Matching response to need: What makes social networks fit for providing bereavement support?

Abstract

The objectives of this study were to explore the goodness of fit between the bereaved peoples’ needs and the support offered by their social networks; to ascertain whether this support was experienced as helpful or unhelpful by bereaved people; and to explore both the types of social networks that offer effective support and the characteristics of the communities that encourage and nurture such networks. This study was based on qualitative interviews from twenty bereaved people, in Western Australia, interviewed in 2013. A framework analysis of these interviews was undertaken using a deductive approach based on the goodness of fit framework. Much of this support is provided informally in community settings by a range of people already involved in the everyday lives of those recently bereaved; and that support can be helpful or unhelpful depending on its amount, timing, function and structure. Improving the fit between the bereaved person’s needs and the support offered may thus involve identifying and enhancing the caring capacity of existing networks. An important strategy for achieving this is to train community members in mapping and developing these naturally occurring networks. Some such networks will include relationships of long standing, others may be circles of care formed during a period of caring. Peer support bereavement networks develop from these existing networks and may also recruit new members who were not part of the caring circle. The findings endorse social models of bereavement care that fit within a public health approach rather than relying solely on professional care. As exemplified by Compassionate Communities policies and practices, establishing collaboration between community networks and professional services is vital for effective and sustainable bereavement care.

Full text

RESEARCH ARTICLE
Matching response to need: What makes
social networks fit for providing bereavement
support?
Samar M. AounID
1,2
*, Lauren J. Breen
3
, Bruce Rumbold
1
, Kim M. Christian
3
, Anne Same
4
,
Julian Abel
5
1Palliative Care Unit, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria,
Australia, 2The Perron Institute for Neurological and Translational Science, Perth, Western Australia,
Australia, 3School of Psychology, Faculty of Health Sciences, Curtin University, Perth, Western Australia,
Australia, 4School of Occupational Therapy, Social Work and Speech Pathology, Faculty of Health
Sciences, Curtin University, Perth, Western Australia, Australia, 5Compassionate Communities UK,
Honorary Senior Researcher, University of Bradford, Bradford, United Kingdom
*s.aoun@latrobe.edu.au
Abstract
The objectives of this study were to explore the goodness of fit between the bereaved peo-
ples’ needs and the support offered by their social networks; to ascertain whether this sup-
port was experienced as helpful or unhelpful by bereaved people; and to explore both the
types of social networks that offer effective support and the characteristics of the communi-
ties that encourage and nurture such networks. This study was based on qualitative inter-
views from twenty bereaved people, in Western Australia, interviewed in 2013. A framework
analysis of these interviews was undertaken using a deductive approach based on the
goodness of fit framework. Much of this support is provided informally in community settings
by a range of people already involved in the everyday lives of those recently bereaved; and
that support can be helpful or unhelpful depending on its amount, timing, function and struc-
ture. Improving the fit between the bereaved person’s needs and the support offered may
thus involve identifying and enhancing the caring capacity of existing networks. An important
strategy for achieving this is to train community members in mapping and developing these
naturally occurring networks. Some such networks will include relationships of long stand-
ing, others may be circles of care formed during a period of caring. Peer support bereave-
ment networks develop from these existing networks and may also recruit new members
who were not part of the caring circle. The findings endorse social models of bereavement
care that fit within a public health approach rather than relying solely on professional care.
As exemplified by Compassionate Communities policies and practices, establishing collabo-
ration between community networks and professional services is vital for effective and sus-
tainable bereavement care.
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 1 / 17
a1111111111
a1111111111
a1111111111
a1111111111
a1111111111
OPEN ACCESS
Citation: Aoun SM, Breen LJ, Rumbold B, Christian
KM, Same A, Abel J (2019) Matching response to
need: What makes social networks fit for providing
bereavement support? PLoS ONE 14(3):
e0213367. https://doi.org/10.1371/journal.
pone.0213367
Editor: Heidi H. Ewen, University of Indianapolis,
UNITED STATES
Received: August 25, 2018
Accepted: February 19, 2019
Published: March 7, 2019
Copyright: ©2019 Aoun et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: Ethical approval by
Curtin University Research Ethics Committee
specifies that all results are in aggregate form to
maintain confidentiality and privacy and precludes
individual level data being made publicly available.
Interested and qualified researchers may send
requests for additional data to Samar Aoun at s.
aoun@latrobe.edu.au, who will liaise with the
funeral providers regarding data access.
Funding: This work was supported by Department
of Health, Government of Western Australia. The

Introduction
Bereavement can be an extremely stressful and difficult experience for an individual [1,2].
Adverse outcomes can occur across multiple domains: emotional (e.g., sadness, anger, guilt),
physical (e.g., fatigue, agitation, pain), behavioural (e.g., sleep and appetite disturbance, absent-
mindedness), and cognitive (e.g., disbelief, confusion, hallucinations). Alongside these conse-
quences, the bereaved must also cope with the secondary losses that arise as a result of
bereavement, including social isolation and stigma [3], financial loss [4], and changes of roles
and responsibilities [5]. Additionally, bereavement is associated with an increased risk of mor-
tality [6], a higher risk of suicide and suicidal ideation [4] and a higher risk of developing
mood, anxiety, and adjustment disorders, and complicated/prolonged grief reactions [7].
Bereaved individuals often seek and receive social support [8], understood here as “an
exchange of resources between at least two individuals perceived by the provider or the recipi-
ent to be intended to enhance the well-being of the recipient” [9, p.19]. With this definition,
social support does come from formal and informal caregivers. Although the receipt of social
support is typically viewed as a protective factor in bereavement [10,11], it is not necessarily
helpful and can even lead to the bereaved experiencing more distress [12]. Differentiating ben-
eficial from harmful social support involves more than distinguishing helpful and unhelpful
activities, for the same activity that is helpful for one may be regarded as unhelpful by another
[13]. The bereaved individual’s perception of helpfulness or unhelpfulness of support is thus
important [12,14]. It is social support that is perceived by the bereaved recipient to be helpful
that is important, not the provision of social support itself [1,14], and unhelpful social support
is linked to depression [15]. These ambiguous outcomes of social support underline the need
for further exploration of offering and receiving support. Weenolsen’s work [16] reminds us
that, as loss may present itself in a number of domains and associated losses, support is needed
in all these aspects of the bereaved person’s experience if loss is to be transcended.
A population-based study of bereaved adults demonstrated that the primary sources of
bereavement support for most people are their existing social networks, supplemented for
some by networks formed during a period spent caring for a dying family member [17]. These
additional supporting caring networks may not have formed where an unexpected death has
occurred e.g. due to suicide, drowning, accident or homicide. In networks pre-dating dying
and bereavement, family and friends were the top sources of bereavement support, followed
by financial or legal advisors and religious or spiritual advisors. The community-based net-
works which formed during the caregiving period typically included the general practitioner,
nursing home, hospital, pharmacist, community group, palliative care service, and school-
based advisor. Funeral providers were a highly-valued source of support in bereavement. It
was not always clear whether these community-based practitioners continued to provide direct
support during bereavement, or whether it was the memory of their contribution earlier in the
bereavement that continued to sustain the bereaved person. A few people, particularly those in
the high risk group of complicated or prolonged grief, sought support during bereavement
from professional sources such as a facilitated bereavement support group or a mental health
professional such as a social worker, psychologist or psychiatrist [17]. The data from this sur-
vey provided empirical evidence for building a community’s capacity to provide the type of
social and practical support advocated by the Compassionate Communities approach [18]
which relies on identifying and developing local caring networks around the dying person and
their family. Compassionate communities normalize seeking and accepting help from family,
friends, neighbours, schools and workplaces for emotional and social support not just for end
of life support but as part of everyday living [11,19–21].
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 2 / 17
funders had no role in study design, data collection
and analysis, decision to publish, or preparation of
the manuscript.
Competing interests: The authors have declared
that no competing interests exist.

As noted above, the social and practical support offered to bereaved individuals may not
always meet their needs. In examining the ‘fit’ between the need for and satisfaction with six
types of functional social support in relation to bereavement outcomes, Bottomley, Burke and
Neimeyer showed that satisfaction with practical support in the months following loss through
homicide was the best predictor of favourable bereavement outcomes [1]. With those bereaved
by homicide, there are specific impacts on the social network and the grief response (eg anxi-
ety, awkwardness, perception of voyeurism/intrusiveness) which might affect availability/
access/satisfaction with social support. It is important, however, to note that Bottomley et al.
investigated the functional types of support provided independent of the relationships and
contexts in which this support occurred [1]. This neglects evidence suggesting that the per-
ceived effectiveness of support depends on a positive fit between the provider and the recipient
of the support such that the same functional type of support may be found by some to be help-
ful, by others unhelpful. For example, some people find advice giving unhelpful, others find it
to be beneficial [22].
Several ‘Goodness of Fit’ factors of social support have been identified as having a role in
determining whether social support is perceived by the recipient as helpful. These factors are
the source, amount, structure, timing, and function of support.[23]Sources of support found
in the bereavement survey have already been investigated in previous reports [17,18,24]. The
amount of support has to meet the recipient’s needs; too much or too little can determine
whether it is perceived as helpful or unhelpful. The structure of social support relates to how
connected the members of the recipients’ social networks are and the extent to which they too
have been affected by bereavement, which can affect the helpfulness of the support they intend
to offer [25]. The helpfulness of social support can also be related to when it was received;
some forms of support are more helpful at particular times than others. Function relates to
types of support, whether informational, instrumental, emotional or appraisal. Although
Vachon and Stylianos proposed their model in 1988, there are no studies that have tested this
model using empirical data.
Objectives
The current study is based on qualitative accounts from interviewed bereaved people. Its
objectives are:
• to explore the goodness of fit between the support offered by the bereaved social networks
and the needs of the bereaved, in terms of the source, amount, timing, structure, and
function.
• to ascertain whether the support related to these factors was experienced as helpful or
unhelpful by bereaved people.
• to explore the types of social networks that offer effective support and the characteristics of
the communities that encourage and nurture such networks.
Method
Ethics approval was granted by curtin university research ethics committee
(HR 57/2012)
In-depth face to face interviews were conducted with twenty bereaved individuals in Western
Australia (WA) in 2013. This qualitative study formed part of a larger study on bereavement
support where data were collected through an anonymous postal survey with participants
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 3 / 17

recruited from databases of funeral providers, and who had been bereaved 6–24 months
(Aoun et al, 2015). At the end of the survey questionnaire, respondents who wished to take
part in an in-depth interview, were invited to leave their name, contact details and the best
time to be contacted. There was information within the survey indicating that at most thirty
respondents would be invited for an interview. One hundred and ninety-three respondents
expressed their interest to be interviewed or 43% of those who completed the survey in WA
(n = 447).
Purposeful sampling was used in order to include a variety of characteristics in terms of the
setting whether rural (n = 8) or metropolitan (n = 12), the age of the bereaved (40–79 years)
and their relationship to the deceased (4 mothers, 2 fathers, 4 daughters, 5 husbands, 5 wives),
their bereavement risk (2 low, 13 medium and 5 high as determined from the survey tool on
prolonged grief PG-13), whether they perceived receiving enough support from all sources
after the death of their relative as determined from the survey (9 had enough support, 11 not
enough support) (Table 1). Other variables included the age of the deceased (18–95 years) and
gender of the deceased (11 males and 9 females), the cause of their death (eg cancer, heart dis-
ease, stroke, accident, suicide, homicide) and whether the death was expected (10 unexpected
and 10 expected). (Table 1)
The interviewer contacted by phone the selected survey participants who had agreed to par-
ticipate in the interview phase, provided an explanation about this phase of the study, and set
appointments. The information sheet and consent form were posted prior to the interviews.
All participants signed their consent forms and handed theirs to the interviewer before the
start of the interview. Data were collected face-to-face using a semi structured interview proto-
col. Interviews were conducted five months from the survey date and the same interviewer
conducted all interviews in the home of the interviewees or in an agreed location. The taped
interviews were of 23–66 minutes duration (mean 42.00 minutes and SD 12.76). However, the
interviewer spent considerable longer times with the interviewees building rapport at the start
and then debriefing after the interview (90–180 minutes). The in-depth interview elicited
bereaved participants’ thoughts and feelings in relation to their loss, the impact of supports
and also the helpfulness or unhelpfulness of their supports prior to and immediately after their
relative’s death. Examples of the questions included: “What form of support or help have you
received from friends, family, and others? Was this support helpful or unhelpful and in what
ways?” The interview protocol is uploaded as a “supporting information” file (S1 File).
Analysis
We undertook a framework analysis of these interviews using a deductive approach [26,27]
based on the goodness of fit framework [23]. Interviews were digitally recorded, professionally
transcribed and de-identified. One co-author conducted the initial coding of the relevant sec-
tions of the transcripts which was then verified by another co-author. Emerging themes, pat-
terns, and sentiments were then uncovered and identified to determine the impact of the
social supports on the bereaved in relation to the goodness of fit factors (source, amount, tim-
ing, structure, and function).
Findings
The deductive analysis clearly identified the four main factors relating to the goodness of fit
framework (beyond the Source): Amount, Timing, Function, and Structure. The analysis also
revealed that these factors were interrelated and therefore, some overlapping between the fac-
tors existed.
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 4 / 17

Amount
The amount of social support received was found to be an important factor in determining
whether the participant perceived the support as helpful. For some participants, when there
was too much informal support they found it overwhelming and intrusive and hence the sup-
port was often perceived to be more of a burden than helpful. This was illustrated by one par-
ticipant’s comment:
Table 1. Characteristics of the bereaved and their deceased relatives.
ID Bereaved age
(yrs)
Relation-ship to
deceased
Deceased age
(yrs)
Deceased
gender
Cause of death Expected or
unexpected death
Bereavement Risk
category
Support
received
1020M 51 Mother 18 Male Homicide unexpected High Not enough
support
1254M 79 Wife 80 Male Stroke unexpected High Enough
support
1212M 57 Mother 27 Male Injury/ accident unexpected High Not enough
support
1360M 52 Wife 62 Male Pneumonia following
cancer therapy
unexpected Medium Not enough
support
1075M 63 Wife 63 Male AML and mesothelioma expected Medium Enough
support
1087M 65 Wife 63 Male Cancer expected Medium Not enough
support
1185M 51 Daughter 91 Female Heart disease expected Low Not enough
support
1089M 49 Daughter 75 Male Lung disease expected Low Enough
support
1312M 40 Mother 9 Female Drowning linked to epilepsy unexpected Medium Enough
support
1301M 63 Husband 65 Female Meningitis/ventriculitis unexpected Medium Enough
support
1013M 73 Husband 76 Female Heart disease expected Medium Not enough
support
1444M 67 Husband 62 Female Secondary breast cancer expected Medium Enough
support
1291R 72 Husband 68 Female Intracerebral haemorrhage
into cerebellum
unexpected Medium Enough
support
1098R 69 Father 40 Female Leimyosarcoma expected Medium Enough
support
1385R 66 Daughter 95 Female Neurological, bowel cancer,
leukaemia
expected Medium Not enough
support
1127R 47 Father 19 Male Suicide expected Medium Not enough
support
1382R 48 Daughter 80 Male Cancer expected Medium Enough
support
1119R 59 Mother 31 Male Suicide unexpected High Not enough
support
1183R 40 Wife 42 Male Injury/accident unexpected High Not enough
support
1023R 74 Husband 66 Female Aneurysm unexpected Medium Not enough
support
Note: M = metropolitan and R = Rural
https://doi.org/10.1371/journal.pone.0213367.t001
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 5 / 17

Trying to be helpful; people were trying to do everything for me and get me involved in
this and visit there and that and in the end I just had to say “I’m sorry but I can’t do it”.
It was easier to come home to a lonely house than it was to cope with another visit to
somewhere else for tea that was totally foreign and have to talk about it again or what-
ever . . .(P1075)
Although participants expected support from people they had close relationships with or
from people in the community who knew them, several participants did not receive as much
support as they would have liked. As an example of this, another participant reported that her
brother offered her no support and that consequently she had to deal with everything herself
during this stressful time:
Look it was,it was a busy time and I got no help from my brother at all.He isn’t helpful and
to this day isn’t helpful,so I’ve been left with it all. (P1385)
Yet another participant explained that she felt the community, including her doctor, was
very judgemental and offered no support:
You know,my doctor,devastated me; my doctor who I’d been with for years and years and
years; I wasn’t one to go to the doctor on a regular basis.It was almost like I was having a tan-
trum.“Stop your tantrum and just get yourself back to work because it will do you the
world. . .” no sympathy . . . (P1020)
In contrast to this, a different participant expressed her satisfaction with the amount of
social support she received from informal sources. This participant felt that her, and her part-
ner’s, social support needs were met because their family and friends understood how much
support they required:
I just prefer my closest family with me and the support we had from our friends luckily I think
they knew where we stood and they gave us the amount of support we needed.If we needed
more we could always ask and I think from friends and then our daughter was family and
then in [husband name] I had all the support that I needed. (P1127)
Timing
Several participants spoke about the timing of the social support they received and how this
was helpful. Some participants thought that the ideal time to receive support is not immedi-
ately after bereavement but later in the process. Some of the types of support that were helpful
at a later timeframe were: Social support from friends, family, work colleagues and the com-
munity to alleviate continuing loneliness and isolation and to have the opportunity to talk
about the deceased after the initial bereavement; organised support groups; practical help with
chores in the home that the partner had previously attended to; social phone calls and visits
from friends of the deceased; and being involved in volunteering and helping others. One par-
ticipant felt that a few months after bereavement is the best time to be offered support because
by that time most people are able to talk about their experience:
I think that is the best way to go and speak to somebody.Not necessarily straight away; maybe
some people can’t talk about it straight away,but I think somewhere in a few months you
should go and speak and put it in its place where it needs to be I think. (P1382)
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 6 / 17

In contrast, other participants felt that support was helpful when they received it early on
and that it became less helpful as time passed:
At times I think it was good,at other times you’re just not interested; you want everybody to
just leave you alone.I think the first couple of days after [husband’s name] passing it was
probably good; maybe the first week or two and then after we didn’t really want to see any-
body or talk about it. (P1127)
Interviewees were asked specifically about their own experience of social support during
bereavement. At times, they also reflected on the impact of the death on their immediate fam-
ily, extended family and friends and their experiences of support, hence the use of ‘we’ in the
previous quote.
Another participant illustrated that support should be offered more than once, and that
those offering should not assume that refusal at the start means that support will never be
needed:
. . .but as far as support goes; everyone says “if I can do anything for you”,but they don’t offer
again. This is what they say in that first couple of weeks, but once the funeral has been no-one
comes and knocks on the door “what do you want me to do?” (P1183)
Other participants again expressed how they valued the ongoing support after bereavement
from both informal and community sources. One participant commented on how supportive
his church has been, “. . . I’ve got my church and I’ve got my support there and really tremendous
support and they’ve never stopped in two years” (P1444). Another participant experienced
ongoing support from her chemist: “Chemist,the chemist down here at [area name] is amazing;
so supportive and he still asks me now how I am and how are you going,good days,bad days”
(P1360).
Function
Analysis showed that the social support participants received has served different functions
according to whether the support offered was instrumental, emotional, informational, or
appraisal support. Participants spoke about the helpfulness of instrumental support provided
by informal sources. For example, this participant expressed how beneficial it was having his
son take control of the situation and organise what needed to be done:
My son was fabulous; our oldest son.He just went back and got a list of all the; he did have a
list for me of all the people I had to contact to let them know what had happened; all the peri-
odical payments,tax; he did this big list and he started making the phone calls himself rather
than me doing it. (P1444)
Other participants appreciated instrumental support such as handling funeral and wake
arrangements, providing meals, sorting out probate or simply getting their loved ones back on
their feet.
And then after the funeral my sister stayed longer with me and she was fantastic; it’s my eldest
sister and she said “let’s get you into a routine. What we’ll do is we’ll make a diary every day”
and she said “just simple tasks like get up, have a shower, got to walk the dog every morning,
have some breakfast then lunch” so just things like that I still found it very hard to eat.
(P1360)
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 7 / 17

Participants also shared their experiences of receiving emotional support from both infor-
mal and community sources. For this participant, knowing that her friends and family were
there to offer her emotional support was comforting, “Oh look,they’re just there if you feel like
talking or you know,they’re just there; they just support you emotionally” (P1089). Another par-
ticipant valued emotional support from the community in the form of a card and phone call:
. . .the doctors and the paediatrician and her neurologist gave me a personal phone call.He
was in so much shock because he was on annual leave.Between all the specialists in the com-
munity,they were great.The local doctor sent a card,so yeah the local community was very
good to me. (P1312)
Informational support provided by informal, community, and professional sources was
perceived as helpful by several participants. Some of the forms of helpful informational support
were: Targeted brochures and details about support groups specific to the participants circum-
stance eg a support group for the sudden death of a young child; pamphlets and websites on
bereavement and grief reactions; written advice on children attending at funerals; information
from schools on managing children’s experience of bereavement; formal information on wills
and estates, executors and banking in relation to the death; updates and reports on the circum-
stances and cause of unexpected deaths and the ongoing legal and/or financial processes.
Some participants found the information provided by funeral providers helpful, “They were
actually the people who had all the pamphlets about the bereavement and who you can contact
and all of that.That was pretty good” (P1127). Others spoke about their community providing
them with information. One participant found it helpful to be able to speak to someone in the
community to get answers without being judged:
The pastoral care people at [hospital].I knew them because of me being involved down there
and they offered great support.I could just go and talk to them and try and get explanations
and what have you which was excellent.It was very helpful to have someone to sit down and
talk to; you didn’t have to worry about what you said; just spurt it all out. (P1291)
Professional sources of support also provided information to the bereaved. However, one
participant reported that she had expected counsellors to provide her with problem solving
information, but she did not receive this support and so found them to be unhelpful:
I think I gave counsellors a crack at me because I thought,I can’t be stoic all the time and
maybe I could see things differently,but to me a counsellor is supposed to give you tools and
ideas on how to deal with things.I never got that in the three people that I saw. (P1212)
Participants also spoke about receiving appraisal support from both community and profes-
sional support sources, often for social comparison purposes. For example, a participant who
had lost her mother explained that receiving support from others who had also lost their moth-
ers allowed her to talk freely about her loss:
Yeah this woman,who I’ve met,a new friend through a friend; she lost her mother this year so
we started talking as you do when you lose your mother and so she said to me “would you like
to join our group of Mothers without Mothers?. . . So we go out for lunch on the day of our
mother’s birthday.Not the day of our mother’s passing . . .then I got to talk all about my
mother and then they told me about their mother.Well this is a fantastic group of friends
because we talk about our mother and it’s ok to sit there for the whole lunch and talk about
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 8 / 17

your dead mum and no one’s going to “oh god can we get off the dead mum subject you
know?”(P1185)
Professional sources also provided some participants with appraisal support. One partici-
pant found it helpful to speak to a professional about what she was experiencing so she could
better understand her grief. However, timing played an important role in determining whether
the participant found this support helpful:
Sometimes it was positive in a sense that it was nice to go somewhere private and talk to some-
one about how I felt.They didn’t judge me,they didn’t know me.That was capable of; or I
could ask a question and I’d say I feel like this and then them sort of explain; this is why
you’re feeling like this and this is going to be this and then other times I didn’t like going
because I didn’t want to talk about it and it upset me and it put me back a step. (P1020)
Structure
The structure of the social support networks of the bereaved was identified as important for
determining whether the social support was helpful. Participants spoke about how close their
friendship networks were. One participant explained how her close-knit group of friends was
able to use their network to offer help. This meant participants did not need to rely only on
their family for support:
I’m just so lucky that I had a really good network of school mums and work that I didn’t really
need a family to—and family were great,but I just think the combination of it all,because
we’ve all got to get on with day to day; I just feel very fortunate because the school mums
cooked for two weeks and did a roster and I didn’t expect that because there’s no way I was
cooking. (P1312)
Another participant reflected how friends were able to use their close network to offer her
effective support:
So,you know,my close-knit group of friends were there and they dropped everything,left
work and rushed to help me and I actually checked myself into the [area name] Mental Health
unit and I got in there and they like,had organised a room and everything for me and I started
to look around. (P1360)
Some participants reported how their informal support networks were also distressed by
the loss, which may have affected their ability to provide helpful support. One participant
spoke about how her former husband was not able to support her because he was also grieving,
“My former husband or [the dead person’s] dad; he was sort of; he wasn’t supportive but he was
going through the same thing . . .”(P1212). Another participant explained that he was able to
turn to most of his family for support, but not his daughter because she was too distressed.
This affected the participant because he felt he had to conceal what he was going through so
that he would not upset his daughter:
If I needed them I could go to them but the real difficult one is my daughter; she was so,so
very close to her mum.They were like sisters rather than mum and daughter and she still gets
very,very upset and whenever I’m with her I try not to show my own sort of loss because it
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 9 / 17

just sends her off completely; she misses her so much,so my relationship with my wife and
daughter was so very close. (P1444)
Discussion
This qualitative study builds on previous work by our research team in exploring the bereave-
ment experience of a community-based sample and the individual factors that are associated
with bereavement [17,24,28,29]. We found that not everyone who receives bereavement sup-
port needs it and not everyone who needs bereavement support receives it. It was important to
know not only who best provides bereavement support, but more so who is perceived by
bereaved people to have offered them the type and amount of support they needed, at the time
they needed it. To our knowledge this is the first study to explore all factors of the goodness of
fit framework in order to address this question.
Several studies have looked at these factors separately and echoed the experience of the
bereaved in this study. Instrumental support such as providing meals and handling funeral
arrangements was considered helpful to bereaved participants [3,12,30]. Participants in these
studies appreciated emotional support which included compassionate gestures such as flowers
and cards, behaviours honouring the deceased, and being listened to without any judgement.
Informational support can be helpful particularly when sought, but also perceived as unhelpful
if insensitive advice is offered [12,31]. Appraisal support in the form of social comparison as
delivered by support groups was considered helpful [8,12,32,33].
The notion that the structure of social support can impact the perceived helpfulness of the
support was demonstrated by Dyregrov [34] who found that supporters, who were members
of the bereaved parents’ social network, were also dealing with their own grief because they
knew the deceased, and that this consequently put strain on the network. Supporters were
aware of the possibility of ‘network burn-out’ and some needed to have time-out from sup-
porting the bereaved for self-care purposes [34]. This was also reported recently in the context
of family bereavement, with the authors recommending that health professionals/therapists
help grievers to focus on creating opportunities to share their grief experiences outside of the
family so as to avoid overloading each other’s grief [35].
In the qualitative accounts of this current study, reports of the helpfulness of funeral provid-
ers and in some instances the unhelpfulness of counsellors echo some the quantitative findings
from the same bereavement survey by Aoun et al [18]. Mental health professionals such as psy-
chiatrists, social workers, case coordinators and school based advisors had the highest propor-
tion of perceived unhelpfulness (33–46%) while about 22% of respondents rated psychologists
and counsellors as unhelpful. By contrast, funeral providers, family and friends had the lowest
ratings for unhelpfulness (8–12%). It appears that informal social support is most valued as
helpful: the emotional bonds (attachment), the practical assistance (tangible alliance) and the
perceived sense of belonging (social integration) provided by the existing networks of family
and friends are of primary importance [18]. The experiences with funeral service providers
reported by the bereaved make it clear that these providers had a vital role to play in bereave-
ment support as one of the community-based assets within the social networks of the bereaved
[29,36]. At a time of major disruption, funeral providers provide a framework for action and
undertake a range of tasks that are crucial both to acknowledging the loss and confirming
bereaved people in their changed social role.
That some mental health professionals, as reported earlier, had the highest proportion of
perceived unhelpfulness deserves further comment. Many of these professionals lack training
in loss, grief, and bereavement issues, and often the little knowledge they have is based around
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 10 / 17

the rudimentary 5-stage Ku¨bler-Ross model of emotional adjustment [37]. It is not surprising
if bereaved people, finding their counsellors lack a nuanced understanding of their situation,
describe some mental health professionals as being unhelpful. This is not to dismiss or dimin-
ish the potential contributions of such professionals. Rather, it points to the need for more
training and skill development appropriate for working with people experiencing high and
chronic distress [38].
In terms of the timing and the amount of social support offered, bereaved people felt some-
times there was too much offering of support which did not meet their needs [39]. Mistimed
offers of support may reflect a mismatch between the supporters’ assumptions and a bereaved per-
son’s needs at that time. Stroebe and Schut remind us that bereavement may be described as a
dual process, alternating between a focus on the loss and a focus on restoration [40]. Supporters
who fail to enquire about or look for indications of where a bereaved person’s attention is focused
may address their offers of support inappropriately. Timing is also important in the sense of dura-
tion of support. Participants expressed the importance of ongoing support after bereavement
because it is common for support to be offered straight after bereavement and then slowly falls
away [39]. Both the need to attend to alternation between loss and restoration in the experience of
bereavement, and the importance of sustaining care beyond the time leading up to a death, are
recognised in a compassionate communities approach to bereavement. Abel and Townsend note
that networks of care often disband after someone has died, and they recommend that support be
maintained until at least the one-year anniversary of the death [41]. This is even more important
given that recent findings from this bereavement survey showed that just half of the bereaved who
used palliative care services had a follow-up contact from the palliative care services at three to six
weeks, only a quarter had a follow-up at 6 months, and that the standardised routine approach to
bereavement support adopted by the services was deemed unhelpful [24]. The need for support
networks to connect bereaved people with their lives before loss and with possibilities following
loss, not just to focus on the loss itself, also underlines the need to involve bereaved people’s
extended networks. Networks formed solely to support the dying process are more likely to focus
on the loss of bereavement and have less to offer about restoration. Compassionate communities
that engage people over their life span will naturally attend to inclusion, maintenance and restora-
tion: life’s problems will be addressed in the context of life’s possibilities.
Aoun et al have advocated that a public health approach, as exemplified by Compassionate
Communities policies and practices [20], should be adopted to support the majority of
bereaved people, as much of this support is already provided in informal and other community
settings by a range of people already involved in the everyday lives of those recently bereaved
[18]. It is important that people need to learn to accept help as refusing it leads to “shutting
down valuable support networks at a time when they need to be nourished and built” in end of
life care and through to bereavement [42]. As important is the need for the support network to
offer help in a more appropriate way, such as being specific with offers of help and making
these repeatedly, as exemplified by the quotes. To improve the goodness of fit between the
bereaved person’s needs and the support offered, identification of existing networks and
enhancement of naturally occurring networks requires training community members in net-
work mapping and development. To this end, citizen volunteering in compassionate commu-
nities has been developed, with volunteers recruited, trained and connected in an integrated
effort to support people, their families and communities [21,43,44].
Implications for social models of bereavement care
The importance of a population level approach is underlined by Holt-Lunstad et al, who dem-
onstrate that social relationships have a larger impact on reducing mortality than any other
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 11 / 17

existing intervention, over and above giving up smoking, alcohol drinking, exercise, diet, etc
[45]. There is a variety of well documented reasons which help explain the impact of compas-
sionate communities. This impact has recently been demonstrated in Frome (UK) where there
has been a 30% reduction in hospital admissions as these concepts of community support have
been combined with clinical practice [46].
Bereavement arises from the death of a family member or friend, and the majority of these
deaths occur in institutional contexts under professional care. The first year of bereavement in
particular is marked by an increased number of encounters with professional care providers
arising from a range of stress-related health issues [47,48]. It is thus unsurprising that in recent
decades professional care providers have developed an interest in, and a range of responses to,
bereavement needs. Nor is it surprising that, lacking effective strategies for referral to informal
care networks, professionals can find themselves offering treatment to people whose primary
need is social inclusion. Herein lies a dilemma. Offering treatment to those who are struggling
with life, whether self-identified or professionally referred, risks obscuring the preventive effect
and healing potential of socially inclusive communities. Professional care thus attempts to
compensate for support that would ideally be provided through everyday social interactions.
However, the lack of socially inclusive communities, and of pathways through which referrals
can be made, perpetuates a situation in which need, first identified in health service contexts,
is then addressed in those contexts rather than linked back to the informal support of the com-
munity. The implication is that care should be shared between professional services and sup-
portive networks according to the expertise of each. Thus, professional services should be
aware of, encourage, facilitate and enrich community networks, collaborating with them in
mutually understood ways. This has two advantages: The first is that supportive networks are
open to everyone while professional bereavement support is available only to a small percent-
age of those bereaved. Secondly, stretched professional services can reserve their care for those
most in need.
It is interesting (although not surprising) that bereaved people often report that they’re not
“allowed” to talk about it anymore [3,49], hence an interview opportunity, like in the current
study, where debriefing extended between 90 and 180 minutes, opens the flood gates in pro-
viding permission or a space to tell their stories. The high percentage of bereaved respondents
to this survey who expressed interest in participating in the interview (almost a half) is likely
an indicator of the current dearth of social support they experienced and that, for those people,
their networks might not have been as supportive as they could be. Therefore, a public health
approach that links personal need with social life and connects formal care with informal sup-
port is foundational to a balanced approach to bereavement care.
Our findings endorse social approaches to bereavement care, and we outline here two mod-
els of grief that fit in with a public health approach. The first is network enhancement which
happens when caring for someone who is dying [50]. Strong, resilient supportive networks can
be formed in caring for someone at the end of life, and the number and depth of relationships
increases. This enhancement continues to be an important part of social support into bereave-
ment. It is a virtuous circle which resonates for years, maybe even generations [50] and ele-
ments of this are indicated in the interview quotes.
The second model is peer support networks into bereavement, such as the Buddy Group in
the UK [51] set up to help bereaved people find meaning and value through their grief. Com-
ments in this study described how good it was to talk about the person who had died with
other people who had been bereaved, highlighting the need for an approach that does not rely
principally on professional care. At the same time, other comments pointed to the problems
experienced by some in continuing to mention the bereaved person with family members.
While the findings of the Australian survey [18] demonstrated that 41% of bereaved
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 12 / 17

respondents reported that bereavement support groups were of little benefit to them, the men-
tion in these interviews of a peer support group that is specifically for mothers who lost their
mothers is an example of how well these groups have to be tailored to specific needs in order
to be a good fit. A peer support model can be valuable for people who do not have extensive
networks beyond their family, or indeed may not have anyone to talk to. Another key point is
that often the people who are most sensitive are the ones who have been through or are going
through bereavement themselves. This is probably why peer support groups can be so helpful
as they intuitively know what goodness of fit is [49]. More work however is clearly needed in
Australia for these support groups to provide a better fit.
Connecting peer support with professional services is a critical factor in improving aware-
ness of and signposting to peer support. The Health Connections Mendip Service Directory
[44], which is part of an overall community development approach and has a range of options
which can be matched to people’s bereavement needs and preferences, is a good example of
how a public health approach can be brought into routine clinical practice [42]. The directory
lists assets, including peer support networks, available in the community, and can be consulted
during the GP, or other primary care, appointment.
Limitations
These qualitative accounts come from interviews with twenty people from one geographical
area in Australia. Participants were selected on the basis of their willingness to supplement
their survey responses, and in order to represent a cross-section of the larger survey popula-
tion. Their responses however echo the quantitative findings obtained from a national survey
of bereaved people [18]. In our discussion we have used the interview data to link with wider
explanatory frameworks in the bereavement care and public health palliative care literature
and suggest ways in which improvements to bereavement care at a population level might be
explored.
The majority of respondents to our survey were people who had experienced an expected
bereavement, usually preceded by a period of caregiving [17,24]. While some respondents
reported their experience of bereavement following an unexpected death, the number of these
was too small to identify a pattern behind the expected individual variations, although it might
be noted that sudden or unexpected deaths were more prevalent in the respondents experienc-
ing prolonged grief (64% of unexpected deaths of a total of 6.4% with prolonged grief) [17]. A
larger general population sample, or more targeted studies, would be required to find out
whether members of bereaved people’s social networks respond differently if bereavement fol-
lows sudden death, particularly through accident, homicide or suicide.
Focusing on the small sample of interviewees in this article, the number of those who
reported not having had enough support is similar for the two groups of expected and unex-
pected deaths, though more of the unexpected death group were in the high-risk grief category.
This at least suggests that, while there may be differences, we cannot assume that there will be
differences in support from social networks just because of the type of death.
Conclusion
The research literature emphasizes the many negative consequences of bereavement, with
increases in physical and psychological morbidity and mortality, and the disruption of social
relationships being a primary determinant of both health and mortality. This puts the impact
of bereavement squarely into a public health perspective that pursues health equity. We argue
here for adopting and strengthening a compassionate communities approach, not only for end
of life care for dying people but also along the continuum of bereavement support. To support
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 13 / 17

this approach, more research is needed into practice models that connect health and social ser-
vices with local neighbourhoods and cultural life. Settings such as workplaces, schools, social
and sporting clubs, and faith communities all have potential in making these connections.
Fundamentally, however, the issue we have identified here in relation to bereavement is one
endemic to contemporary social organisation, a steady increase in social inequality and its neg-
ative consequences for well-being [52]. Inequality contributes to social exclusion, particularly
for those of reduced means. However, social inclusion is needed not only at end of life, but at
all stages of life. Ideally, the networks that support us at end of life will be those that have sup-
ported us through life, and the end of life provides both a further opportunity for existing net-
works to be revived and strengthened, and new networks formed. However, the nature of
contemporary society is that those with economic power may retain their social networks and
be able to purchase professional support, while those without economic power may lack access
to both. As our previous quantitative findings [18] and more recent qualitative findings here
indicate, bereavement support is about the circles of care [53] that are formed during the car-
ing process, combined with peer support perhaps from people who were not part of the caring
circle. It is imperative that these circles transcend social divisions and become available to all
members of the community.
Supporting information
S1 File. Bereavement interview protocol.
(DOCX)
Acknowledgments
The authors acknowledge the cooperation of funeral providers who assisted with the recruit-
ment of participants, and the bereaved families who agreed to complete the survey and inter-
views and contributed to our understanding in this field. Special thanks to Prof Bev
McNamara for advice on the overall project and to Denise Howting for assistance in the tech-
nical aspects of the manuscript.
Author Contributions
Conceptualization: Samar M. Aoun, Lauren J. Breen, Bruce Rumbold.
Data curation: Samar M. Aoun, Kim M. Christian, Anne Same.
Formal analysis: Samar M. Aoun, Lauren J. Breen, Bruce Rumbold, Kim M. Christian.
Funding acquisition: Samar M. Aoun.
Investigation: Samar M. Aoun, Lauren J. Breen, Bruce Rumbold, Julian Abel.
Methodology: Samar M. Aoun, Lauren J. Breen, Bruce Rumbold, Kim M. Christian, Anne
Same.
Project administration: Samar M. Aoun.
Resources: Samar M. Aoun.
Supervision: Samar M. Aoun.
Validation: Samar M. Aoun, Lauren J. Breen, Bruce Rumbold, Julian Abel.
Visualization: Samar M. Aoun.
Writing – original draft: Samar M. Aoun, Kim M. Christian, Julian Abel.
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 14 / 17

Writing – review & editing: Samar M. Aoun, Lauren J. Breen, Bruce Rumbold, Kim M. Chris-
tian, Anne Same, Julian Abel.
References
1. Bottomley JS, Burke LA, Neimeyer RA. Domains of Social Support That Predict Bereavement Distress
Following Homicide Loss. Omega (Westport). 2017; 75(1):3–25. https://doi.org/10.1177/
0030222815612282 PMID: 28395645
2. Holmes TH, Rahe RH. The Social Readjustment Rating Scale. J Psychosom Res. 1967; 11(2):213–8.
https://doi.org/10.1016/0022-3999(67)90010-4 PMID: 6059863
3. Breen LJ, O’Connor M. Family and social networks after bereavement: experiences of support, change
and isolation. Journal of Family Therapy. 2011; 33(1):98–120. https://doi.org/10.1111/j.1467-6427.
2010.00495.x
4. Turvey C, Stromquist A, Kelly K, Zwerling C, Merchant J. Financial loss and suicidal ideation in a rural
community sample. Acta Psychiatr Scand. 2002; 106(5):373–80. https://doi.org/10.1034/j.1600-0447.
2002.02340.x PMID: 12366472
5. Kissane DW, Bloch S. Family grief. Br J Psychiatry. 1994; 164(6):728–40. https://doi.org/10.1192/bjp.
164.6.728 PMID: 7952979
6. Christakis NA, Iwashyna TJ. The health impact of health care on families: a matched cohort study of
hospice use by decedents and mortality outcomes in surviving, widowed spouses. Soc Sci Med. 2003;
57(3):465–75. https://doi.org/10.1016/S0277-9536(02)00370-2 PMID: 12791489
7. Prigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, Goodkin K, et al. Prolonged grief disor-
der: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med. 2009; 6(8):
e1000121. https://doi.org/10.1371/journal.pmed.1000121 PMID: 19652695
8. Benkel I, Wijk H, Molander U. Family and friends provide most social support for the bereaved. Palliat
Med. 2009; 23(2):141–9. https://doi.org/10.1177/0269216308098798 PMID: 18952747
9. Shumaker SA, Brownell A. Toward a Theory of Social Support: Closing Conceptual Gaps. Journal of
Social Issues. 1984; 40(4):11–36. https://doi.org/10.1111/j.1540-4560.1984.tb01105.x
10. Burke LA, Neimeyer RA. Prospective risk factors for complicated grief: A review of the empirical litera-
ture. In: Stroebe MS, Schut H, van den Bout J, editors. Complicated grief: Scientific foundations for
healthcare professionals. London: Routledge; 2013. p. pp. 145–61.
11. Stroebe W, Zech E, Stroebe MS, Abakoumkin G. Does social support help in bereavement? Journal of
Social and Clinical Psychology. 2005; 24(7):1030–50. https://doi.org/10.1521/jscp.2005.24.7.1030
12. Toller P. Bereaved Parents’ Experiences of Supportive and Unsupportive Communication. Southern
Communication Journal. 2011; 76(1):17–34. https://doi.org/10.1080/10417940903159393
13. Logan EL, Thornton JA, Breen LJ. What determines supportive behaviors following bereavement? A
systematic review and call to action. Death Stud. 2018; 42(2):104–14. https://doi.org/10.1080/
07481187.2017.1329760 PMID: 28494205
14. Nam IS. Effects of psychoeducation on helpful support for complicated grief: a preliminary randomized
controlled single-blind study. Psychol Med. 2016; 46(1):189–95. https://doi.org/10.1017/
S0033291715001658 PMID: 26490710
15. Ingram KM, Jones DA, Smith NG. Adjustment among People who have Experienced Aids-Related Mul-
tiple Loss: The Role of Unsupportive Social Interactions, Social Support, and Coping. OMEGA—Jour-
nal of Death and Dying. 2016; 43(4):287–309. https://doi.org/10.2190/tv1j-543l-m020-b93v
16. Weenolsen P. Transcendence of loss over the life span. New York: Hemisphere Publishing Corpora-
tion; 1988.
17. Aoun SM, Breen LJ, Howting DA, Rumbold B, McNamara B, Hegney D. Who needs bereavement sup-
port? A population based survey of bereavement risk and support need. PLoS One. 2015; 10(3):
e0121101. https://doi.org/10.1371/journal.pone.0121101 PMID: 25811912
18. Aoun SM, Breen LJ, White I, Rumbold B, Kellehear A. What sources of bereavement support are per-
ceived helpful by bereaved people and why? Empirical evidence for the compassionate communities
approach. Palliat Med. 2018; 32(8):1378–88. https://doi.org/10.1177/0269216318774995 PMID:
29754514
19. Grindrod A, Rumbold B. Healthy End of Life Project (HELP): a progress report on implementing commu-
nity guidance on public health palliative care initiatives in Australia. Ann Palliat Med. 2018; 7(Suppl 2):
S73–S83. https://doi.org/10.21037/apm.2018.04.01 PMID: 29764174
20. Kellehear A. Compassionate communities: end-of-life care as everyone’s responsibility. QJM. 2013;
106(12):1071–5. https://doi.org/10.1093/qjmed/hct200 PMID: 24082152
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 15 / 17

21. National Palliative and End of Life Care Partnership. Ambitions for Palliative and End of Life Care: A
National Framework for Local Action 2015–2020. London: NHS England; 2015.
22. Lehman DR, Ellard JH, Wortman CB. Social support for the bereaved: Recipients’ and providers’ per-
spectives on what is helpful. Journal of Consulting and Clinical Psychology. 1986; 54(4):438–46. https://
doi.org/10.1037/0022-006x.54.4.438
23. Vachon MLS, Stylianos SK. The Role of Social Support in Bereavement. Journal of Social Issues.
1988; 44(3):175–90. https://doi.org/10.1111/j.1540-4560.1988.tb02084.x
24. Aoun SM, Rumbold B, Howting D, Bolleter A, Breen LJ. Bereavement support for family caregivers: The
gap between guidelines and practice in palliative care. PLoS One. 2017; 12(10):e0184750. https://doi.
org/10.1371/journal.pone.0184750 PMID: 28977013
25. Logan EL, Thornton JA, Kane RT, Breen LJ. Social support following bereavement: The role of beliefs,
expectations, and support intentions. Death Stud. 2018; 42(8):471–82. https://doi.org/10.1080/
07481187.2017.1382610 PMID: 28985147
26. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of
qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013; 13:117.https://doi.
org/10.1186/1471-2288-13-117 PMID: 24047204
27. Gilgun J. Chicago School Traditions: Deductive qualitative analysis and grounded theory: CreateSpace
Independent Publishing Platform; 2014.
28. Breen LJ, Aoun SM, Rumbold B, McNamara B, Howting DA, Mancini V. Building Community Capacity
in Bereavement Support. Am J Hosp Palliat Care. 2017; 34(3):275–81. https://doi.org/10.1177/
1049909115615568 PMID: 26566928
29. Rumbold B, Aoun S. An assets-based approach to bereavement care. Bereavement Care. 2016; 34
(3):99–102. https://doi.org/10.1080/02682621.2015.1115185
30. Wilsey SA, Shear MK. Descriptions of social support in treatment narratives of complicated grievers.
Death Stud. 2007; 31(9):801–19. https://doi.org/10.1080/07481180701537261 PMID: 17886412
31. Almberg BE, Grafstrom M, Winblad B. Caregivers of relatives with dementia: Experiences encompass-
ing social support and bereavement. Aging & Mental Health. 2010; 4(1):82–9. https://doi.org/10.1080/
13607860056026
32. Peters K, Cunningham C, Murphy G, Jackson D. Helpful and unhelpful responses after suicide: Experi-
ences of bereaved family members. Int J Ment Health Nurs. 2016; 25(5):418–25. https://doi.org/10.
1111/inm.12224 PMID: 27037948
33. Possick C, Shamai M, Sadeh RA. Healing the social self: how parents whose children were killed in ter-
ror attacks construct the experience of help. Community Ment Health J. 2014; 50(4):487–96. https://doi.
org/10.1007/s10597-013-9631-5 PMID: 23765183
34. Dyregrov K. Experiences of Social Networks Supporting Traumatically Bereaved. OMEGA—Journal of
Death and Dying. 2016; 52(4):339–58. https://doi.org/10.2190/claa-x2lw-jhqj-t2dm
35. Hooghe A, Neimeyer RA, Rober P. The complexity of couple communication in bereavement: an illus-
trative case study. Death Stud. 2011; 35(10):905–24. https://doi.org/10.1080/07481187.2011.553335
PMID: 24501858
36. Aoun S, Lowe J, Christian K, Rumbold B. Is there a role for the funeral service provider in bereavement
support within the context of Compassionate Communities? Death Stud. 2018:1–10. https://doi.org/10.
1080/07481187.2018.1506835 PMID: 30265833
37. Breen LJ, Fernandez M, O’Connor M, Pember AJ. The preparation of graduate health professionals for
working with bereaved clients: an Australian perspective. Omega (Westport). 2012; 66(4):313–32.
https://doi.org/10.2190/OM.66.4.c
38. Dickinson GE. Twenty-First Century End-of-Life Issues in Selected U.S. Professional Schools. Illness,
Crisis & Loss. 2012; 20(1):19–32. https://doi.org/10.2190/IL.20.1.c
39. Scott SB, Bergeman CS, Verney A, Longenbaker S Markey MA, Bisconti TL. Social Support in Widow-
hood: A Mixed Methods Study. J Mix Methods Res. 2007; 1(3):242–66. https://doi.org/10.1177/
1558689807302453 PMID: 23785307
40. Stroebe M, Schut H. The dual process model of coping with bereavement: rationale and description.
Death Stud. 1999; 23(3):197–224. https://doi.org/10.1080/074811899201046 PMID: 10848151
41. Abel J, Townsend D. Developing community support networks at the end of life in Weston-super-mare,
UK. In: Wegleitner KH K., & Kellehear A. editor. Compassionate Communities: Case studies from Brit-
ain and Europe. London: Routledge; 2016.
42. Abel J. Compassionate communities and end-of-life care. Clin Med (Lond). 2018; 18(1):6–8. https://doi.
org/10.7861/clinmedicine.18-1-6 PMID: 29436431
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 16 / 17

43. McLoughlin K, Rhatigan J, McGilloway S, Kellehear A, Lucey M, Twomey F, et al. INSPIRE (INvestigat-
ing Social and PractIcal suppoRts at the End of life): Pilot randomised trial of a community social and
practical support intervention for adults with life-limiting illness. BMC Palliat Care. 2015; 14:65. https://
doi.org/10.1186/s12904-015-0060-9 PMID: 26603516
44. Health Connections Mendip. Bereavement. 2018. Available from: https://healthconnectionsmendip.org/
category/bereavement/. Accessed July 3, 2018.
45. Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review.
PLoS Med. 2010; 7(7):e1000316. https://doi.org/10.1371/journal.pmed.1000316 PMID: 20668659
46. Abel J, Kingston H, Scally A, Hartnoll J, Hannam G, Thomson-Moore A, et al. Reducing emergency hos-
pital admissions: a population health complex intervention of care co-ordination and compassionate
communities. Br J Gen Pract. 2018; 68(676):e803–e10. https://doi.org/10.3399/bjgp18X699437 PMID:
30297434
47. Stroebe M, Schut H, Stroebe W. Health outcomes of bereavement. Lancet. 2007; 370(9603):1960–73.
https://doi.org/10.1016/S0140-6736(07)61816-9 PMID: 18068517
48. Guldin MB, Jensen AB, Zachariae R, Vedsted P. Healthcare utilization of bereaved relatives of patients
who died from cancer. A national population-based study. Psychooncology. 2013; 22(5):1152–8.
https://doi.org/10.1002/pon.3120 PMID: 22745052
49. Breen LJ, O’Connor M. Acts of resistance: breaking the silence of grief following traffic crash fatalities.
Death Stud. 2010; 34(1):30–53. https://doi.org/10.1080/07481180903372384 PMID: 24479174
50. Horsfall D, Yardley A, Leonard R, Noonan K, Rosenberg JP. End of life at home: Cocreating an ecology
of care. Penrith, NSW: Western Sydney University; 2015.
51. Riley SG, Pettus KI, Abel J. The buddy group—peer support for the bereaved. London J Prim Care
(Abingdon). 2018; 10(3):68–70. https://doi.org/10.1080/17571472.2018.1455021 PMID: 30042806
52. Wilkinson R, Pickett K. The Inner Level: How More Equal Societies Reduce Stress, Restore Sanity and
Improve Everyone’s Wellbeing: Allen Lane; 2018.
53. Abel J, Walter T, Carey LB, Rosenberg J, Noonan K, Horsfall D, et al. Circles of care: should community
development redefine the practice of palliative care? BMJ Support Palliat Care. 2013; 3(4):383–8.
https://doi.org/10.1136/bmjspcare-2012-000359 PMID: 24950517
Matching response to need in bereavement support
PLOS ONE | https://doi.org/10.1371/journal.pone.0213367 March 7, 2019 17 / 17