtained in the format of video, photos, written material, and field notes. The data were analyzed using a grounded theory approach with conceptualization, constant comparison, coding and discovery of categories.

Findings: The emerged core category ‘The Balancing Man’ hypothesizes that people with a chronic illness have a constant need for balancing their identity and life due to ongoing changes. The different changes and imbalances were conceptualised into four sub-categories: ‘Bodily Infirmities’, the experience of physical changes; ’Lowered Bar’, the experience of everyday life changes; ‘Challenging Relations’, the experience of social changes and ‘Changeable Moods’ the experience of emotional changes. The changes and imbalances appeared with different degree and effect in each individual and were shared more across the different diseases than within.

Conclusion: The knowledge about the shared perceptions of life with a chronic illness as expressed with the concept of ‘The Balancing Man’ can be useful for Health Care Professionals when planning and delivering group-based patient education across different diseases in order to recognize the changes and imbalances shared by the group and thereby also their needs. The findings also apply to the education of the individual patient since many patients often suffer from more than one chronic illness e.g. type 2 diabetes and heart disease.

Keywords: Chronic illness, Health education

CORRESPONDING AUTHOR: Engelund Gitte, Steno Diabetes Center, Denmark;



Székely A.1, Cserép Z.2, Toth R.3, Balog P.4, Takó K.5, Juhász B.6

1 Semmelweis University, Department of Anesthesia and Intensive Care, Budapest, Hungary

2 Semmelweis University, Department of Anesthesiology and Intensive Therapy, Budapest, Hungary

3 Semmelweis University, School of PhD Studies, Budapest, Hungary

4 Semmelweis University, Institute of Behavioural Sciences, Budapest, Hungary

5 Semmelweis University, Budapest, Hungary

6 Gottsegen Hungarian Institute of Cardiology, Department of Cardiac Surgery, Budapest, Hungary

Psychosocial factors have shown independent predictive value in the development of cardiovascular diseases. Although there is strong evidence to support the role of psychosocial factors in cardiovascular mortality, there is a scarcity of knowledge about how these factors are related. Therefore, we investigated the relationship between depression, anxiety, education, social isolation and mortality 10 years after cardiac surgery.

After informed consent, 180 patients undergoing cardiac surgery between July 2000 and May 2001 were prospectively enrolled and followed for ten years. During the follow-up period, the patients were contacted annually by mail. Anxiety (Spielberger State-Trait Anxiety Inventory, STAI-S/STAI-T), depression (Beck Depression Inventory, BDI) and the number and reason for major adverse cardiac and cerebral events (MACCE) were assessed each year. Those patients who did not respond were contacted by telephone, and national registries were searched for deaths. During a median follow-up of 9.8 years (25th to 75th percentile, 9.3 to 10.3 years), the mortality rate was 29.4 % (53 deaths). In a Cox regression model, the risk factors associated with an increased risk of mortality were a higher EUROSCORE (points; Adjusted Hazard Ratio (AHR):1.26, 95%CI:1.12-1.41), a higher preoperative STAI-T score (points; AHR:1.04, 95%CI 1.01-1.08), lower education level (school years; AHR:0.89, 95%CI:0.81-0.98), and the occurrence of MACCE during follow up (AHR:2.62, 95%CI:1.48-4.6). In the postdischarge model, the postoperative BDI score (points; AHR: 1.07, 95%CI: 1.03-1.12) was independently associated with mortality. Our results suggest that the assessment of psychosocial factors, particularly anxiety, depression and education may help identify patients at an increased risk for long-term mortality after cardiac surgery.

Keywords: depression, anxiety, cardiac surgery

CORRESPONDING AUTHOR: Székely Andrea, Semmelweis University, Budapest;



Gonzalez EW.1, Lippa CF,.2, Polansky M.3

1 Drexel University, College of Nursing & Health Professions, Philadelphia, USA

2 Drexel University, School of Medicine, Philadelphia, USA

3 Drexel University, School of Public Health, Philadelphia, USA

Purpose: This study examined the effects of enhancing resourceful skills on caregiver’s resourcefulness, anxiety, preparedness and frequency of care-recipient’s behavior problems while caring for persons with dementia.

Theoretical rationale: Enhancing resourceful skill in family caregivers is postulated to enable caregivers to achieve goals by self-regulation of negative emotions, apply problem-solving skills, cognitively reframe the caregiving issues and maintain confidence to function at an optimal level.

Methodology: A stratified randomized clinical trial (ethnicity and resourcefulness) was used to compare the effectiveness of enhancing resourceful skills versus the standard care in 102 family caregivers (47 experimental; 55 control). Outcomes were measured at baseline, 6 weeks and 3 months post intervention. Resourcefulness was measured using Rosenbaum’s (1982) Self-Control Scale. Anxiety was measured using the State-Trait Anxiety Inventory –State subscale (Spielberger et al, 1982). Caregiver preparedness was measured using Preparedness for Caregiving Scale (Archbold et al., 1990), Frequency of behavior problems was measured using the Revised Behavior Problem Checklist (Teri et al, 1992). Descriptive statistics and general linear model (univariate) were used to analyze the data.

Results: The ANCOVA analysis showed that after controlling for baseline resourcefulness, family caregivers in the intervention group demonstrated increased resourcefulness immediately post intervention (6 weeks) F(1,99) =15.74, p < .001 and at 3 months, F(1,70) = 4.18,p < .05 compared to those in the control group. At 6 weeks the intervention group reporting higher anxiety F(1,86) = 6.86, p < .01 was compared to the control group. There were no significant differences between groups on preparedness F(1,81) = .99,p = .32 and occurrence of behavior problems. At 3 months, there was a significant difference between groups on preparedness F(1,70) = 5.12, p = .03 although not on anxiety F(1,70) = 1.13,p = .29 and occurrence of behavior F(1,65) = 3.69,p = .06. However, anxiety in the intervention group decreased (mean = 35; SD = 11.5) while those in the control (mean = 40.4; SD = 11.7) group increased. Similarly, occurrence of behavior in the intervention group decreased while those in the control group increased. Enhancing resourceful skills improves caregiver resourcefulness, preparedness and decrease occurrence of patient behavior problems.

The project described was supported by Grant Number R15 NR0009490-01A1from the National Institute of Nursing Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health.

Keywords: Aging; Anxiety

CORRESPONDING AUTHOR: Gonzalez Elizabeth W, Drexel University;

Workplace Interventions to Improve Health



Odeen M., Tveito T., Heide Magnussen L., Mæland S., Larun L., Eriksen H.

Uni Health/Uni Research, Bergen, Norway

Background: The workplace is increasingly being used as a venue for interventions where the goal is to prevent and to reduce sick leave, aimed at variety of medical conditions.

Objectives: This review attempts to give an overview of the general effectiveness of active interventions in the workplace aimed at preventing and reducing sick leave, across diagnostic categories.

Methods: Searches were conducted in Pubmed, Embase, Psych-info and ISI web of knowledge (December 2011). Inclusion criteria were studies where: 1) The participants were over 18 years, and have an active role in the intervention, 2) the intervention was done (at least partly) at the workplace or at the initiative of the workplace, and 3) sick leave was measured quantitatively. Two reviewers independently screened articles, extracted data and assessed risk of bias using the Cochrane risk of bias tool.

Results: From an original database of 1871 articles we assessed 75 for eligibility. 34 articles were included for analysis, with a total of 46 comparisons. Risk of bias analysis showed 4 high quality, 12 medium and 18 low quality studies. 12 Interventions from 10 different studies showed a statistically significant effect on sick leave, 7 of these were on back pain. Studies documenting positive or negative effect were significantly smaller (median n = 113) than studies with no effect (median n = 264). A qualitative synthesis of the data was done, and we found evidence of effect of the Sheerbrooke model and graded activity on sick leave. Furthermore, there was evidence that education and physical activity, done either separately or together, was not effective in reducing sick leave. For other interventions the results were too few or too divergent to make a judgment. When assessing the studies by diagnostic groups, interventions focusing on musculoskeletal and mental health complaints were most effective. None of the 16 interventions aiming at multiple health complaints or prevention were significant. Results were similar for high and low quality studies, and for studies using register data or self-report data on sick leave.

Conclusion: Active workplace interventions were generally not effective in reducing sick leave, but there were evidence of effect of the Sheerbrooke model and of Graded Activity.

Keywords: Worksite health, occupational health, intervention

CORRESPONDING AUTHOR: Odeen Magnus, Uni Heatlh, Bergen, Norway;



Trudel X.1, Gilbert-Ouimet M.1, Brisson C.2, Milot A.3, Vézina M.2, Masse B.4

1 URESP du Centre de Recherche FRSQ du CHA Universitaire de Québec, Department of Social and Preventive Medicine, Quebec, Canada

2 Laval University, Department of Social and Preventive Medicine, Quebec, Canada

3 Laval University, Department of Medicine, Quebec, Canada

4 University of Montreal, Department of Social and Preventive Medicine, Montreal, Canada

Background: Adverse psychosocial work factors have been shown to contribute to the development of chronic health problems, such as hypertension. Preventive interventions aimed at reducing psychosocial work factors have been conducted in workplaces. However, few studies have rigorously evaluated their effectiveness in reducing psychosocial work factors and improving blood pressure (BP). This study assessed the long term effects of a preventive psychosocial workplace intervention on ambulatory BP.

Methods: An intervention was conducted in a large public insurance company to reduce adverse psychosocial work factors. These factors and ambulatory BP were measured at baseline, 6- and 30-month post-intervention. Ambulatory BP measurements were taken every 15 minutes during a working day. Psychosocial work factors were measured using validated scales. Associations between exposure to psychosocial work factors and BP were also examined, using generalized estimating equations (GEE). The study sample consisted of 2132 workers and 4263 observations.

Results: During the entire study period, workers exposed to high psychological demands, job strain and effort-reward imbalance had mean blood pressure approximately 2 mmHg higher than workers not exposed to these factors. By the 6 and 30 month follow-up, three of the targeted factors had significantly decreased (high psychological demands, low reward and effort-reward imbalance). The 30 month follow-up also showed significant reductions in the prevalence of hypertension (16.4% to 12.5%), mean systolic BP (126.1 to 123.9 mmHg) and mean diastolic BP (80.6 to 78.8 mmHg).

Conclusion: These results suggest that interventions that aim to reduce adverse psychosocial work factors may lead to improvements in BP.

Keywords: Hypertension Intervention

CORRESPONDING AUTHOR: Trudel Xavier, Université Laval;



Cserhati Z., Stauder A., Adam SZ., Konkolÿ Thege B., Pilling J., Purebl GY., Szekely A., Kopp M.

Semmelweis University, Institute of Behavioural Sciences, Budapest, Hungary

Background: Work-family conflict is a form of interrole conflict in which the role pressures from the work and family domains are incompatible. Time-based, stress-based and behavior-based forms are differentiated. Work-family conflict can have various outcomes like decrease in work performance, burnout, psychological strain, depression and physical health complaints. Interventions targeting work-family conflict are mostly organization-focused, whilst individual factors like negative affect and coping strategies also serve as antecedents. Stress management interventions (SMIs) are individual-focused interventions which are proved to be beneficial in improving well-being and reducing stress-related complaints. Their effects on work-family conflict were not investigated earlier.

Methods: 472 employees from diverse background received one of two different types of 16-hours stress management interventions (Williams LifeSkills Program and risk reduction training) or a three-hour lecture on stress and coping (comparison group). Techniques used in cognitive behavioral therapy and relaxation were elements of both types of trainings, while risk reduction training put additional emphasis on healthy lifestyle components. In a one-year follow up, we included 259 participants. Work-family conflict was measured by the Carlson Multidimensional Scale. For work-related stress, the Siegrist Effort-Reward Imbalance Scale (ERI), for perceived stress, the Cohen Perceived Stress Scale (PSS10) was used.

Results: There was significant decrease in the level of stress-based work-family conflict (p < 0.001) and perceived stress (p < 0.05) in both SMI groups, while there was no significant change in comparison group. Behavior-based work-family conflict decreased significantly only in risk reduction training group (p < 0.01), time-based work-family conflict remained unchanged in all groups. Improvement in work-related stress was measured only in Williams LifeSkills group (p < 0.05).

Discussion: Stress-management interventions can be beneficial in reducing work-family conflict. Investigating the interactions between work-related stress or perceived stress and different forms of work-family conflict may require further research.

Research supported by the Hungarian Ministry of Health.

Keywords: stress, intervention, worksite health

CORRESPONDING AUTHOR: Cserhati Zoltan, Semmelweis University Budapest;



Rugulies R.1, Madsen I.1, Hjarsbech P.1, Hogh A.2, Borg V.1, Carneiro I.1, Aust B.1

1 National Research Centre for the Working Environment, -, Copenhagen, Denmark

2 University of Copenhagen, Department of Psychology, Copenhagen, Denmark

Background: Adverse psychosocial working conditions may play a role in the aetiology of major depressive episodes (MDE). The aim of this study was to analyze whether exposure to workplace bullying increases risk of onset of MDE among 5701 females employees in the Danish eldercare sector.

Methods: We sent out questionnaires about working conditions and health to eldercare workers in 2004/2005 and again in 2006/2007. Response rates were 78.1% (9949 out of 12744) at baseline and 63.4% (6304 out of 9949) at follow-up. Mean time of follow-up was 20 months. Participants were given a definition of bullying and were subsequently asked "Have you been exposed to bullying at your current workplace within the last 12 months?", with the response categories "no", "yes, now and then", "yes, monthly", "yes, weekly", "yes, daily or almost daily". We created a 3-level exposure variable, with the categories (1) "no bullying" (reference group), (2) "occasional bullying" (combining "now and then" and "monthly) and (3) "frequent bullying" (combining "weekly" and "daily/almost daily"). MDE was assessed with the "Major Depression Inventory", an instrument that follows the DSM-IV diagnosis of major depression. The instrument had been previously validated in both clinical and population-based studies. We used multiple logistic regression analyses to investigate the prospective association between exposure to bullying at baseline and onset of MDE at follow-up among participants free of MDE at baseline. Further, we analyzed reciprocal effects, i.e. whether MDE at baseline predicted bullying at follow-up.

Results: The prevalence of bullying at baseline was 10.0% (occasional bullying) and 1.9% (frequent bullying), respectively. Onset rates of MDE at follow-up were 1.5%, 3.4%, and 11.3% in the groups of no, occasional and frequent bullying, respectively. Both occasional bullying (OR = 2.22, 95% CI = 1.31-3.76) and frequent bullying (OR = 8.45, 95% CI = 4.04-17.70) predicted onset of MDE, after adjustment for age, cohabitation, type of job, seniority, and length of follow-up. In the analyses on reciprocal effects, MDE at baseline did not predict bullying at follow-up (OR = 0.93, 95% CI = 0.47-1.84).

Conclusion: Exposure to workplace bullying strongly increased risk of MDE among female eldercare workers. MDE did not predict risk of bullying. Eliminating bullying at work may be an important contribution to the prevention of MDE.

Keywords: Depression; Occupational Health

CORRESPONDING AUTHOR: Rugulies Reiner, NRCWE, Copenhagen;



Bria M.1, Baban A.1, Spanu F.1, Lucacel R.1, Rotar I.2, Constantea N.2

1 Babes-Bolyai University, Psychology, Cluj-Napoca, Romania

2 Iuliu Hatieganu University of Medicine and Pharmacy, Faculty of Medicine, Cluj-Napoca, Romania

Aim: Moderate levels of physical activity have been shown to reduce the impact of work stress on mental health and work performance. In the organizational context, much of the research has focused on the buffering effect of job resources in the relationship work demands – burnout, while individual strategies have received less attention. The aim of the present research was to investigate the role of physical activity in reducing the impact of job demands on burnout.

Method: Data were collected from a sample of 311 health professionals in Romania (165 physicians and 146 nurses). Maslach Burnout Inventory was used to collect data on emotional exhaustion and depersonalization. Physical, organizational and emotional work demands in medical settings were measured using an instrument developed for the ORCAB European project. All scales show good reliability coefficients. Physical activity was measured using self reported data on the frequency of exercising / week. Moderation effects were tested using hierarchical regression in SPSS.

Results: A negative relationship was found between the frequency of physical activity and depersonalization, but not emotional exhaustion. Physical activity was found to moderate the impact of organizational demands (ΔR2 = .013, F(1, 305) = 4.963, p > .05, β = -.115), and emotional demands (ΔR2 = .019, F(1, 307) = 7.323, p > .01, β = -.140) on depersonalization. No similar effect was found for the relationship physical demands – depersonalization.

Conclusions: The results show that when confronting with the same level of organizational and emotional demands, health professionals that engage more frequent in physical activity report lower levels of depersonalization. These results have implications for interventions aiming at reducing burnout among health professionals, showing that individual strategies, like engaging in physical activity, might help decrease burnout symptoms.

Keywords: occupational health, physical activity

CORRESPONDING AUTHOR: Bria Mara, Babes-Bolyai Univ., Cluj-Napoca;



SU TC.1, Cheng Y.2, DU CL.3

1 National Taiwan University, Internal Medicine, Taipei, Taiwan

2 National Taiwan University, Institute of Health Policy and Management, Taipei, Taiwan

3 National Taiwan University, Department of Occupational and Environmental Medicine, Taipei, Taiwan

Introduction: Return to work (RTW) is an important measure of success in the treatment of patients with CHD or AMI. In addition to medical factors, previous studies indicated that psychosocial work hazards, including job demands, job control and workplace justice are important predictors for the risk and prognosis of coronary heart diseases (CHD, including acute myocardial infarction and severe CHD). The study aimed to examine the impact of psychosocial work hazards on return to work at 12 months following the first onset of above diseases in a tertiary hospital of Taiwan.

Subjects and Methods: From Jan, 2008 though Nov, 2011, 327 male patients, 25-65 years of age, who were first diagnosed with AMI, severe CHD s/p CABG or POBAS and had a formal job before disease onset were recruited before discharge or within 2 weeks after discharge. Psychosocial work hazards were assessed by a standardized self-administered questionnaire, which included validated scales for job demands, job control and workplace justice, as well as items for other work characteristics such as work hours, shift work. A case manager collected questionnaires and checked for their completeness. Vascular risk factors and clinical information, such as blood sugar, serum lipids level and history of hypertension, diabetes status were also recorded from detailed chart review and personal communication at the recruitment, 4th and 12th months after the disease onset. Unsuccessful RTW was inquired at 4th and 12th months by structured questionnaire and reconfirmed at 12 months if patients failure to RTW

Results: After controlling for multiple confounding factors, workers with a high demand and low control job were more likely to have an unsuccessful RTW (OR (95% C.I.) =2.75 (1.13-6.71), p < 0.05) as compared to reference groups (other three quadrants of job strain model), while workers with higher level of workplace justice were less likely to have a unsuccessful RTW (OR = 0.21, P < 0.01). While we combined both workplace justice and work strain in the same model for multivariate analysis, workplace justice but not work strain remained a strong negative predictor of unsuccessful RTW in CHD patients, with an odds ratio (95% C.I.) of 0.24 (0.08-0.73).

Conclusion: These findings underscore the importance of psychosocial work factors, especially workplace justice, in predicting successful RTW. To facilitate successful RTW for CHD patients, it is important to incorporate interventions for the improvement of psychosocial work conditions.

Keywords: coronary heart disease, occupational health

CORRESPONDING AUTHOR: Du Chung-Li, NTU Hospital, Taipei;

Psychophysiology and Functional Symptoms



Strahler J.1, Fischer S.1, Nater U.1, Ehlert U.2, Gaab J.3

1 University of Marburg, Clinical Biopsychology, Marburg, Germany

2 University of Zurich, Clinical Psychology and Psychotherapy, Zurich, Switzerland

3 University of Basel, Clinical Psychology and Psychotherapy, Basel, Switzerland

Chronic Fatigue Syndrome (CFS) is a disorder of unknown etiology characterized by severe fatigue lasting 6 months or longer. CFS has previously been associated with a state of disturbed (re-)activity of the sympathetic nervous system (SNS) that might be explained by an increased sensitivity to stressful stimuli. However, research on neuroendocrine markers of the SNS, such as epinephrine (E) and norepinephrine (NE) in CFS is scarce.

To investigate SNS reactivity in CFS patients, we mimicked real-life stress using a standardized cycle ergometry test until exhaustion (ERGO) (Study 1). Further, we implemented a highly standardized pharmacological challenge test (the Insulin Tolerance Test, ITT; Study 2). 21 CFS patients (10 women) were compared with 20 age-, sex- and BMI-matched healthy controls (9 women). Plasma E and NE were collected immediately before, as well as 10 and 30 min after the ERGO in Study 1 and injection of 0.15U/kg soluble insulin in Study 2.

Both ERGO and ITT induced significant catecholaminergic responses after stimulation (all p < .001). During the ERGO, baseline E (but not NE) levels were lower in CFS patients (p = 0.005). Catecholaminergic responses to the ERGO differed significantly between groups (E: p = 0.048; NE: p = 0.041). However, the inclusion of baseline E abolished this effect. In the ITT, groups did not differ at baseline or in their response (E: p = .235; NE: p = .842). Descriptively, CFS patients showed a reduced mean E response in both conditions (EERGO: p = .063; EITT: p = .216) while NE mean responses were significantly lower only during the ERGO (NEERGO: p = .032 NEITT: p = .909).

Our results suggest a marked catecholaminergic response to two different types of stress in CFS. Our results of lower baseline levels of E in CFS patients are in contrast to prior studies. Likewise, we report evidence of a hyporesponsive SNS in CFS, indicating a dampened sympatho-adrenal counterregulatory response to an active physical stressor and metabolic challenge in these patients. A better understanding of a dysregulation of the SNS might improve diagnosis and treatment options of CFS.

Keywords: Chronic fatigue syndrome, Exercise, Reactivity, Metabolic regulation

CORRESPONDING AUTHOR: Strahler Jana, University of Marburg, Marburg;



Sheehan A.1, McGee H.1, Jennings S.2, McAdam B.3

1 Royal College of Surgeons in Ireland, Psychology, Dublin, Ireland

2 Health Services Executive, Ireland, Population Health, Dublin, Ireland

3 Beaumont Hospital, Ireland, Cardiology, Dublin, Ireland

Introduction: Chest pain is one of the most frequent complaints in medical settings, yet more than half of cases have no detectable cause. These patients are typically discharged with a label of non-cardiac chest pain (NCCP). Patients with NCCP have been shown to have poor outcomes in terms of continued symptoms and persistent health service use. Predictors of poor outcomes have been largely unexplored.

Aim: This study sought to examine the predictors of persistent pain and health service use for patients in whom a cardiac diagnosis had been excluded.

Methodology: A prospective cohort study was initially conducted with 169 participants with chest pain who attended exercise stress testing and had normal test results. Baseline and one-year assessments were conducted using validated self-completion measures. A 92% follow-up participation rate was achieved.

Results: At one year follow-up, 69% reported continued pain. In addition, nearly half of participants had returned to their general practitioner and one in ten re-attended at the emergency department for the investigation of chest pain. Logistic regression analyses examined predictors of persistent pain and persistent health service use. The results indicated that physical, psychological and service-related factors were predictive of persistent pain, in particular, pain precipitated by movement, cardiac anxiety, and lack of communication about test results. When participants with continued chest pain were categorised into persistent healthcare users and non-persistent healthcare users, psychological factors including anxiety, cardiac anxiety, depression and illness perceptions distinguished participants with persistent healthcare use. These factors did not distinguish participants with no further chest pain from those with persistent pain who did not persist in healthcare-seeking behaviour.

Conclusion: Psychological factors appear to drive persistent service use in patients with NCCP and interventions targeting these are likely to reduce medical costs. A multi-disciplinary approach to understanding and managing NCCP is needed. Patients with NCCP are not a homogenous patient group and an individualised, stepped-care approach to management is warranted.

Keywords: Pain; Illness behaviour; Cognitive factors




Bishop GD.1, Zhang X.2, Ngau F.1, Tai ES.3, Lee J.3

1 National University of Singapore, Department of Psychology, Singapore

2 National University of Singapore, Duke-NUS Graduate Medical School, Singapore

3 National University of Singapore, Department of Medicine, Singapore

Objective: This research investigated the role of perceived discrimination (PD) in cardiovascular responses among Chinese, Indians, and Malays in Singapore.

Methods: 325 Singaporeans (147 Chinese, 88 Indian, 90 Malay; 177 females, mean age 48.2 yrs) engaged in two baseline periods and two laboratory tasks (mental arithmetic and anger recall) during which blood pressure and heart rate were recorded. As no interactions were obtained involving task, reactivity was averaged across tasks. Perceived discrimination was measured using the Perceived Discrimination Scale (Williams et al., 1997). Participants were also genotyped for the tri-allelic 5HTTLPR. Due to relative rarity individuals with two copies of the high active allele (HH) were not included in analyses.

Results: PD varied by race with Indians showing the lowest PD (p < .05). PD was higher among males than females (p < .05) and also higher among those with the two copies of the low acting allele (LL) for 5HTTLPR (p < .01) than was the case for those with one copy of the high acting allele (LH). Baseline measures for both SBP and DBP showed a significant interaction between race and PD (p < .05 for both) such that for Indians SBP baseline was higher as a function of higher PD whereas it was lower for Chinese. No effect was found for Malays. For DBP reactivity race, genotype and PD interacted (p < .005) such that for Chinese with the LH genotype higher PD was associated with lower DBP reactivity whereas this was not true for those with the LL genotype. For Indians with the LL genotype higher PD was associated with lower reactivity whereas this was not true for those with the LH genotype. For Malays the interaction was not significant. A near significant interaction between genotype and PD was found for heart rate reactivity (p < .06) such that individuals with the LL genotype showed a stronger positive relationship between PD and reactivity than was the case for those with the LH genotype.

Conclusions: These data show that PD varied by race, sex, and genotype. Further the effects of PD on cardiovascular responses varied by race and genotype with the strongest interactions of genotype and PD being for Chinese and Indians.

Keywords: blood pressure, ethnic differences, genetics

CORRESPONDING AUTHOR: Bishop George, Nat. Univ of Singapore;



Loerbroks A.1, Herr R.1, Subramanian SV.2, Bosch JA.3

1 Heidelberg University, Mannheim Institute of Public Health, Social and Preventive Medicine, Heidelberg, Germany

2 Harvard School of Public Health, Department of Society, Human Development & Health, Boston, USA

3 University of Amsterdam, Department of Clinical Psychology, Amsterdam, The Netherlands

Background: Epidemiological studies have shown that asthma is positively associated with depression. Most of this evidence stems from studies conducted in Western populations (e.g., Europe, North America and Australia). It is still elusive whether such findings generalize to non-western countries. To address this question, the present study investigated the association of asthma and wheezing with depression in a large multinational sample.

Methods: We used data from the 2002 World Health Survey. Participants reported physician-diagnosed asthma and attacks of wheezing within the last 12 months. Questions on depressive symptoms, their duration and persistence were used to define presence of a major depressive episode (MDE) within the last 12 months. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated by logistic regression for the entire sample, by continent (Australia, Europe, South America, Asia, and Africa), and by country. Complete information was available for 57 countries.

Results: Both asthma and wheezing were associated with MDE in the entire sample (OR = 2.45, 95%CI = 2.18-2.75 and OR = 3.16, 95%CI = 2.84-3.52, respectively). Similar associations were found for all continents with generally stronger ORs in South America, Asia, and Africa for both asthma (ORs > = 1.8) and wheezing (ORs > = 3.0).On the country-level, wheezing showed a consistent pattern of association with MDE. Similar patterns were found for asthma.

Conclusions: Despite a range of country differences that could affect the association of asthma with depression, such as access to health care, the results of this study indicate that the co-occurrence of asthma and depression is a universal phenomenon.

Keywords: Asthma, Depression, Epidemiology, World Health Organization

CORRESPONDING AUTHOR: Loerbroks Adrian, Heidelberg University;



Riva R.

Stockholm University, Department of Psychology, Stockholm, Sweden

Musculoskeletal disorders (MSDs) are very common. Regional chronic shoulder and neck pain (SNP) and widespread chronic pain due to fibromyalgia syndrome (FMS) are examples of MSDs characterized by altered physiology of the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal (HPA) axis. The aims of the present study is to compare the cortisol awakening response (CAR) in SNP women, FMS patients and healthy controls, and to compare salivary cortisol levels, urinary catecholamine levels (adrenaline, noradrenaline, and dopamine), and cardiovascular responses in FMS patients and healthy controls. Self-ratings of sleep, anxiety, perceived stress, and pain were also investigated. CAR tended to be higher in SNP women than in healthy controls, whereas it was significantly higher than in FMS patients. Moreover, CAR was significantly lower in FMS patients than in healthy controls. Cortisol levels were lower in FMS patients than in healthy controls during the rest of the day as well. In addition, adrenaline and dopamine (but not noradrenaline) levels were significantly lower in FMS patients than in healthy controls. Resting heart rate was significantly higher in FMS patients than in healthy controls, but no differences emerged during stress provocation or unconstrained daily activities. Finally, SNP women and FMS patients reported more pain and health complaints than did healthy controls, but SNP women were less affected. Potential confounders (e.g., age, obesity, smoking habit, employment fraction, sleeping problems, and physical exercise) had no effects on the findings. Taken together, the findings show altered ANS and HPA axis regulation in FMS patients. Specifically, the hyperactive HPA axis found in SNP women (i.e., higher cortisol levels) might constitute a preliminary stage of a hypoactive HPA axis in FMS patients (i.e., lower cortisol levels). In view of this, an altered regulation of the HPA axis in the progression from regional to widespread MSDs may follow a temporal development.

Keywords: cortisol, musculoskeletal disorders, psychoneuroendocrinology, stress

CORRESPONDING AUTHOR: Riva Roberto, Stockholm University, Stockholm;

Psychosocial Factors and Interventions in Diabetes Management



Schmitz N.1, Gariepy G.2, Smith K.1, Badawi G.1, Malla A.1, Wang J.3, Boyer R.4, Strychar I.5, Lesage A.4

1 McGill University, Psychiatry, Montreal, Canada

2 McGill University, Department of Epidemiology and Public Health, Montreal, Canada

3 University of Calgary, Psychiatry, Calgary, AB, Canada

4 University of Montreal, Psychiatry, Montreal, Canada

5 University of Montreal, Nutrition, Montreal, Canada

Context: The longitudinal course of depression in general population samples is poorly understood, especially in the context of people with chronic conditions like diabetes.

Objective: The aim of the present study was to identify and describe pathways of depression in a community sample of people with diabetes in Quebec, Canada.

Design, Setting, and Participants: A prospective community based study (Diabetes Health and Wellbeing Study, DHS) in Quebec was carried out between 2008 and 2011 (n = 2003). Participants with self-reported diabetes were assessed at baseline and at 1, 2 and 3 years follow-ups.

Main: Outcome MeasuresMinor and major depression was assessed using the Patient Health Questionnaire (PHQ-9).

Results: Longitudinal latent class analysis was performed by using minor and major depression categories. Analysis yielded four clusters representing different pathways of depression: Cluster 1 (“no depression”; 67 %): participants had neither minor nor major depression over time. Cluster 2 (“slowly increasing prevalence of minor and major depression over time”; 20%): participants had low levels of depression at baseline but increasing levels of minor and major depression over time; while most of the Cluster 3 (“increasing major depression”; 6%) participants had high and increasing levels of major depression over time. Participants in Cluster 4 (“improved depression”, 7%) started with high levels of depression but progressed to low levels of depression. Clusters showed statistically significant differences in disability, lifestyle related behavior and socio-demographic characteristics (p < 0.01).

Conclusion: Our results provide important evidence of different pathways of depression in people with type 2 diabetes. Identification of four distinct groups of participants might improve our understanding of the course of depression and may provide a basis of classification for intervention.

Keywords: Depression, Diabetes

CORRESPONDING AUTHOR: Schmitz Norbert, McGill University;



Costa V., Pereira M G.

University of Minho, School of Psychology, Braga, Portugal

Background: At diagnosis, a large proportion of people with diabetes have to readjust their daily routines in order to integrate self-care behaviors related to diabetes. Social-cognitive variables regarding self-monitoring of blood glucose (SMBG) and relationship with health care system have an important impact on adherence and glycemic control in diabetes. The aim of this study is to analyze the relationship between trust in physicians, satisfaction with health services, beliefs about medicines, social-cognitive variables (intention, attitude, subjective norms, perceived behavioral control, action and coping planning), adherence and glycemic control in type 2 diabetes.

Method: 179 subjects with type 2 diabetes, diagnosed in the past 12 months, answered the instruments: Trust in Physician Scale (Anderson, & Dedrick, 1990), Patient Satisfaction Questionnaire (McIntyre, Pereira, Silva, Fernandes, & Correia, 1999), Questionnaire on Beliefs about Medicines (Horne, Weinman, & Hankins, 1999), Social-Cognitive Variables in Diabetes Self-Care Questionnaire (Pereira, Araújo-Soares & Costa, 2008), Revised Summary of Diabetes Self-Care Activities Measure (Toobert, Hampson, & Glasgow, 2000) and Medication Adherence Report Scale (Horne, 2001). Glycemic control was assessed by HbA1c value.

Results: Satisfaction with health care is positively related to SMBG, as well as to adherence to diet, beliefs about medicines, subjective norms and action planning. Trust in physician is positively related to beliefs about medicines, perceived behavior control, action planning, and adherence to oral anti-diabetics, SMBG and diet. In turn, trust in physician reveals itself as an important predictor of adherence to medicines and to SMBG, and intentions to perform SMBG predicts the adherence to this self-care behavior. Results also reveal a significantly relation between beliefs about medicines and intention, attitudes, subjective norms, perceived control and coping planning. Intention, subjective norms, perceived control, action and coping planning are associated with adherence to SMBG. Glycemic control is positively related to adherence to SMBG, intention, subjective norms and negatively related to action planning.

Conclusions: Results show that a positive relationship between type 2 diabetics and health professionals can influence the adherence and adoption of healthy behaviors related to diabetes. Thus, it is pertinent to emphasize, in the contexts of health, the importance of communication and interaction of health professionals with patients as a means of promoting adherence to the care required in the management of diabetes

Keywords: Diabetes, adherence, beliefs

CORRESPONDING AUTHOR: Costa Vera, University of Minho, Braga;



Turner RJ.1, Gellman MD.2

1 Quintiles, Integrated Clinical Services, -, Durham, USA

2 University of Miami, Department of Psychology, Miami, USA

Diabetes is a global public health concern of staggering proportions. In the United States the 2011 National Diabetes Fact Sheet noted that 25.8 million children and adults—8.3% of the population—have diabetes, and another 79 million have prediabetes. In 2011 the International Diabetes Federation observed that 366 million people had diabetes, a figure expected to rise to 552 million by 2030. Most people with diabetes live in low- and middle-income countries, which will also see the greatest increases over the coming decades.

Randomized clinical trials have convincingly demonstrated that behavioral approaches to the prevention of diabetes can be efficacious. The Diabetes Prevention Program, conducted at 27 centers in the United States, had three treatment groups: medication (metformin), medication placebo control, and lifestyle intervention. The 3,234 subjects were all 25 years of age or older, had impaired glucose tolerance, and a BMI of at least 24 kg/m2. The behavioral intervention was successful in reducing the risk for developing T2DM by 58% compared with a 31% reduction with metformin at 2.8 years of follow-up, and, importantly, was effective regardless of age, sex, and race. The Finnish Diabetes Prevention Trial reported very similar findings. It is now important to investigate the large-scale effectiveness of such behavioral interventions and to pursue their role in public health and health policy.

It is also noteworthy that pharmaceutical therapy for T2DM is currently in a state of crisis. Awareness of potential cardiovascular side-effects has led to new regulatory mandates that may severely restrict the flow of new anti-diabetic drugs. Additionally, nonadherence rates to available regimens are alarmingly high. Since nonadherence is a behavioral (and sociocultural) issue, Behavioral Medicine is extremely well positioned to provide greatly-needed assistance.

Behavioral Medicine approaches to diabetes prevention at the public health level should be pursued as vigorously as possible. Additionally, this presentation will provide examples of how scientists and physicians in Behavioral Medicine can work with various other organizations in the medical community to improve medication adherence when such therapy is indicated.

Keywords: Adherence, Diabetes

CORRESPONDING AUTHOR: Turner Rick, Quintiles, Durham;



Kasteleyn M., Gorter K., Rutten G.

University Medical Center Utrecht, Julius Centre, Utrecht, The Netherlands

Background: In Type 2 Diabetes Mellitus (T2DM) patients, an Acute Coronary Syndrome (ACS) may result in a decreased quality of life and depressive symptoms. We aim to develop and evaluate a tailored supportive intervention by a trained diabetes nurse to help them cope with the consequences of an ACS after discharge from hospital. Here we describe the development of the intervention and the first experiences.

Focus groups: To investigate their needs and wishes we conducted two semi-structured focus groups with 14 T2DM patients (71% male, aged 61-77 yrs). One focus group with three partners (2 males, aged 64-75) was conducted. Patients with an ACS mostly mentioned problems on physical exercise (n = 7), sexuality (n = 7) and medical treatment (n = 8). Fewer problems were experienced on diet (n = 1). The patients (n = 9) were not satisfied with the information and support offered by healthcare professionals. Partners had a lot of concerns about the patients as well (n = 3). Both patients and their partners welcomed our program.

Intervention: Trained diabetes nurses will visit the patients three times at home, following a strict protocol. The first visit (65 minutes) will take place within three weeks after discharge from the hospital, focusing on information exchange and self-efficacy. The second visit (45 minutes) is two weeks later, with the focus on self-efficacy and illness perceptions. The third visit (45 minutes), 2 months later, focuses on the future. Close relatives will be involved.

Training: Six experienced diabetes nurses were trained during a course by the executive researcher, a cardiac nurse, a GP and a psychologist. Furthermore, a patient with diabetes and an ACS was shared his experience of the period after discharge.

Pilot study: To optimize the intervention and to check the feasibility, we conducted a pilot study. Three patients were visited twice by three different diabetes nurses. Nurses and patients gave feedback, leading to a change in the duration of the visits and in questionnaires.

The trial: The effectiveness of this intervention will be tested in a RCT. Patients will be recruited by their cardiologist directly at discharge from the hospital. The control group (n = 100) will receive a telephonic consultation. Primary outcomes are diabetes related distress, health status, well-being and self-management behavior. Outcomes will be measured with questionnaires directly after discharge from the hospital and five months later. Currently we included 26 patients.

Conclusions: TDM who experience an ACS are in need of tailored support after discharge from the hospital. We developed a tailored intervention that is tested in a RCT.

Keywords: Diabetes, Self management, Self-efficacy, Coping and Coronary Heart Disease

CORRESPONDING AUTHOR: Kasteleyn Marise, UMC Utrecht;



Maindal HT.1, Bonde A.2, Aagaard-Hansen J.2

1 Aarhus University, Department of Public Health, Aarhus, Denmark

2 Steno Health Promotion Centre, Gentofte, Denmark

Background and aim: Despite strong evidence for lifestyle interventions in diabetes prevention, the interventions are not always feasible and the clinical effects not replicable, when delivered in routine clinical care. The aim of the study was to develop and test a lifestyle intervention for people with prediabetes tailored to general practice in Denmark. The intervention should be feasible in terms of time, resources and competencies available in general practice, and effective in terms of health outcome indicators with the perspective of preventing diabetes.

Methods: General practitioners, practice nurses and researchers worked together to propose new courses of action in diabetes prevention. Two action research circles were used to integrate researcher’s approach with the practitioners’ strategies, practices, and knowledge of the local contexts. The first circle was exploratory whereas the second circle focused and tested lessons learned from the first circle. In total 64 patients were included in the project from eight general practices. Data collection included HbA1c and BMI on a patient level and process data on a practice level.

Results: An intervention feasible for use in general practice with nurses employed was developed. The intervention contained partly basic, constant components such as pedagogical approaches and structural procedures; and partly dynamic components, such as use of pedagogical material and sequences of behaviour changes targeted. The follow up data from 43 patients three months after inclusion showed statistically significant decreases in HbA1cand BMI. The actions research circles revealed a need for future upgrade of the practitioners’ competences in health promotion; and major limitations for the deliverance of the intervention in Danish general practice according to professional, organizational factors and economic remuneration.

Conclusion: The use of action research in the development of a lifestyle intervention targeted people with prediabetes contributed with new perspectives on pedagogical approaches, structural and implementation challenges in general practice. The evaluation suggested that the developed intervention may be effective in terms of prevention of diabetes, but the resource utilization and generalisability may be questioned.

Keywords: Diabetes, prevention, health behaviour change, Physician intervention

CORRESPONDING AUTHOR: Maindal Helle Terkildsen, Aarhus university, Aarhus;

Implementation Science? Translating the Efficacy of Drug Abuse Treatment Research into the Community



Horigian V., Stoutenberg M.

University of Miami, Department of Epidemiology and Public Health, Miami, USA

Implementation science is a key element of translational research. This symposium will highlight the implementation of behavioral-based drug abuse treatment strategies through the National Drug Abuse Treatment Clinical Trials Network (CTN) of the U.S. National Institute on Drug Abuse. Recent research has produced advances in understanding drug abuse and addiction leading to the development of new treatments and therapies to help individuals with drug abuse problems. However, the efficacy of these treatments has been demonstrated primarily in specialized research settings. The CTN is an attempt to fulfill the promise of these advances by partnering with drug abuse treatment centers to provide a platform for the collaboration of academic investigators and community treatment agencies in community-based settings. The first session of this symposium, presented by Viviana Horigian, M.D., will describe the structure of the CTN and examples of successful, behavioral-based trials highlighting implementation science at work in a community setting. This session will highlight two multi-site randomized trials: Motivational Enhancement Treatment for Patients in Treatment for Substance Use Disorders (CTN 004) and Low Cost Motivational Incentives for Stimulant Abusing Patients in Outpatient Psychosocial Treatment Programs (CTN 006) and highlight their impact on current practice and adoption of interventions tested by the CTN. Second, Mark Stoutenberg, Ph.D., will provide an example of how the CTN platform can be used to implement behavioral-based efficacy trials. The STimulant Reduction Intervention using Dosed Exercise (STRIDE) is an ongoing, randomized controlled trial that examines the addition of exercise to treatment as usual in improving drug treatment outcomes in stimulant abusers. Finally, Rodrigo Marin Navarrete, Ph.D. (Unidad de Ensayos Clínicos, Mexico City) will provide an example of how the framework of the CTN is being replicated for use in an international setting, serving as a platform for behavioral-based implementation trials in Mexico. Based on these presentations the symposium will conclude with a discussion led by Dr. Marc Gellman focusing on the implications the CTN approach and the need for additional Implementation Science in Behavioral Medicine.

Keywords: Community intervention, addictive behaviors, effectiveness, evidenced based, research to practice translation

CORRESPONDING AUTHOR: Stoutenberg Mark, University of Miami;



Horigian V.

University of Miami, Department of Epidemiology and Public Health, Miami, USA

Over the past several years, research programs within the National Institutes on Drug Abuse have produced dramatic advances in understanding drug abuse and addiction. However, growing literature demonstrated the failure to properly disseminate, adopt, and implement these evidence-based discoveries. In response to this gap between research and practice, The National Drug Abuse Treatment Clinical Trials Network (CTN) was established by the National Institutes on Drug Abuse in 1999 to improve the quality of addiction treatment using science as a vehicle. This network brings together providers from community treatment centers and scientists from university-based research centers in partnership to cooperatively develop, validate, refine, and deliver new treatment options to patients in Community Treatment Programs. This session will present the structure of the CTN and its impact on practice highlighting results from two behavior-based randomized clinical trials in drug abuse treatment: Motivational Enhancement Therapy for Patients in Treatment for Substance Use Disorders (CTN 004) and Low Cost Motivational Incentives for Stimulant-Abusing Patients in Outpatient Psychosocial Treatment Programs (CTN 006). CTN 004 compared the effectiveness of motivational enhancement therapy (MET) with counseling as usual (CAU) for increasing retention and reducing substance use in a multisite randomized clinical trial of 461 patients treated in 5 outpatient substance abuse programs. There were no retention differences between the 2 brief intervention conditions. MET resulted in more sustained substance use reductions than CAU among alcohol users, but there were no differences for primary drug users. These results prompted recognition and acceptance of rigorous training and supervision in Motivational Interviewing (MI) and MET. CTN 006 randomized 415 stimulant abusers in 8 community-based outpatient psychosocial drug abuse treatment programs to treatment as usual (TAU) with or without a prize draw incentive program. The abstinence-based incentive group had significantly better results in retention and abstinence outcomes. Findings from this study and other secondary analyses inspired treatment providers to the adoption and promotion of motivational incentives.

Keywords: community intervention, effectiveness, addictive behavior, research to practice translation

CORRESPONDING AUTHOR: Stoutenberg Mark, University of Miami;



Stoutenberg M.

University of Miami, Department of Epidemiology and Public Health, Miami, USA

Clinical data examining the use of exercise as a treatment for the abuse of nicotine, alcohol, and other substances suggest that exercise may also provide a therapeutic effect for stimulant abuse, with direct effects on decreased use and craving. In addition, exercise has the potential to improve other health domains that may be adversely affected by stimulant use or its treatment, such as cardiovascular diseases, weight gain, cognitive function, mood, and overall quality of life, as it has been demonstrated to improve many of these domains in other clinical disorders. Furthermore, behavioral evidence suggests that exercise may serve as a distraction from unwanted behavior and serve as a substitute in place of addictive substances, thereby positively affecting treatment outcomes. This symposium session outlines the methods in which the National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN), originally designed for behavioural-based, implementation trials, has been modified to serve as a platform for a behavior, randomized, clinical trial. The Stimulant Reduction Intervention using Dosed Exercise (STRIDE) study is a multisite randomized clinical trial that compares the efficacy of exercise compared to health education as potential treatments for stimulant abuse. The STRIDE study is enrolling three hundred and thirty eligible individuals diagnosed with stimulant abuse or dependence who are receiving treatment in a residential setting. These participants are then randomized to one of two treatment arms: a Vigorous Intensity High Dose Exercise Intervention or a Health Education Intervention, in addition to Treatment as Usual. The treatment arms are structured such that the quantity of visits is similar to allow for equivalent contact between groups. In both arms, participants begin with 3 individually supervised sessions per week during a 12-week acute phase of the study. Following the 12-week acute phase, participants begin a 6-month continuation phase during which time they will attend one weekly supervised within their intervention. If proven to be efficacious, the addition of exercise to traditional behavioral counselling may provide a novel treatment strategy for stimulant disorders.

Keywords: community intervention, addictive behavior, exercise, randomized controlled trial

CORRESPONDING AUTHOR: Stoutenberg Mark, University of Miami;



Marin Navarrete R.

National Institute of Psychiatry, Unidad de Ensayos Clínicos, Mexico City, Mexico

The National Institute of Psychiatry (NIP) Ramon de la Fuente Muniz is a decentralized public organization within the National Institutes of Health in Mexico. The NIP fulfills the functions of research, treatment, and training. The Clinical Trials Network (CTN) Florida Node Alliance (FNA) at the University of Miami has been implementing behavioral-based effectiveness trials for more than 10 years as part of the CTN, and given their expertise in Hispanic research and research with monolingual Spanish clients, is ideally suited to support the development of research infrastructure in Spanish speaking countries. This symposium session highlights the ongoing collaboration between the FNA and the NIP in providing the training and mentorship to enable the NIP to successfully launch future initiatives to improve the quality of drug abuse treatment throughout Mexico through the dissemination of evidence-based practices in community settings. The ultimate mission of this collaboration is to develop the infrastructure for the creation of a clinical trials network for addictions and mental health treatment in Mexico. The first six months of this collaboration consisted of a series of trainings and mentorship activities to develop the resources to implement effectiveness clinical trials. This included training in general research principles and assisting in the development of systems for clinical trial implementation and management and included specific training in clinical trials methodology, quality assurance, and data management. During the second six months the focus shifted towards providing hands on training and practical experience in preparation for the implementation of a randomized clinical trial to commence in the second year. The second year of this training collaboration is structured around implementing a randomized clinical trial (investigating the effectiveness of motivational enhancement therapy vs counseling as usual in individuals seeking drug abuse treatment) where ongoing practical experience and training is provided. The FNA is providing its expertise through the delivery of protocol specific training, the oversight of quality assurance systems in Mexico and management of the trial at participating sites.

Keywords: community intervention, effectiveness, research to practice translation, training

CORRESPONDING AUTHOR: Stoutenberg Mark, University of Miami;

Psychosocial and Behavioral Aspects of HIV/AIDS



Ferguson A.1, Holttum S.2, Gibson S.3, Fernie BA.3

1 Kings College London University, Academic Department of Rheumatology, London, United Kingdom

2 Canterbury Christ Church University, Department of Applied Psychology, Salomons, Tunbridge Wells, United Kingdom

3 South London and Maudsley NHS Foundation Trust, CASCAID, London, United Kingdom

Health related quality of life (HR-QOL) has become a relevant outcome for researchers in chronic diseases, including the Human Immunodeficiency Virus (HIV). However little is known about positive psychological resources such as resilience that are associated with HR-QOL. This cross sectional study investigated the relationships between HR-QOL and a number of positive resources that reflect ‘resilience’ (self-esteem, self-mastery, optimism and self-efficacy) in a mixed ethnicity group of HIV positive women in the UK. Fifty-nine women completed a battery of measures (utilising either online or paper versions) consisting of the Revised Life Orientation Scale (LOT-R), the Rosenberg Self-Esteem Scale (RSE), the Self − Mastery Scale (SMS), HIV Treatment Adherence Self-Efficacy Scale (HIV-ASES) and the Medical Outcomes Study HIV Health Survey (MOS-HIV). Demographic variables (age, number of children, and year of diagnosis) and a biomedical marker of disease progression (CD4 count) were also recorded. Correlation analyses showed that self-esteem, self-mastery and HIV-related self-efficacy (integration) were significantly and positively associated with physical HR-QOL. Optimism, self-esteem, self-mastery and both self-efficacy integration and perseverance were significantly and positively associated with mental HR-QOL. However no significant association was found between HR-QOL and demographic variables or CD4 count. The results are discussed in the context of HIV service provision in the UK with a review of the study’s limitations.

Keywords: HIV, Resilience

CORRESPONDING AUTHOR: Ferguson Anna, King's College London University;



Setswe G.

School of Public Health and Preventive Medicine, Monash University Australia, Department of Health Sciences, Melbourne, South Africa

Introduction: South Africa has over 5.6 million people living with HIV (PLHIV), but has made significant progress in scaling up some key interventions, with the main goals being to reduce the HIV incidence and to expand access to antiretroviral treatment to people in need. However, the number of new infections continued to outstrip the number of AIDS-related deaths - an indication that prevention efforts were failing to keep pace with the HIV epidemic.

Methods: A desk study was conducted on published and unpublished documents about HIV in South Africa, and a secondary data analysis of three bio-behavioural HSRC surveys and two national communication surveys (NCS) behavioural surveys through both bivariate and multivariate analysis

Findings and Discussion: Urban informal areas are associated with highest HIV prevalence compared to the other three types of location. In 2008, women living in urban informal areas were 57% more likely to be HIV infected than those in urban formal areas.

Frequency of reported multiple partners varied by race, was highest in African men. In 2009, 16.7% of men and 2.3% of women aged 16-55 reported >1 partner (among those who ever had sex). HIV prevalence was higher in respondents reporting more sexual partners. Women reporting >1 partner at the time of survey in 2005 were 4.3 times more likely to be HIV + (p = 0.0001).

Girls 15-19 years reporting age-disparate relationship with older were 72% more likely to be HIV + than those girls with similar-aged partners (HIV prevalence 29.5% vs. 17.2%). Men and women who have partners much younger or older than themselves were more likely to be HIV + compared to people who reported having partner of similar age only. Reported frequencies of transactional sex are 2 - 52% (F) and 4 - 30% (M) in different SA surveys.

About 2% of men reported ever having paid for sex in 2005. Having had sex with a sex worker almost trebled men’s odds for HIV infection. Three bio-surveys in sex workers reported HIV prevalence levels of around 60%.

In 2008, HIV prevalence among self-identified MSM was 9.9% (all men aged 25-49 years: 23.7% HIV+). There was a high frequency of self-reported unprotected anal sex and other risk behaviours among MSM and some evidence of sero-sorting when partners are acquired.

Conclusion: This study is provided evidence of social and behavioural factors that has impacted the HIV epidemic in South Africa.

Keywords: behavioral factors; social

CORRESPONDING AUTHOR: Setswe Geoffrey, Monash University, Johannesburg;



Lua P. L.1, Abdul Rahman A. K.2, Sulaiman F. N.2, Hassan R.3, Abdul Aziz A. B.3

1 Universiti Sultan Zainal Abidin, Centre for Clinical & Quality of Life Studies , Kuala Terengganu, Malaysia

2 Hospital Sultanah Nur Zahirah, Department of Medicine, Kuala Terengganu, Malaysia

3 Hospital Sultanah Nur Zahirah, Department of Pharmacy, Kuala Terengganu, Malaysia

In view of HIV’s devastating impacts on overall life condition, specific healthcare services have been devised to ensure that patients’ clinical, economic and psychosocial concerns are adequately addressed in treatment management. Our prospective randomised study intended to compare health-related quality of life (HRQoL) outcomes between conventional care (Control; routine medical counselling) versus holistic care (Intervention; medical counselling + educational SMS + spiritual advice) among HIV patients. Sixty-two consenting out-patients (stabilised on HAART) from Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia were randomly selected into either the Control (n = 31) or Intervention arm (n = 31). HRQoL status was measured using the HIV/AIDS - Targeted Quality of Life (HAT-QoL) instrument. Data was analysed via descriptive and non-parametric techniques in SPSS 16.0. Most participants have been diagnosed for > 6 months (median age = 40; male = 61.3%; divorced/widowed = 40.3%; self-employed = 37.1%; ex-drug addicts = 51.6%). Pre-intervention, no significant HRQoL difference was reported between the two arms (except for Health Worries). Unexpectedly at post-intervention, the Control cohort had fared significantly better in Financial Worries compared to its counterpart (p = 0.009). Separately however, patients in both arms interestingly experienced significant improvement in Sexual Functioning over time (p Control  = 0.024; p Intervention  = 0.008). Although more elaborated, the holistic care did not seem beneficial with regard to HRQoL per se, suggesting that a further re-look at its components and implementation is necessary. The limited sample size may have also deterred more extensive detection of statistical significance. Nonetheless, efforts to improve the well-being of HIV population either through the provision of medication therapy or through non-pharmacological modalities must constantly be encouraged and supported.

Keywords: HIV, health education, health outcomes, quality of life

CORRESPONDING AUTHOR: Lua Pei Lin, Universiti Sultan Zainal Abidin;



Salles C M., Seidl E M.

University of Brasilia, Institute of Psychology, Brasilia, Brazil

The present study aimed to analyze the effects of a psychological intervention over the antiretroviral treatment adherence behavior by seropositive adolescents with difficulties in adhering to Highly Active Antiretroviral Therapy (HAART). Conditioning aspects of adherence and non-adherence to HAART were investigated, along with self-efficacy expectancy to HAART adherence. The participants were three female adolescents, aware of their diagnosis, infected by the HIV virus through vertical transmission, with adherence indexes lower than 95%, or with other relevant difficulties to adherence, considering the number of pills prescribed in the therapeutic regimen in the previous three days, previous week and previous month. The study was characterized as a short-term longitudinal study, with a quasi-experimental design. The evaluation of the target behaviors was conducted before the psychological interventions (baseline), just after the ending of them and three months after that (follow-up). The instruments used were: interview guides for the adolescent and for the caregiver and self-efficacy scale to adherence to HAART. The medical record was consulted to search for information about laboratory measurements of viral load and CD4 cells. The interventions were directed to the building and strengthening of pro-adherence responses, using cognitive-behavioral and behavioral techniques. The data evaluation was intra-subject, with the subject being the measure of their own change control. The results of the study showed change in the pattern of involvement of all of the adolescents, promoting ingestion of drugs in the prescribed times and according to the level required for the treatment of HIV/aids (≥ 95%), expanding the descriptive verbal repertoire about the process of health maintenance towards treatment and a greater self-efficacy expectation related. It was concluded that the intervention had positive effects to the promotion of adherence to HAART among adolescents. Study was limited by the small number of cases. It is suggested that future studies should be developed so that the results can be compared. It is also hoped that the data presented can guide psychological interventions pro-adherence, in a prompt, continuous, regular and preventive approach.

Keywords: Adherence, AIDS, adolescents, psychological intervention

CORRESPONDING AUTHOR: Salles Caroline, Brasília University, Brasília;



Alcaide L .1, Mumbi M.2, Chitalu L.2, Jones L.3

1 University of Miami, Department of Medicine, Miami, United States

2 University of Miami, Pediatrics, Miami, Zambia

3 University of Miami, Behavioural Science Institute, Miami, United States

Intravaginal practices (VP) are the introduction of products inside the vagina for hygienic, health or sexuality reasons. In sub-Saharan Africa VP are common and strongly influenced by cultural and social beliefs. VP are associated with transmission and acquisition of HIV and Sexually Transmitted Infections. This pilot study tested a bio-behavioral intervention aimed to reduce VP in HIV positive women in the Zambian community.

Methods: HIV infected women were enrolled in 2 conditions: control and experimental. Women in both conditions completed questionnaires assessing sexual risk factors and VP. VP questionnaires were developed after conducting focus groups in the same community and included questions related to reasons for VP, products used for VP and perceptions about VP. Women enrolled in the control condition received brief traditional counseling about VP. Women enrolled in the experimental condition received a 20-30 minute individual session regarding VP using the information, motivation, behavioral skills model. Participants were assessed for VP 8 weeks after the baseline visit. Comparisons within conditions over time were conducted using McNemar statistics.

Results: 20 women were enrolled in the control and experimental condition respectively. At baseline, 100% of participants engaged in VP. Among women receiving the intervention findings were: decrease in the use of VP for hygienic reasons by 50% and for pleasure by 45% (McNemar = 1.03, p = 0.007); decrease in the use of water and cloths (McNemar = 0.84 and 1.32 respectively, p < 0.05); cessation of use of herbs and cloths, both very prevalent at baseline. Such differences were not observed in women enrolled in the control condition at follow up. Women enrolling in the experimental condition reported discussing about VP with their sexual partners (Chi square = 4.2, p < 0.05).

Conclusion: Our intervention was effective in decreasing VP in HIV infected women in Zambia. Our results suggest that a bio-behavioral intervention can decrease VP in HIV infected women in Sub-Saharan Africa. It may also be useful in increasing communication with sexual partners. Modifying VP should be considered a key element as part of multidisciplinary HIV prevention plans. This study was funded by a grant from NICHD, R01HD058481-S1.

Keywords: AIDS, women's health

CORRESPONDING AUTHOR: Alcaide Maria, University of Miami;

Poster Session B



Aparicio G.1, Cunha M.1, Duarte J.1, Pereira A.2

1 Instituto Politécnico de Viseu, School of Health, Viseu, Portugal

2 Aveiro University, Department of Education, Aveiro, Portugal

Background: Despite several studies conclusions showed higher prevalence of overweight in teenagers and adults that sleep less hours than what is recommended, those evidences regarding young children are still scarce. However, there is consensus that less than 60 minutes of daily activity is associated to higher risk of overweight.

This study aimed to measure the sleeping patterns and daily physical activity in preschool children and explain its relation with overweight.

Methods: Cross-sectional and observational study, comprising 792 preschool children, average age 4,39 years old (SD = 0,911) residents in centre region of Portugal. Child sleep duration and physical activities was obtained from a record of daily hours provided by parents. Children’s anthropometric measurement was obtained, and the classification was based on the NCHS reference (CDC, 2000).

Results: From the sample of children, 31,3% were overweight, pre-obesity was higher for girls (20,5%) and obesity for boys (13,8%). During the week, children sleep in average 10,34 hours (SD = 0,67) per night, sleeping time varying between 8,30 and 13,0 hours without statistic significance between gender (t = -0,463; p = 0,6449). 70,4% of children are daily transported mostly by car, 67,2% usually play in the street, mainly boys, occupying on average about 60 minutes when they play, 53,4% spend about 1 hour in “screen time” and 78,6% do not practice any scheduled sport. After multivariate regression analysis, only “sleeping time” and “playing in the street” entered in the model analysis, revealing that the less sleeping time (r = -0,059; p = 0,026) and the less playing in the street (r = -0,059; p = 0,019) the higher BMI, revealing to be significant predictors of overweight.

Conclusion: Results suggest an inverse relationship between sleep time and playing outside home and the increase of the BMI percentile. Therefore, in children’s intervention programmes healthier lifestyles must be promoted and for these to be effective they should be supported by a positive approach, based on parent’s potential and their strongest points. This will revert in benefit of the growth and development of the child.

Keywords: Children's health, Obesity, Health behaviors

CORRESPONDING AUTHOR: Aparicio Graça, Polytechnic Institute of Viseu;



Goes AR., Barros L.

University of Lisbon, Department of Psychology, Lisbon, Portugal

Background: The rising prevalence of developmental and behavioral disorders brought new recommendations regarding the use of validated screening tools. Clinicians are also recommended to rely on parental concerns to guide developmental and behavioral surveillance. Sleep problems in early childhood are common and have adverse associations with child behavior. The success rates of intervention and prevention programs for sleep problems emphasize the need for early detection.

Objectives: To investigate the usefulness of a screening tool based on parental concerns about child’s development (Parents’ Evaluation of Developmental Status – PEDS) in the detection of sleep problems.

Methods: 200 parents with children aged 20-72 months were recruited. Parents’ concerns were elicited using the PEDS. Sleep was evaluated by using a questionnaire about sleep habits (e.g. bedtime, waking time, sleep latency, night waking, method for falling asleep).

Results: Only 3% of parents reported concerns regarding child's sleep on PEDS. 12.8% reported a mild sleep problem, and 2.1% a severe one. However, several indicators of possible sleep problems were present: bedtime resistance (15.5%), difficulty in falling asleep (4.1%), long latency in falling asleep (35.9), night wakings (7.1%), and going to parents’ bed during the night (14.9%) were reported to happen 5-7 times a week. Using criteria for sleep problems, 71 children met criteria for a settling problem and 13 for a night waking problem. The duration of night sleep was associated with the number of concerns not predictive of developmental disabitilies (e.g. behavior, socio-emotional, self-help).

Discussion: Parents’ concerns have been proved to be an effective method to screen for developmental and behavioral problems. Sleep is an important correlate of childhood development and behavior and sleep intervention programs are highly effective. However, parents may not report their child's sleep problems spontaneously. A global screening tool may not be enough to detect sleep problems. The results support the need to specifically ask parents about their child's sleep habits and patterns. Anticipatory guidance about childhood sleep needs and positive habits may also contribute to raise parents’ awareness regarding their child sleep problems.

Keywords: Children, Sleep, Screening

CORRESPONDING AUTHOR: Barros Luísa Barros, Univeridade de Lisboa, Lisboa;



De Decker E.1, De Craemer M.1, De Bourdeaudhuij I.1, Wijndaele K.2, Duvinage K.3, Koletzko B.3, Grammatikaki E.4, Iotova V.5, Usheva N.5, Fernández-Alvira JM.6, Zych K.7, Manios Y.4, Cardon G.1

1 Ghent University, Movement and Sports Sciences, Ghent, Belgium

2 Medical Research Council Epidemiology Unit, Cambridge, Institute of Metabolic Science, Cambridge, United Kingdom

3 Dr. von Hauner Children’s Hospital, University of Munich Medical Centre, Munich, Germany

4 Harokopio University, Department of Nutrition and Dietetics, Athens, Greece

5 Clinic of Paeditric Endocrinology, UMHAT ‘St. Marina’, Varna, Bulgaria

6 University of Zaragoza, Growth, Exercise, Nutrition and Development Research Group, Zaragoza, Spain

7 The Children’s Memorial Health Institute, The Children’s Memorial Health Institute, Warsaw, Poland

Introduction: Sedentary behaviour (e.g. sitting down, watching TV) is not only highly prevalent in adults, also preschool children spend significant proportions of their waking time being sedentary (1). Screen time (i.e. TV viewing, computer use) is the most commonly examined sedentary behaviour and has been associated with a number of health outcomes in this age group. Moreover, sedentary behaviour is identified as a predictor of obesity in adulthood. As parents play a key role in the health behaviours of preschoolers (2), identifying parental perceptions of preschoolers’ screen time in multi-country focus groups has the potential to provide important novel information for interventions focusing on decreasing this behaviour.

Methods: Focus groups were executed with parents of low and medium-high socioeconomic status in municipalities with a high prevalence of overweight in six European countries. All countries were trained in how they should execute the study and how they should report their findings. Key findings were reported by each of the countries. The country specific final reports were analysed and summarized using qualitative data analysis software.

Results: A total of 122 parents participated in 24 focus groups. Almost all parents reported that their child likes to watch TV and most parents did not express worries about their children’s TV viewing time. Education and the fact that the TV keeps the children quiet are considered to be the main benefits of watching TV. Computer and active games use at home are less frequent. Weather conditions and parental habits at home are the most important factors influencing children’s screen time.

Discussion: This study suggests that preschool children tend to like watching TV and that the TV is often used as a babysitter. Awareness about the importance of limiting TV time has to be raised. Alternatives for screen activities and information on how to set rules for screen time should be provided to parents to assist them in decreasing screen time.

References: Hinkley et al. Correlates of sedentary behaviour in preschool children: a review. Int J Behav Nutr Phys Act 2010;7:66-76

Olstad DL et al. Prevention of overweight and obesity in children under the age of 6 years. Appl Physiol Nutr Metab 2009;34:551-570

Keywords: children, obesity, intervention

CORRESPONDING AUTHOR: De Decker Ellen, Ghent University, Ghent, Belgium;



Bognar V.

Eötvös Loránd University Budapest, Faculty of Social Sciences, Budapest, Hungary

The goal of the study is to investigate the relationship between the perception of autistic symptoms in children by their female primary caregivers (96% mothers) and caregivers’ life satisfaction. There is some evidence on the relevance of family and household functioning in this group of parents, but additional knowledge on this topic is needed. (Rao and Beidel, 2009; Manning, Wainwright, Bennett, 2011)

Methods: voluntary survey with members of the Hungarian Autistic Society (N = 232) – principal component analysis and Binary Logistic Regression; content analysis of semi-structured interviews (N = 20). Dependent variable: life satisfaction of female primary caregivers (not at all or not really satisfied (23.7%), generally or fully satisfied with her actual life (76.3%)). Autism perception dimensions: verbality, self-reliance, general and social behavior, strengths, eating disorder, sleeping disorder. Other control variables: time passed after the diagnosis, mental retardation and sex of the child; employment status, education level, partnership status, problem-centered coping of the caregiver, family functioning, financial crisis of the household in the previous year.

Results: we found (with CI level of 95% and significance level of p < 0,05): the chance of a low level of life satisfaction is: higher in case of worse complex autism perception (OR = 1.68, CI:1.18–2.37), more years passed after the diagnosis (OR = 1.07, CI:1.02–1.12) and financial crisis of the household (OR = 2.14, CI:1.06–4.34). Higher level of problem-centered coping decrease the chance of low life satisfaction (OR = 0.89, CI:0.83–0.95). In the case of the subsample of caregivers living in a partnership (N = 179) complex autism perception was not so important factor in the model (p < 0,1), however, the significance of the financial crisis (OR = 3.28, CI:1.38–7.78) has risen. Qualitative data give some retrospective information on the longitudinal psychosocial adaptation process of parents and family.

Conclusions: (1) Time passed after the diagnosis remained significant when controlling autism symptoms and several other factors. This indicates the importance of future psychosocial support for parents of young and adult autistic persons. (2) In case of family support high-functioning partnership and financial management of the household are relevant factors.

Keywords: parent-child transactions, coping, disability, family

CORRESPONDING AUTHOR: Bognar Virag, ELTE University, Budapest;



Koseki S., Koseki M.

Social & Health Research Center, Japan

In Japan, special needs education has received remarkable attention for using concrete strategies based on cognitive behavioral therapy and applied behavior analysis. In the last two or three years, it has been revealed that social skills training (SST) increases interactions between special needs children and other children and decreases psychological stress responses (Koseki, et al., 2010). This study aimed to clarify the effects of SST for special needs children. In particular, the behavioral interaction between special needs children and other children can be clarified through behavioral self-monitoring. Behavioral self-monitoring can be of two types: checking for own helping behavior, for example, “I lent my textbook to Mami” and checking for received helping behavior, for example, “Shun lent his textbook to me.” Through this self-monitoring protocol, the number of interactions in this class was revealed. SST was conducted for 29 fifth graders by the author and other staff. The target skill was “how to help each other in this class.” The children were split into three groups based on the self-monitoring results: the “high-skill group (N = 18),” which could execute social skills and perceive others’ execution of them, the “middle-skill group (N = 8),” which could either execute social skills or perceive them, and the “low-skill group (N = 3),” which could neither execute social skills nor perceive them. As a result, in all groups, scores for pro-social skills significantly increased (F(1, 26) = 6.62, p < .05) and those for psychological stress responses, “depression and anxiety” (F(1, 26) = 3.82, p < .05) and “irritability and anger” (F(1, 26) = 3.72, p < .05), significantly decreased. As explained above, it was suggested that SST enhanced the execution of pro-social skills and reduction of “depression and anxiety” and “irritability and anger.” Furthermore, self-monitoring was useful in assessing the interaction of the classroom group’s dynamics when executing the target skills and in the development of relationships among friends in the classroom. In the future, on the basis of this study, SST should be implemented effectively to assess social skills execution in students, select functional target skills, and discuss the effects of group intervention.

Keywords: stress, intervention

CORRESPONDING AUTHOR: Koseki Shunsuke, Aichi University of Education;



Kanemaru R., Kondo T., Takata Y., Sakata Y.

University of Tsukuba, Graduate School of Comprehensive Human Sciences, Tsukuba, Japan

Introduction: The health issues caused by bad life style have been increased in Japanese adolescents. We need to catch their symptoms of health problem as soon as possible in order to intervene in the effective period.

Purpose: To examine the trend of adolescent height, weight and blood Hemoglobin status (HbA1c).

Method: The subjects were 1573 students in a Japanese junior high school, who were surveyed over a 10 year period from 2000 to 2009. We measured their height, weight and HbA1c values once a year. The trend analysis was used to examine the tendency of change about those values.

Result: First grade boys’ weight showed the decreasing trend in the 10 years (R2 = .446, p = .070). Their HbA1c values also showed the decreasing trend (R2 = .551, p = .035). On the other hand, their height did not show any trend of change.

Conclusion: Japanese boys who are just entered junior high school are getting thinner. In addition, their Hemoglobin statuses are getting worse. One of the reason that they are losing weight, in spite of they are not getting lower, might be their drive for thinness. Though many professionals have warned how it is dangerous to pursue thinness, young people don’t give up the desire. We need to teach them that pursuit of thinness leads to the bad blood health.

Keywords: Adolescents, Health

CORRESPONDING AUTHOR: Kanemaru Ryuta, University of Tsukuba, Japan;



Bob M.1, Mocean F. 2, Lotrean L.2, Prodea C.3, Gabor-Harosa F.2

1 University of Medicine and Pharmacy Cluj-Napoca, Department of Morphology, Cluj-Napoca, Romania

2 University of Medicine and Pharmacy Cluj-Napoca, Department of Community Medicine, Cluj-Napoca, Romania

3 Babes-Bolyai University, Department of Education, Cluj-Napoca, Romania

Introduction: The educational process can have a positive influence on socializing, thus on quality of life in general, on growth and development of children. However, if hygienic norms of infrastructure and functioning of schools are constantly broken, education in schools may lead to intellectual fatigue.

Objectives: The objective of this study is to gather the opinions and practices of students related to school activity and the tiredness provoked by it.

Methods: Anonymous questionnaires were filled by 267 school students from rural areas of one county of Romania in 2008.

Results and discussions: Most students stated that they feel tired at the end of a school day. 43.5% declared themselves tired at the end of the week in the first semester of the school year 2007/2008, while in the second semester the percentage has increased statistically significant (p <0.05 at χ2 test) to 79.5%. Only 26.00% of students declared that they failed to fully prepare their homework at home. Nevertheless, school and out-of-school activities made 80.50% of the respondents to consider the educational process difficult.

Conclusion: The study reveals that for health promotion in schools is necessary to implement reforms in the education process that can prevent fatigue, stress and violence among school students from rural areas, in order to optimize their quality of life.

Keywords: Quality of life, Health education, Environment, Fatigue, Health promotion

CORRESPONDING AUTHOR: Bob Mihai, University of Medicine, Cluj;



Buttigieg K.1, Bergman P.2, Rodda C.2, Hay M.1

1 Monash University, Health Psychology and Behavioural Medicine Unit, School of Psychology and Psychiatry, Melbourne, Australia

2 Monash University, Department of Paediatrics, Melbourne, Australia

Introduction: Previous research has noted the difficulties faced by clinicians in identifying young people with type 1 diabetes who may be experiencing psychological distress, with illness management not necessarily a reliable indicator (Grey et al., 1998). This study explored psychosocial factors that may be helpful in identifying those children and adolescents coping well with their condition, versus those who are experiencing difficulties. In this paper, the results from an Australian cross-sectional study are presented.

Method: Eighty children and adolescents were recruited from a paediatric diabetes outpatient clinic in Melbourne, Australia. All participants had been diagnosed with type 1 diabetes for at least twelve months, and were aged 7-15 years old. During a clinic appointment or home visit, screening of depressive and anxiety symptoms (using the CDI and RCMAS-2) was undertaken. Diabetes-specific family support (DFBS), diabetes-related self-efficacy (DMSES), diabetes-related coping (ICI-C) and diabetes knowledge (DKN) were also assessed.

Results: The results of a discriminant function analysis identified a significant difference in the psychosocial characteristics of participants coping well with diabetes-related issues that 'upset', and those experiencing difficulties (Wilk’s lambda = .71, Chi square(7) = 22.9, p < .01). Mood symptoms (depression and anxiety), coping with diabetes-related tasks that are ‘hard to do’ for their diabetes, and self-efficacy were the psychosocial factors that best differentiated between these groups. 71.8% of participants were correctly classified using this model.

Conclusions: The results presented suggest that mood symptoms, coping with 'hard to do' aspects of diabetes and self-efficacy are important psychosocial factors in predicting coping with 'upsetting' aspects of diabetes. As these factors are potentially modifiable, these findings may assist in the development of coping interventions for children and adolescents with diabetes.

Keywords: Diabetes, Coping, Depression, Anxiety, Children, Adolescents, Mental Health, Children's Health

CORRESPONDING AUTHOR: Hay Margaret, Monash University, Melbourne;



Buttigieg K.1, Bergman P.2, Rodda C.2, Hay M.1

1 Monash University, Health Psychology and Behavioural Medicine Unit, School of Psychology and Psychiatry, Melbourne, Australia

2 Monash University, Department of Paediatrics, Melbourne, Australia

Introduction: Screening for psychological concerns, such as depression and anxiety symptoms, is highly recommended in international clinical guidelines regarding the clinical care of children and adolescents with type 1 diabetes. This study explored the relationship between psychosocial factors and gender in young people who are living with type 1 diabetes.

Method: Eighty children and adolescents were recruited from a paediatric diabetes outpatient clinic in Melbourne, Australia. All participants had been diagnosed with type 1 diabetes for at least twelve months, and were aged between 7-15 years old. Screening of depression (CDI) and anxiety (RCMAS-2) symptoms was undertaken. Diabetes-related family support (DFBS), self-efficacy (DMSES), coping (ICI-C) and knowledge (DKN) were also assessed.

Results: A discriminant function analysis identified a significant difference in the psychosocial characteristics of girls versus boys, Wilk’s lambda = .760, Chi square(8) = 17.879, p < .05. The interpretation of the group centroids data suggests that males coped better with the ‘hard to do’ and ‘upsetting’ aspects of their type 1 diabetes, and were also less anxious than girls. 73.2% of participants were accurately classified using this model.

Conclusions: While psychological screening is recommended for all paediatric diabetic patients, girls appear more likely to display anxiety symptoms and coping difficulties.

Keywords: Children, Adolescents, Children's Health, Coping, Anxiety, Mental Health

CORRESPONDING AUTHOR: Hay Margaret, Monash University, Melbourne;



Buttigieg K.1, Bergman P.2, Rodda C.2, Hay M.1

1 Monash University, Health Psychology and Behavioural Medicine Unit, School of Psychology and Psychiatry, Melbourne, Australia

2 Monash University, Department of Paediatrics, Melbourne, Australia

Introduction: Children and adolescents with type 1 diabetes may be more likely to experience depression and anxiety. This paper presents case studies illustrating the relationship between illness outcomes, family support and individual psychosocial factors.

Method: Eighty participants aged 7-15 years were recruited from a paediatric diabetes outpatient clinic in Melbourne, Australia. Participants had been diagnosed with type 1 diabetes for at least twelve months. Depression (CDI) and anxiety (RCMAS-2) screening was undertaken. Diabetes-related family support, self-efficacy, coping and knowledge were also assessed.

Results: Depression and/or anxiety symptoms were present in 14% of participants. Case studies of participants experiencing psychological distress are presented, with a view to providing “in-depth” examples of the relationship between depression, anxiety, diabetes management and individual psychosocial factors.

Conclusions: Some young people with type 1 diabetes may display psychological distress. The case studies presented suggest that the experience of depression and anxiety in children and adolescents in the context of type 1 diabetes also encompasses family and illness management factors.

Keywords: Depression, Anxiety, Mental Health, Children, Children's Health, Adolescents

CORRESPONDING AUTHOR: Hay Margaret, Monash University, Melbourne;



Hysing M.

Uni Health/Uni Research, Bergen, Norway

Background: Disturbed eating behaviour has been found in clinical and cross-sectional studies in children with chronic illness, but little is known about the development of disturbed eating over time and possible predictors.

Aim: To longitudinally assess change in rates over time in disturbed eating among children with and without chronic illness.

Method: Using data from a longitudinal total population study in Norway, The Bergen Child Study, data on eating disturbances, chronic illness and potential confounders were assessed at ages 7-9 and 11-13. Eating disturbances was assessed using the Eating Disturbance Scale (EDS-5: wave 2), and Eating Disturbance Inventory (wave 1).

Results: Children with chronic illness had an increased rate of parent-reported disturbed eating behaviour when they were 7-9 years old. There was also an increased rate of disturbed eating behaviour as measured by both parent and child report 4 years later. The role of emotional problems, BMI and body image on the development of disturbed eating will be further explored.

Conclusion: Children with chronic illness are at increased risk of developing disturbed eating behaviours, and preventive efforts for healthy eating habits are recommended.

Keywords: children, chronic illness, eating disorders




Töttösi A.1, Lelovics ZS.1, Zombori J.2

1 International Institute of Nutrition Research, -, Pécs, Hungary

2 Semmelweis University, Faculty of Health Sciences, Budapest, Hungary

Introduction: Children become more and more the targets of food industry companies and also the media. The incremental generation had never been under the influence of the mass media to such extent. By the age of 14 children spend 18,000 hours in front of screens, and 14,000 hours behind desks. According to the researches of the German ZAW, 38% of children between the age of four and six cannot make a distinction between advertisements and TV programs. They can be influenced most easily because of their age. Attention is frequently aroused by showy and friendly cartoon characters to purchase a given product. Beside this, childhood obesity and overweight are increasing. More and more national and international programs were born to fight against widespread obesity but the efficiency of these efforts we can be questioned. Every year there are 400,000 new overweight and 85,000 new obese children in the EU. Based on this data there were 15 million obese children in the EU in 2010. Nowadays, watching TV is often linked to snacking. This is one of the most important problems of childhood obesity.

Methods: In order to map the knowledge of brands and elements of marketing, focus consulting was carried out amongst toddlers (n = 138, average age: 7.0+/-2.0years).

Results: 76.7% of school children know given figures of brands, moreover, products associated to figures and messages suggested by them. 55.6% of kindergarten kids know at leas