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Building Sangha in the American Healthcare Setting for Persons With Chronic Disease
Abstract
Background:
For persons with chronic disease, participation in meditation interventions can reduce anxiety, depression, and chronic disease symptoms in a dose dependent fashion. Unfortunately, information about how to support long-term participation in such an intervention is lacking. Therefore, a recent discovery of persons with chronic lung disease who have maintained a self-led meditation group for more than four years created an opportunity to analyze experiences, meanings and relationship dynamics of this community-based meditation group.
Methods:
A focused ethnography was conducted using the following techniques: participant observation of four group meditation sessions, semi-structured interviews of six group participants, the interviewer's reflective practice and collection of demographic information. Analysis of transcribed audio-recordings followed an iterative approach.
Results:
Findings highlighted the inclusive nature of the group sessions that supported meditation practice through the processing of ancient wisdom traditions similar to a traditional Sangha. Reflecting the current culture of non-affiliation, the group often moved beyond religious teachings to use the environment, literature and pop culture representations to teach wisdom traditions. Data analysis revealed that the holistic group characteristics of wisdom circling, non-Stopping, organic way-finding and sacred space were supported by identifiable yet inseparable individual and group actions. This holistic pattern is best described through the metaphor of flocking birds.
Conclusions:
This self-led group supports long term meditation practice and provides a sense of eudemonic well-being for a diverse group of individuals in an accessible community setting.
... Mindfulness in the West is often missing is the aspect of having a sangha. Sangha means a community of like-minded individuals who are also interested in and practicing together meditation or mindfulness-based activities (Chan et al., 2018). Becoming intersubjective through community is just as, if not more, important in practicing mindfulness. ...
Anger and shame are individually explicated through intrapsychic, interpersonal, and emotional-motivational processes. The phenomenon of shame-rage, a common psychological defensive strategy, is described and illuminated as an unconscious avoidance mechanism that involves maladaptive expressions of anger and shame separately. Shame-rage strategies are empirically found in individuals who exhibit vulnerable narcissistic traits; this population is selected to discuss the development and consequences of shame-rage strategies. Compassion is suggested as a necessary therapeutic framework to support individuals suffering from shame-rage related afflictions. Affective neuroscientific concepts are embedded throughout this thesis to link shame-rage phenomenology to the evolutionary and empirical study of neuroscience in an effort to support therapeutic endeavours.
In this paper I focus on a distinctive kind of sociological ethnography which is particularly, though not exclusively, adopted in applied research. It has been proposed that this branch of ethnography be referred to as focused ethnography. Focused ethnography shall be delineated within the context of other common conceptions of what may be called conventional ethnography. However, rather than being opposed to it, focused ethnography is rather complementary to conventional ethnography, particularly in fields that are characteristic of socially and functionally differentiated contemporary society. The paper outlines the background as well as the major methodological features of focused ethnography, such as short-term field visits, data intensity and time intensity, so as to provide a background for future studies in this area.
URN: urn:nbn:de:0114-fqs0503440
Background:
In chronic obstructive pulmonary disease (COPD), the problem of poor patient participation in studies of self-management (SM) and pulmonary rehabilitation (PR) programmes (together referred to as COPD support programmes) is established. Understanding this problem beyond the previously reported socio-demographics and clinical factors is critical.
Aims:
The aim of this study was to explore factors that explain patient participation in studies of COPD support programmes.
Methods:
Thematic 'framework' synthesis was conducted on literature published from 1984 to 1 February 2015. Emergent themes and subthemes were mapped onto the adapted 'attitude-social influence-external barriers' and the 'self-regulation' models to produce analytical themes.
Results:
Ten out of 12 studies were included: PR (n=9) and SM (n=1). Three descriptive themes with 38 subthemes were mapped onto the models' constructs, and it generated four analytical themes: 'attitude', 'social influences' and 'illness' and 'intervention representations'. The following factors influenced (1) attendance-helping oneself through health improvements, perceived control of worsening condition, perceived benefits and positive past experience of the programme, as well as perceived positive influence of professionals; (2) non-attendance-perceived negative effects and negative past experience of the programme, perceived physical/practical concerns related to attendance, perceived severity of condition/symptoms and perceived negative influence of professionals/friends; (3) dropout-no health improvements perceived after attending a few sessions of the programme, perceived severity of the condition and perceived physical/practical concerns related to attendance.
Conclusions:
Psychosocial factors including perceived practical/physical concerns related to attendance influenced patients' participation in COPD support programmes. Addressing the negative beliefs/perceptions via behaviour change interventions may help improve participation in COPD support programmes and, ultimately, patient outcomes.
The rapidly growing body of research regarding the use of meditation interventions in chronic disease presents an opportunity to compare outcomes based on intervention content. For this review, meditation interventions were described as those interventions delivered to persons with chronic disease where sitting meditation was the main or only content of the intervention with or without the addition of mindful movement. This systematic review identified 45 individual research studies that examined meditations effect on levels of anxiety, depression, and chronic disease symptoms in persons with chronic disease. Individual studies were assessed based on interventional content, the consistency with which interventions were applied, and the research quality. This study identified seven categories of meditation interventions based on the meditation skills and mindful movement practices that were included in the intervention. Overall, half of the interventions had clearly defined and specific meditation interventions (25/45) and half of the studies were conducted using randomized control trials (24/45).
© The Author(s) 2015.
Educational researchers and practitioners are frequently asking questions about how better to understand educational theory and practice. Through the years, they have employed a variety of both quantitative and qualitative methods to elucidate the world of education. In this article, the author explores the epistemological legitimacy of metaphor analysis as a viable means for qualitative educational inquiry. In so doing, he explores the concepts of the theory of abduction, educational research and social constructivism, categories of metaphors, and metaphorical analysis in educational research. In addition, a review of the literature on educational research that uses metaphor analysis as the primary methodology revealed five major themes.
Purpose
The purpose of this study was to examine the prevalence and correlates of suicidal ideation (SI) in patients with stable moderate to very severe chronic obstructive pulmonary disease (COPD).
Patients and methods
We conducted an exploratory mixed methods analysis of data from participants in a longitudinal observational study of depression in COPD. We measured depression with the Patient Health Questionnaire-9 (PHQ-9), which includes an item on SI. We compared participants with and without SI in relation to sociodemographics, symptoms, anxiety, and healthcare resource use with independent t-tests and chi-square tests. Content analysis was performed on qualitative data gathered during a structured SI safety assessment.
Results
Of 202 participants, 121 (60%) had depressive symptoms (PHQ ≥6); 51 (25%) had a PHQ-9 ≥10, indicating a high likelihood of current major depression; and 22 (11%) reported SI. Compared to the 99 depressed participants without SI, those with SI were more likely to be female (59% vs 27%, P=0.004); had worse dyspnea (P=0.009), depression (P<0.001), and anxiety (P=0.003); and were also more likely to have received treatment for depression and/or anxiety (82% vs 40%, P<0.001) and more hospitalizations for COPD exacerbations (P=0.03) but had similar levels of airflow obstruction and functioning than participants without SI. Themes from the qualitative analysis among those with SI included current or prior adverse life situations, untreated or partially treated complex depression, loss of a key relationship, experience of illness and disability, and poor communication with providers.
Conclusion
Our findings suggest that current SI is common in COPD, may occur disproportionately in women, can persist despite mental health treatment, and has complex relationships with both health and life events. Adequate management of SI in COPD may therefore require tailored, comprehensive treatment approaches that integrate medical and mental health objectives.
A growing literature in human social genomics has begun to analyze how everyday life circumstances influence human gene expression. Social-environmental conditions such as urbanity, low socioeconomic status, social isolation, social threat, and low or unstable social status have been found to associate with differential expression of hundreds of gene transcripts in leukocytes and diseased tissues such as metastatic cancers. In leukocytes, diverse types of social adversity evoke a common conserved transcriptional response to adversity (CTRA) characterized by increased expression of proinflammatory genes and decreased expression of genes involved in innate antiviral responses and antibody synthesis. Mechanistic analyses have mapped the neural "social signal transduction" pathways that stimulate CTRA gene expression in response to social threat and may contribute to social gradients in health. Research has also begun to analyze the functional genomics of optimal health and thriving. Two emerging opportunities now stand to revolutionize our understanding of the everyday life of the human genome: network genomics analyses examining how systems-level capabilities emerge from groups of individual socially sensitive genomes and near-real-time transcriptional biofeedback to empirically optimize individual well-being in the context of the unique genetic, geographic, historical, developmental, and social contexts that jointly shape the transcriptional realization of our innate human genomic potential for thriving.
We took EEG recordings to measure task-free resting-state cortical brain activity in 35 participants under two conditions, alone (A) or together (T). We also investigated whether psychological attachment styles shape human cortical activity differently in these two settings. The results indicate that social context matters and that participants' cortical activity is moderated by the anxious, but not avoidant attachment style. We found enhanced alpha, beta and theta band activity in the T rather than the A resting-state condition, which was more pronounced in posterior brain regions. We further found a positive correlation between anxious attachment style and enhanced alpha power in the T vs. A condition over frontal and parietal scalp regions. There was no significant correlation between the absolute powers registered in the other two frequency bands and the participants' anxious attachment style.
The current investigation examined whether anxiety sensitivity (fear of anxiety-related sensations) explains the relation between emotional non-acceptance (unwillingness to experience unwanted emotions) and panic, social anxiety, and depressive symptoms among treatment-seeking daily smokers (N = 342, 46.2% female; Mage = 37.4, SD = 13.3). Consistent with hypotheses, emotional non-acceptance was found to be uniquely related to panic, social anxiety, and depressive symptoms. Additionally, emotional non-acceptance was found to have a significant indirect effect on panic, social anxiety, and depressive symptoms through anxiety sensitivity. All observed effects were evident above and beyond the variance accounted for by theoretically relevant variables including tobacco-related medical illness, number of cigarettes smoked per day, alcohol use problems, and negative affectivity. These findings are discussed in relation to the mechanisms underlying the expression of anxiety/depressive symptoms among daily smokers.
Importance:
Psychological and health-restorative benefits of mind-body therapies have been investigated, but their impact on the immune system remain less defined.
Objective:
To conduct the first comprehensive review of available controlled trial evidence to evaluate the effects of mind-body therapies on the immune system, focusing on markers of inflammation and anti-viral related immune responses.
Methods:
Data sources included MEDLINE, CINAHL, SPORTDiscus, and PsycINFO through September 1, 2013. Randomized controlled trials published in English evaluating at least four weeks of Tai Chi, Qi Gong, meditation, or Yoga that reported immune outcome measures were selected. Studies were synthesized separately by inflammatory (n = 18), anti-viral related immunity (n = 7), and enumerative (n = 14) outcomes measures. We performed random-effects meta-analyses using standardized mean difference when appropriate.
Results:
Thirty-four studies published in 39 articles (total 2, 219 participants) met inclusion criteria. For inflammatory measures, after 7 to 16 weeks of mind-body intervention, there was a moderate effect on reduction of C-reactive protein (effect size [ES], 0.58; 95% confidence interval [CI], 0.04 to 1.12), a small but not statistically significant reduction of interleukin-6 (ES, 0.35; 95% CI, -0.04 to 0.75), and negligible effect on tumor necrosis factor-α (ES, 0.21; 95% CI, -0.15 to 0.58). For anti-viral related immune and enumerative measures, there were negligible effects on CD4 counts (ES, 0.15; 95% CI, -0.04 to 0.34) and natural killer cell counts (ES, 0.12, 95% CI -0.21 to 0.45). Some evidence indicated mind-body therapies increase immune responses to vaccination.
Conclusions:
Mind-body therapies reduce markers of inflammation and influence virus-specific immune responses to vaccination despite minimal evidence suggesting effects on resting anti-viral or enumerative measures. These immunomodulatory effects, albeit incomplete, warrant further methodologically rigorous studies to determine the clinical implications of these findings for inflammatory and infectious disease outcomes.
Objective:
Kindness-based meditation (KBM) is a rubric covering meditation techniques developed to elicit kindness in a conscious way. Some techniques, for example, loving-kindness meditation and compassion meditation, have been included in programs aimed at improving health and well-being. Our aim was to systematically review and meta-analyze the evidence available from randomized controlled trials (RCTs) comparing the effects of KBM on health and well-being against passive and active control groups in patients and the general population.
Method:
Searches were completed in March 2013. Two reviewers applied predetermined eligibility criteria (RCTs, peer-reviewed publications, theses or conference proceedings, adult participants, KBM interventions) and extracted the data. Meta-analyses used random-effects models.
Results:
Twenty-two studies were included. KBM was moderately effective in decreasing self-reported depression (standard mean difference [Hedges's g] = -0.61, 95% confidence interval [CI] [-1.08, -0.14]) and increasing mindfulness (Hedges's g = 0.63, 95% CI [0.22, 1.05]), compassion (Hedges's g = 0.61, 95% CI [0.24, 0.99]) and self-compassion (Hedges's g = 0.45, 95% CI [0.15, 0.75]) against passive controls. Positive emotions were increased (Hedges's g = 0.42, 95% CI [0.10, 0.75]) against progressive relaxation. Exposure to KBM may initially be challenging for some people. RESULTS were inconclusive for some outcomes, in particular against active controls. The methodological quality of the reports was low to moderate. RESULTS suffered from imprecision due to wide CIs deriving from small studies.
Conclusions:
KBM showed evidence of benefits for the health of individuals and communities through its effects on well-being and social interaction. Further research including well-conducted large RCTs is warranted.
The Framework Method is becoming an increasingly popular approach to the management and analysis of qualitative data in health research. However, there is confusion about its potential application and limitations.
The article discusses when it is appropriate to adopt the Framework Method and explains the procedure for using it in multi-disciplinary health research teams, or those that involve clinicians, patients and lay people. The stages of the method are illustrated using examples from a published study.
Used effectively, with the leadership of an experienced qualitative researcher, the Framework Method is a systematic and flexible approach to analysing qualitative data and is appropriate for use in research teams even where not all members have previous experience of conducting qualitative research.
Although membership in voluntary associations has been presumed to be a central element in the building of social capital, micro-level knowledge about whether and how voluntary associations make their members more trusting and cooperative has been lacking. The link between trust and involvement in associations in Germany and Sweden was explored by means of a questionnaire concerning traits of individuals and of the associational groups to which they belong. The analysis of the resulting data set considered the extent to which various group characteristics (such as demographic diversity, in-group trust, and engagement level) are related to the generalized trust of the members. The results indicate that more diverse, more engaged voluntary associations, and those with weak ties, indeed accommodate more trusting people. In particular, time spent in groups with foreigners, or in groups with weaker ties, affects the generalized trust levels of the members.
Prior research has shown that an additional training session immediately after acute stress decreases release of salivary cortisol in a college student group trained with 5-day integrative body-mind training (IBMT) in comparison with a control group given the same amount of relaxation training. However, 5 days of training does not influence the basal secretion of cortisol. The current study seeks to extend this finding and determine whether increasing amounts of IBMT will decrease the basal cortisol level, suggesting reduced stress to daily activities. Thirty-four Chinese undergraduates were randomly assigned either to 4 weeks of IBMT or a relaxation control. Salivary cortisol levels at baseline before training and the three stages of a stress intervention test (i.e. rest, stress and additional 20-min practice) after 2 and 4 weeks of training were assessed. The basal cortisol level decreased significantly in the IBMT but not in relaxation group after 2 and 4 weeks of training. An additional IBMT practice session immediately after acute stress produced significantly lower cortisol release for the IBMT group in comparison with relaxation at weeks 2 and 4. The results indicate that IBMT produces a change in the basal endocrine system and larger acute effects as the dose of training increases. Copyright © 2013 John Wiley & Sons, Ltd.
To provide an overview of the relevance and strengths of focused ethnography in nursing research. The paper provides descriptions of focused ethnography and discusses using exemplars to show how focused ethnographies can enhance and understand nursing practice.
Orthodox ethnographic approaches may not always be suitable or desirable for research in diverse nursing contexts. Focused ethnography has emerged as a promising method for applying ethnography to a distinct issue or shared experience in cultures or sub-cultures and in specific settings, rather than throughout entire communities. Unfortunately, there is limited guidance on using focused ethnography, particularly as applied to nursing research.
Research studies performed by nurses using focused ethnography are summarised to show how they fulfilled three main purposes of the genre in nursing research. Additional citations are provided to help demonstrate the versatility of focused ethnography in exploring distinct problems in a specific context in different populations and groups of people.
The unique role that nurses play in health care, coupled with their skills in enquiry, can contribute to the further development of the discipline. Focused ethnography offers an opportunity to gain a better understanding and appreciation of nursing as a profession, and the role it plays in society.
Focused ethnography has emerged as a relevant research methodology that can be used by nurse researchers to understand specific societal issues that affect different facets of nursing practice. IMPLICATIONS FOR PRACTICE/RESEARCH: As nurse researchers endeavour to understand experiences in light of their health and life situations, focused ethnography enables them to understand the interrelationship between people and their environments in the society in which they live.
It is well established that a lack of social support constitutes a major risk factor for morbidity and mortality, comparable to risk factors such as smoking, obesity, and high blood pressure. Although it has been hypothesized that social support may benefit health by reducing physiological reactivity to stressors, the mechanisms underlying this process remain unclear. Moreover, to date, no studies have investigated the neurocognitive mechanisms that translate experiences of social support into the health outcomes that follow. To investigate these processes, thirty participants completed three tasks in which daily social support, neurocognitive reactivity to a social stressor, and neuroendocrine responses to a social stressor were assessed. Individuals who interacted regularly with supportive individuals across a 10-day period showed diminished cortisol reactivity to a social stressor. Moreover, greater social support and diminished cortisol responses were associated with diminished activity in the dorsal anterior cingulate cortex (dACC) and Brodmann's area (BA) 8, regions previously associated with the distress of social separation. Lastly, individual differences in dACC and BA 8 reactivity mediated the relationship between high daily social support and low cortisol reactivity, such that supported individuals showed reduced neurocognitive reactivity to social stressors, which in turn was associated with reduced neuroendocrine stress responses. This study is the first to investigate the neural underpinnings of the social support-health relationship and provides evidence that social support may ultimately benefit health by diminishing neural and physiological reactivity to social stressors.
As a social species, humans rely on a safe, secure social surround to survive and thrive. Perceptions of social isolation, or loneliness, increase vigilance for threat and heighten feelings of vulnerability while also raising the desire to reconnect. Implicit hypervigilance for social threat alters psychological processes that influence physiological functioning, diminish sleep quality, and increase morbidity and mortality. The purpose of this paper is to review the features and consequences of loneliness within a comprehensive theoretical framework that informs interventions to reduce loneliness. We review physical and mental health consequences of loneliness, mechanisms for its effects, and effectiveness of extant interventions. Features of a loneliness regulatory loop are employed to explain cognitive, behavioral, and physiological consequences of loneliness and to discuss interventions to reduce loneliness. Loneliness is not simply being alone. Interventions to reduce loneliness and its health consequences may need to take into account its attentional, confirmatory, and memorial biases as well as its social and behavioral effects.
The trust-building process is basic to social science. We investigate it in a laboratory setting using a novel multistage trust game where social gains are achieved if players trust each other in each stage. In each stage, also, players have an opportunity to appropriate these gains or be trustworthy by sharing them. Players are strangers because they do not know the identity of others and they will not play them again. Thus, there is no prospect of future interaction to induce trusting behavior, and we study the trust-building process where there is little scope for social relations and networks.
Standard game theory, which assumes all players are opportunistic and untrustworthy and thus should have zero trust for others, is used to construct a null hypothesis. We test whether people are trusting or trustworthy and examine how inferring the intentions of those who trust affects trustworthiness. We also investigate the effect of stake on trust, and study the evolution of trust.
Results show subjects exhibit some degree of trusting behavior, although a majority of them are not trustworthy and claim the entire social gain. Players are more reluctant to trust in later stages than in earlier ones and are more trustworthy if they are certain of the trustee’s intention. Surprisingly, subjects are more trusting and trustworthy when the stake size increases. Finally, we find the subpopulation that invests in initiating the trust-building process modifies its trusting behavior based on the relative fitness of trust.
Context:
Persons with Chronic Obstructive Pulmonary Disease (COPD) exhibit high levels of comorbid anxiety that severely worsens their sensation of dyspnea and is associated with high levels of avoidance of essential activities resulting in an increase morbidity and mortality. Increasing meditation and mind/body practices have been shown to decrease anxiety, and improve intrapersonal and interpersonal relationships in general populations, however, results of studies in the COPD population have been mixed.
Objective:
Understanding how persons with COPD experience learning meditation and mind/body skills would aid future meditation-focused mind/body intervention design.
Design/setting/patients:
A mixed-method study of a community based meditation-focused mind/body intervention for persons with COPD.
Measures:
Reflective journaling, phone exit interviews and survey measures: chronic disease respiratory questionnaire, and Anxiety Sensitivity 3 questionnaire.
Intervention:
Eight weekly one hour meditation-focused mind/body classes that taught concentration and insight meditation skills along with mind/body exercises that facilitated increased body and emotional awareness.
Results:
Out of 41 participants, 32 (73%) contributed detailed experience about learning and practicing meditation and mind/body practices that distilled into four themes, barriers to practice, learning style, emotional processing, and benefits of practice. Of those 32 participants 21 (73%) identified improvement in physical or emotional symptoms. Overall, 13 (40%) participants provided details regarding how they adapted specific meditation skills into daily life to improve emotional function and lessen dyspnea. Anxiety sensitivity to social situations was associated with a lack of participation. Lessons learned for larger scale application to future meditation and mind/body intervention design for chronic illness populations such as COPD are identified.
Chronic obstructive pulmonary disease (COPD) remains a common and important cause of morbidity and mortality both in the United States and globally. The increasing trends of COPD prevalence, morbidity, and mortality seen in the later part of last century have not continued in the United States. COPD prevalence, hospitalizations, and deaths have remained stable or are decreasing over the last decade. This is likely a function of the overall decreasing prevalence of tobacco use over the past 50 years, along with improved therapies for COPD. Future trends in COPD will probably be driven by factors in addition to tobacco use, such as longer survival in the population, other occupational and environmental exposures, and the increasing prevalence of asthma. Globally, factors such as air pollution and chronic respiratory infections, such as tuberculosis, will remain important predictors of future trends.
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Background:
Widespread application of pulmonary rehabilitation (also known as respiratory rehabilitation) in chronic obstructive pulmonary disease (COPD) should be preceded by demonstrable improvements in function (health-related quality of life, functional and maximal exercise capacity) attributable to the programmes. This review updates the review reported in 2006.
Objectives:
To compare the effects of pulmonary rehabilitation versus usual care on health-related quality of life and functional and maximal exercise capacity in persons with COPD.
Search methods:
We identified additional randomised controlled trials (RCTs) from the Cochrane Airways Group Specialised Register. Searches were current as of March 2014.
Selection criteria:
We selected RCTs of pulmonary rehabilitation in patients with COPD in which health-related quality of life (HRQoL) and/or functional (FEC) or maximal (MEC) exercise capacity were measured. We defined 'pulmonary rehabilitation' as exercise training for at least four weeks with or without education and/or psychological support. We defined 'usual care' as conventional care in which the control group was not given education or any form of additional intervention. We considered participants in the following situations to be in receipt of usual care: only verbal advice was given without additional education; and medication was altered or optimised to what was considered best practice at the start of the trial for all participants.
Data collection and analysis:
We calculated mean differences (MDs) using a random-effects model. We requested missing data from the authors of the primary study. We used standard methods as recommended by The Cochrane Collaboration.
Main results:
Along with the 31 RCTs included in the previous version (2006), we included 34 additional RCTs in this update, resulting in a total of 65 RCTs involving 3822 participants for inclusion in the meta-analysis.We noted no significant demographic differences at baseline between members of the intervention group and those who received usual care. For the pulmonary rehabilitation group, the mean forced expiratory volume at one second (FEV1) was 39.2% predicted, and for the usual care group 36.4%; mean age was 62.4 years and 62.5 years, respectively. The gender mix in both groups was around two males for each female. A total of 41 of the pulmonary rehabilitation programmes were hospital based (inpatient or outpatient), 23 were community based (at community centres or in individual homes) and one study had both a hospital component and a community component. Most programmes were of 12 weeks' or eight weeks' duration with an overall range of four weeks to 52 weeks.The nature of the intervention made it impossible for investigators to blind participants or those delivering the programme. In addition, it was unclear from most early studies whether allocation concealment was undertaken; along with the high attrition rates reported by several studies, this impacted the overall risk of bias.We found statistically significant improvement for all included outcomes. In four important domains of quality of life (QoL) (Chronic Respiratory Questionnaire (CRQ) scores for dyspnoea, fatigue, emotional function and mastery), the effect was larger than the minimal clinically important difference (MCID) of 0.5 units (dyspnoea: MD 0.79, 95% confidence interval (CI) 0.56 to 1.03; N = 1283; studies = 19; moderate-quality evidence; fatigue: MD 0.68, 95% CI 0.45 to 0.92; N = 1291; studies = 19; low-quality evidence; emotional function: MD 0.56, 95% CI 0.34 to 0.78; N = 1291; studies = 19; mastery: MD 0.71, 95% CI 0.47 to 0.95; N = 1212; studies = 19; low-quality evidence). Statistically significant improvements were noted in all domains of the St. George's Respiratory Questionnaire (SGRQ), and improvement in total score was better than 4 units (MD -6.89, 95% CI -9.26 to -4.52; N = 1146; studies = 19; low-quality evidence). Sensitivity analysis using the trials at lower risk of bias yielded a similar estimate of the treatment effect (MD -5.15, 95% CI -7.95 to -2.36; N = 572; studies = 7).Both functional exercise and maximal exercise showed statistically significant improvement. Researchers reported an increase in maximal exercise capacity (mean Wmax (W)) in participants allocated to pulmonary rehabilitation compared with usual care (MD 6.77, 95% CI 1.89 to 11.65; N = 779; studies = 16). The common effect size exceeded the MCID (4 watts) proposed by Puhan 2011(b). In relation to functional exercise capacity, the six-minute walk distance mean treatment effect was greater than the threshold of clinical significance (MD 43.93, 95% CI 32.64 to 55.21; participants = 1879; studies = 38).The subgroup analysis, which compared hospital-based programmes versus community-based programmes, provided evidence of a significant difference in treatment effect between subgroups for all domains of the CRQ, with higher mean values, on average, in the hospital-based pulmonary rehabilitation group than in the community-based group. The SGRQ did not reveal this difference. Subgroup analysis performed to look at the complexity of the pulmonary rehabilitation programme provided no evidence of a significant difference in treatment effect between subgroups that received exercise only and those that received exercise combined with more complex interventions. However, both subgroup analyses could be confounded and should be interpreted with caution.
Authors' conclusions:
Pulmonary rehabilitation relieves dyspnoea and fatigue, improves emotional function and enhances the sense of control that individuals have over their condition. These improvements are moderately large and clinically significant. Rehabilitation serves as an important component of the management of COPD and is beneficial in improving health-related quality of life and exercise capacity. It is our opinion that additional RCTs comparing pulmonary rehabilitation and conventional care in COPD are not warranted. Future research studies should focus on identifying which components of pulmonary rehabilitation are essential, its ideal length and location, the degree of supervision and intensity of training required and how long treatment effects persist. This endeavour is important in the light of the new subgroup analysis, which showed a difference in treatment effect on the CRQ between hospital-based and community-based programmes but no difference between exercise only and more complex pulmonary rehabilitation programmes.
Background: People with aphasia frequently report reduced social networks as well as a desire for increased social interaction. Individuals with aphasia and speech-language pathologists have identified peer support as an important component of adjusting to post-stroke changes and learning to live successfully with aphasia. Peer-led aphasia support groups can provide greater, long-term access to peer support and social communication opportunities for people with aphasia and their families. However, more research is needed to facilitate their development and sustainability in local communities.
Background
Chronic obstructive pulmonary disease (COPD) is a common disease worldwide with significant morbidity and mortality.
Aim
To investigate the effect of a comprehensive COPD management programme in decreasing COPD readmissions 1 year before and 1 year after the programme.
Method
185 (166 males) patients admitted for acute exacerbation of COPD (AECOPD) were recruited between September 2010 and December 2012. COPD care team provided crisis support and maintenance therapy for the COPD patients for a total of 16 weeks. The protocol included COPD clinic run by respiratory physicians, COPD education and nurse clinics by respiratory nurses, out-patient pulmonary rehabilitation programme by physiotherapists, fast track doctor's clinic, telephone hotline for patients and nurse telephone calls to patients. Readmissions over a period of 1 year were assessed.
Results
The mean (SD) age of the subjects and FEV1 % predicted normal were 76.9 ± 7.37 yrs and 44.4 ± 20.7% respectively. 40 (21.6%) patients required non-invasive positive pressure ventilation during the recruitment admission. Admissions for AECOPD decreased from 2.39 ± 2.05 one year before programme to 1.65 ± 2.1 one year after programme (mean difference 0.75 ± 2.11 episodes, p < 0.001). The length of hospital stay was reduced from 12.17 ± 9.14 days one year before programme to 9.09 ± 12.1 days one year after the programme (mean difference 3.09 ± 12.1 days, p < 0.001). The FEV1 percentage predicted and quality of life measured by St George's Respiratory Questionnaire showed no significant improvement at 16 weeks after recruitment into the programme as compared to at 6 weeks.
Conclusion
COPD care programme is effective in decreasing readmissions and length of hospital day for COPD patients.
Purpose:
To explore how patients who refuse referral to pulmonary rehabilitation (PR) appraise acute exacerbations of chronic obstructive pulmonary disease (COPD), in the context of having considered and declined PR.
Method:
Six participants recently hospitalized with an acute exacerbation COPD who refused a referral to PR subsequent to hospital discharge participated in in-depth interviews. Transcripts were subjected to interpretative phenomenological analysis (IPA).
Results:
Three conceptual themes emerged comprising: "Construction of the self", reflecting the impact of the acute exacerbation on personal identity; "Relinquishing control", describing participants" struggle to maintain agency following an acute event; and "Engagement with others", embodying participants' sensitivity and responsiveness to interactions with others.
Conclusions:
Prominent in theses participants' narratives are self-conscious cognitions which appear founded in shame and stigmatization. These cognitions seem to reflect challenges to self-worth and appear associated with reduced help-seeking and isolation. Perceived personal culpability for COPD appears to sensitize participants' towards their interactions with health care professionals, construed as critical and judgmental which may increase avoidant behaviors, such as refusal of PR. When introducing PR, professionals should be aware of such sensitivities and facilitate open discussion which offers, time, compassion and understanding as a means of facilitating uptake.
Implications for rehabilitation:
Patients who decline referral to pulmonary rehabilitation report self-conscious cognitions (i.e., shame, guilt, fear of others evaluation) associated with lowered self-worth and reduced help-seeking. When introducing pulmonary rehabilitation health care professionals need to be mindful of patients' sensitivities to being shamed which stem from perceived culpability for COPD. Professionals should facilitate an open discussion with patients which offers, time, compassion and understanding as a means of facilitating pulmonary rehabilitation uptake. Compassion focused interventions which encourage trust and safety may promote active partnership working and facilitate engagement in pulmonary rehabilitation.
Groups use rituals to create and preserve collective identities. Separation of sacred practices from customary activities has long been considered a key property of ritual. However, customary activities form the basis of some ritual celebrations. We explain how a different process of identity creation results: identity affirmation. We find that groups affirm their customary practices on ritual occasions when they intend to celebrate practices already associated with the sacred, and we explain the structure of such rituals using a case study of a university centennial celebration. We argue that attention to variation in ritual casts light on the values and collective identity of groups.
This article examines the significance of trust in women’s collective efforts for development through self-help groups (SHGs). Community building efforts cannot ignore the importance of trust among group members and, between group members and organisational members. The article explores the manner and forms in which trust manifests itself during periods of formation, activity and defunct stages of SHGs in India. Personalised trust forms the centre of the radius of trust in SHGs and it gets extended to generalised and institutionalised trust. Development interventions for communities often aim to build social capital which is an important corollary of trust. Community and group development efforts aimed at building social capital must take into consideration the factors associated with building and generating trust.
Using Simmel’s notion of sociation, the way in which rural elders in England and Wales relate to, or connect with, each other and others within their community, can be seen to be conflictual as well as consensual. As a vehicle for exploiting this relationship, social capital also can be antithetic as well as convergent and an important element of social capital – trust – can be freely given but also, at the extreme, instrumental and enforced. Measuring trust as a descriptive variable amongst rural elders suggests that personal trust is very high but trust in organisations (system trust), less so. All types of trust tend to be higher amongst the ‘better off’ measured by a number of socio economic and locational variables. Exploring trust as a process suggests that losses of trust and not trusting do damage social capital and connectivity, but rural elders will try and overcome trust loss in a variety of ways. Building personal trust through bridging capital is important here, where a ‘leap of faith’ in trusting and reciprocity are significant. System trust is built around helpfulness, honesty, reasonableness and civility. Instrumental and system trust start with scepticism but can be built through personal experiences and the ‘word of mouth’ of those already trusted, where there is strong bonding capital. ‘Localness’ is seen as an important aspect of building instrumental trust and here familiarity is more important than reassurance or ‘warrants of trust’. Successive government polices promoting trust as a means of building both social capital and connectivity are seen to have limitations as the factors that influence convergent trust largely fall outside of the scope of policy manipulation.
Both mindfulness and emotional intelligence are associated with positive life outcomes, including greater subjective well-being. The present study examined whether emotional intelligence mediates the relationship between mindfulness and subjective well-being. Participants completed measures of characteristic mindfulness, emotional intelligence, and affect and life satisfaction as indices of subjective well-being. Higher levels of mindfulness were associated with greater emotional intelligence, positive affect, and life satisfaction and lower negative affect. Higher levels of emotional intelligence were associated with greater positive affect and life satisfaction and lower negative affect. Emotional intelligence mediated between mindfulness and higher positive affect, lower negative affect, and greater life satisfaction. These results provide information regarding a possible process through which mindfulness exerts its beneficial effects.
Although evidence suggests that loneliness may increase risk for health problems, the mechanisms responsible are not well understood. Immune dysregulation is one potential pathway: Elevated proinflammatory cytokines such as interleukin-6 (IL-6) increase risk for health problems. In our first study (N = 134), lonelier healthy adults exposed to acute stress exhibited greater synthesis of tumor necrosis factor-alpha (TNF-α) and IL-6 by peripheral blood mononuclear cells (PBMCs) stimulated with lipopolysaccharide (LPS) than their less lonely counterparts. Similarly, in the second study (N = 144), lonelier posttreatment breast-cancer survivors exposed to acute stress exhibited greater synthesis of IL-6 and interleukin-1 beta (IL-1β) by LPS-stimulated PBMCs than their counterparts who felt more socially connected. However, loneliness was unrelated to TNF-α in Study 2, although the result was in the expected direction. Thus, two different populations demonstrated that lonelier participants had more stimulated cytokine production in response to stress than less lonely participants, which reflects a proinflammatory phenotype. These data provide a glimpse into the pathways through which loneliness may affect health.
Clinical trials studied Yoga-based lifestyle changes on coronary artery disease patients during the 1970s to early 1990s. Study components included exercise, vegetarianism, Yoga practices, meditation, and a structured group meeting. For almost 25 years, the Research Participants have continued meeting regularly and have reported improved health, better relationships, quicker recoveries, creativity, joie de vivre, and longevity. They continue to experience benefits from this Yoga-based lifestyle for treatment of disease by maintaining a Sangha: a circle of friends, an enduring group circle for coronary artery disease patients.
Quantitative research has shown Mindfulness-based Stress Reduction (MBSR) programmes can reduce mood disturbance, improve quality of life, and decrease stress symptoms of cancer patients. However, the range of subjective effects experienced by programme participants has not been clearly described. Nine cancer patients who had participated in an 8-week MBSR programme through the Tom Baker Cancer Centre's Department of Psychosocial Resources, and who continued to attend weekly drop-in MBSR sessions were interviewed for this study. Qualitative research was conducted using grounded theory analysis. Data from semi-structured interviews and a focus group were analysed using QSR N6 software to identify themes concerning the effects patients experienced by adding meditation to their lives. Five major themes emerged from the data: (1) opening to change; (2) self-control; (3) shared experience; (4) personal growth; (5) spirituality. This information was used to develop specific theory concerning mechanisms whereby MBSR effects change for cancer patients. These understandings may be used to refine and further develop MBSR programmes to better assist patients during cancer diagnosis, treatment and recovery. Copyright © 2006 John Wiley & Sons, Ltd.
The idea that people need high self-esteem in order to be psychologically healthy is almost a truism in Western developmental psychology. Parents are told that one of their most important tasks is to nurture their children's self-esteem. Teachers are encouraged to give all their students gold stars so that each can feel proud and spe- cial. Psychologists worry about the dangerous drop in self-esteem experienced by adolescents as they transition out of childhood and try to find ways to give teens a self-esteem boost. The assumption that high self-esteem is synonymous with well- being applies throughout the lifespan. The elderly benefit from high self-esteem as much as anyone, don't they? The issue is not so simple. In the field of social psychol- ogy, scholars are starting to fall out of love with self-esteem. Yes, it is true that high self-esteem is associated with less depression and anxiety, as well as with greater hap- piness and life satisfaction. However, there are also some dark sides to high self- esteem. For instance, high self-esteem is strongly correlated with narcissism. Twenge (2006) argued that the emphasis placed on self-esteem in American schools and cul- ture at large is responsible for the creation of 'generation me', so named because of the steady and consistent rise in narcissism levels among American college students documented since the mid 1960s. Self-esteem is also associated with the better-than- average effect, the need to feel superior to others just to feel okay about oneself. Re- search shows that most people think they are funnier, more logical, more popular, better looking, nicer, more trustworthy, wiser and more intelligent than others (Alicke & Govorun, 2005). To be average is unacceptable in Western society, so pret- ty much everyone walks around wearing rose-colored glasses (at least when they are looking in the mirror). This comparative dynamic, however, the tendency to puff ourselves up and put others down, creates interpersonal distance and separation that undermines connectedness.
Chronic obstructive pulmonary disease (COPD) is a crippling disease with a high worldwide prevalence. The purpose of this review is to highlight recent studies which define the global impact of COPD on quality of life. There are direct implications for care.
Dyspnea is a dominant and defining symptom for patients with COPD, but the overall degree of impairment suffered by patients with COPD extends far beyond shortness of breath. A series of recent studies gives us insight into both the physical and the psychosocial burdens of the disease and their negative net effects upon quality of life. The suffering of patients with COPD is similar to that of patients with cancer, and palliative measures have been shown to be an important component of comprehensive care.
The symptom burden in patients with severe COPD is high and is comparable to that of patients with cancer. Ironically, patients with COPD could be said to suffer more than those with cancer; the symptom burden is similar, but patients with COPD tend to live longer. The literature is replete with evidence that a palliative care approach to patients with cancer increases the quality of life (and perhaps even the quality of death). The same palliative care approach can and should be used for patients with COPD. There are now objective data to support the benefits of such an approach.
In spite of the well-demonstrated benefits for patients with COPD, pulmonary rehabilitation programmes show considerable drop-out and suboptimal attendance rates. The purpose of this prospective study is to examine causes for drop-out and non-attendance during a 12 week multidisciplinary pulmonary rehabilitation programme, and to investigate whether sociodemographic and medical factors as well as patients' perception of their illness are related to drop-out and non-attendance.
Two hundred and seventeen patients with COPD who were referred to a rehabilitation centre participated in this multicentre study. Prior to treatment, patients received a questionnaire, which included the Illness Perception Questionnaire-Revised. Clinical data were drawn from medical records. Drop-out and attendance were recorded during the programme.
Fifty patients (23%) did not complete the rehabilitation course, of which half was due to medical reasons (e.g. exacerbations, hospitalisations). Non-completion could not be predicted by baseline sociodemographic, clinical or psychological variables. Patients who declined treatment did not differ from patients who dropped out due to medical reasons. On average, patients attended 92% of all scheduled appointments. Of all missed appointments, approximately 20% were accountable to factors beyond patients' control (e.g. absent therapists, hospitalisations). Smoking, living alone, a lower fat free mass and lower confidence in treatment increased the chance of patients not attending an appointment during rehabilitation.
In general, adherence in rehabilitation is high. However, paying attention to patients' nutritional status and creating a positive expectation of treatment during referral and intake appear to be important if one aims to optimise patients' attendance during rehabilitation.
The practice of mindfulness meditation was used in a 10-week Stress Reduction and Relaxation Program to train chronic pain patients in self-regulation. The meditation facilitates an attentional stance towards proprioception known as detached observation. This appears to cause an "uncoupling " of the sensory dimension of the pain experience from the affective/evaluative alarm reaction and reduce the experience of suffering via cognitive reappraisal. Data are presented on 51 chronic pain patients who had not improved with traditional medical care. The dominant pain categories were low back, neck and shoulder, and headache. Facial pain, angina pectoris, noncoronary chest pain, and GI pain were also represented. At 10 weeks, 65% of the patients showed a reduction of greater than or equal to 33% in the mean total Pain Rating Index (Melzack) and 50% showed a reduction of greater than or equal to 50%. Similar decreases were recorded on other pain indices and in the number of medical symptoms reported. Large and significant reductions in mood disturbance and psychiatric symptomatology accompanied these changes and were relatively stable on follow-up. These improvements were independent of the pain category. We conclude that this form of meditation can be used as the basis for an effective behavioral program in self-regulation for chronic pain patients. Key features of the program structure, and the limitations of the present uncontrolled study are discussed.
Scores on the Rotter Interpersonal Trust Scale were evaluated as predictors of psychological well-being, functional health, and longevity in a sample of 100 men and women who were between 55 and 80 years old at baseline (mean age 66.8). Cross-sectionally, high levels of trust were associated with better self-rated health and more life satisfaction. Follow-up over approximately 8 years found baseline levels of trust to be positively related to subsequent functional health, but not to subsequent life satisfaction. Mortality follow-up after 14 years demonstrated that those with high levels of trust had longer survival (p = .03), a finding that was somewhat weakened by controlling for baseline health ratings. These findings illustrate the health protective effects of high levels of trust and suggest the potential usefulness of the trust concept for understanding successful aging.
This article reviews the prevalence of anxiety disorders in patients with chronic obstructive pulmonary disease (COPD) as well as the impact of comorbid anxiety on quality of life in patients with COPD. Published studies on three types of treatments for anxiety are then reviewed: psychopharmacology, psychotherapy, and pulmonary rehabilitation programs.
A PubMed search was conducted of the literature from 1966 through 2002 using the keywords anxiety, chronic obstructive pulmonary disease, respiratory diseases, obstructive lung diseases, and pulmonary rehabilitation. Any articles that discussed the prevalence of anxiety symptoms or anxiety disorders among patients with COPD, the impact of anxiety on patients with COPD, or the treatment of anxiety in COPD patients were included in this review.
Anxiety disorders, especially generalized anxiety disorder (GAD) and panic disorder, occur at a higher rate in patients with COPD compared with the general population. Not surprisingly, anxiety has a significant and negative impact on quality of life of COPD patients. Nonetheless, few studies have examined pharmacological, psychotherapeutic, or pulmonary rehabilitation treatments for anxiety disorders in the context of COPD. Trials of nortriptyline, buspirone, and sertraline have been found to reduce symptoms of anxiety. Similarly, cognitive-behavioral programs that focus on relaxation and changes in thinking also produced declines in anxious symptoms. Finally, multicomponent pulmonary rehabilitation programs can also result in reductions in anxious symptoms.
Studies examining the treatment of anxiety disorders in patients with COPD are promising, yet their efficacy needs to be established. The long-term effects of treatment of anxiety disorders on quality of life of COPD patients have yet to be explored.
This study evaluated associations between general (negative affectivity) and specific (anxiety sensitivity) factors that may relate to the mindfulness skill domains assessed by the Kentucky Inventory of Mindfulness Skills. Participants were 154 young adults (88 females; M(age) = 22.4 years, SD = 7.9) recruited from the community. Partially consistent with predictions, higher levels of negative affectivity were significantly associated with lower levels of Awareness, Acceptance, and Describe mindfulness skills, and higher levels of anxiety sensitivity were significantly associated with lower levels of Awareness and Acceptance mindfulness skills. Additionally, negative affectivity and anxiety sensitivity each demonstrated unique relations to participants' ability to experience the present state without evaluating or judging its content (Accept factor), after accounting for their shared variance, but only anxiety sensitivity demonstrated a unique association to the Act with Awareness factor independent of variance explained by negative affectivity. Findings are discussed in relation to theory and research on mindfulness processes.
Anxiety disorders in patients with COPD: a systematic review
- Willgoss
Willgoss TG, Yohannes AM. Anxiety disorders in patients with
COPD: a systematic review. Respir Care. 2013;58(5):858-866.
Timeless Healing. first ed. Fireside Press
- H Benson
- M Stark
Benson H, Stark M. Timeless Healing. first ed. Fireside Press; 1998.
Growing old in a circle of friends: sangha and the lifestyle heart trial
- Gage