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Improving quality of life using compound mind-body therapies: Evaluation of a course intervention with body movement and breath therapy, guided imagery, chakra experiencing and mindfulness meditation

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Assess changes in quality of life and in sense of coherence (SOC), after an intervention involving a self-development course using mind-body medicine (MBM) activities. A questionnaire study using a health-related quality of life (HRQOL) instrument, the SWEDQUAL, with 13 subscales and scores ranging from 0 to 100, combined with the SOC-13 scale, healthcare utilisation, medication and sick listing data. A training centre for MBM. Eligible course attendants (study group, SG, n = 83) assessed their HRQOL before and 6 months after a 1-week course. A control group (CG) of individuals who had previously attended the course (n = 69), matched for age, sex and length of course time to the SG, also made assessments. Changes in HRQOL and SOC in SG and CG. Of the 13 HRQOL subscales, eight showed clinically significant improvement in the SG (>9%, p < 0.01), namely, General health perceptions (9%), Emotional well-being [negative (45%) and positive (26%)], Cognitive functioning (24%), Sleep (15%), Pain (10%), Role limitation due to emotional health (22%) and Family functioning (16%). Sexual, marital and physical function and role in the SG as well as all CG scores were similar to average population values. The assessed SOC also improved in the SG after intervention (p < 0.01), challenging previous statements of 'the stableness of SOC'. Use of psychotropic medication was slightly reduced in the younger aged SG participants after intervention. This group of men and women (SG), starting from a clinically significant low health assessment, had improved their HRQOL and SOC after the course intervention.
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Improving quality of life using compound mind-body therapies:
evaluation of a course intervention with body movement
and breath therapy, guided imagery, chakra experiencing
and mindfulness meditation
Lotta Fernros ÆAnna-Karin Furhoff Æ
Per E. Wa
¨ndell
Accepted: 10 February 2008 / Published online: 7 March 2008
ÓSpringer Science+Business Media B.V. 2008
Abstract Objective Assess changes in quality of life and
in sense of coherence (SOC), after an intervention
involving a self-development course using mind–body
medicine (MBM) activities.
Design A questionnaire study using a health-related
quality of life (HRQOL) instrument, the SWEDQUAL,
with 13 subscales and scores ranging from 0 to 100,
combined with the SOC-13 scale, healthcare utilisation,
medication and sick listing data.
Setting A training centre for MBM. Eligible course
attendants (study group, SG, n=83) assessed their
HRQOL before and 6 months after a 1-week course. A
control group (CG) of individuals who had previously
attended the course (n=69), matched for age, sex and
length of course time to the SG, also made assessments.
Main outcome Changes in HRQOL and SOC in SG and
CG.
Results Of the 13 HRQOL subscales, eight showed
clinically significant improvement in the SG ([9%,
p\0.01), namely, General health perceptions (9%),
Emotional well-being [negative (45%) and positive (26%)],
Cognitive functioning (24%), Sleep (15%), Pain (10%),
Role limitation due to emotional health (22%) and Family
functioning (16%). Sexual, marital and physical function
and role in the SG as well as all CG scores were similar to
average population values. The assessed SOC also
improved in the SG after intervention (p\0.01), chal-
lenging previous statements of ‘the stableness of SOC’.
Use of psychotropic medication was slightly reduced in the
younger aged SG participants after intervention.
Conclusions This group of men and women (SG),
starting from a clinically significant low health assessment,
had improved their HRQOL and SOC after the course
intervention.
Keywords Breath therapy CAM classification
Guided imagery Health-related quality of life
Holistic health Intervention study
Mindfulness meditation Mind-body medicine
Sense of coherence
Abbreviations
CAM Complementary and alternative medicine
CG Control group
HRQOL Health-related quality of life
MBM Mind–body medicine, subgroup of CAM
(including relaxation techniques)
MBR Mind-body relations (MESH term definition:
the relation between the mind and the body in a
religious, social, spiritual, behavioural, and
metaphysical context. This concept is signifi-
cant in the field of alternative medicine)
PD Psychoactive drugs: (in this study) SSRI
depression medication, tranquillisers and/or
sleeping pills
PMTA Primary modes of therapeutic action
QOL Quality of life (in general)
SG Study group
SOC Sense of coherence
L. Fernros A.-K. Furhoff P. E. Wa
¨ndell
Karolinska Institutet/Stockholm County Council’s
Center for Family and Community Medicine, Huddinge, Sweden
L. Fernros (&)
Center for Family and Community Medicine, Karolinska
Insitutet, Alfred Nobel’s alle
´12, 14183 Huddinge, Sweden
e-mail: lotta.fernros@sll.se
URL: www.cefam.se
123
Qual Life Res (2008) 17:367–376
DOI 10.1007/s11136-008-9321-x
Introduction
A wide range of complementary and alternative medicine
(CAM) methods, all with a traditional, empirical back-
ground, are currently in use many of the world’s societies
[1,2]. Such methods are used for coping with life events or
simply for a conscious optimisation of personal health [2,
3]. As these methods become better researched, some
(acupuncture, diets) are being widely accepted in health-
care systems [4]. The characteristics of CAM users as well
as their attitudes towards CAM have been published [58].
In addition, some CAM methods have subjected to cost–
benefit analyses or reviewed for the strength of their
methodology [911].
To date, there have been few intervention studies carried
out on the CAM methods themselves. During the last years,
many methods, such as mindfulness-based stress reduction,
Qigong, yoga, breath and dance therapy, mental imagery,
massage and hypnosis, have been studied in the context of
diagnoses and age groups; these include breast and prostate
cancer, cardiac patients, ulcerative colitis, inner-city pop-
ulation, chronic low-back pain, asthma and end-of-life,
cystic fibrosis [1230].
A new classification that would enhance the (potential)
user’s overview of all possibilities is now needed in CAM.
Medline uses a few dozen MESH subdefinitions to, rather
randomly, classify diverse CAM therapies. With the aim of
classifying CAM into a few, more easily understood cate-
gories, Astin suggests the use of philosopher Ken Wilber’s
four-quadrant model, which interfaces the human dimen-
sions of ‘interior’ and ‘exterior’ with those of the
‘individual’ and ‘collective’ [31]. In addition, Tataryn
proposes a framework of four basic paradigms—body (BY)
(diets/substances, physical manipulation), body–mind
(=MBM) (meditation, psychotherapy), body-energy (BE)
(energy flows, meridians, chakra system) and body–spirit
(BS) (healing, shamanism) [32]. Jones suggests further
subdivision into six ‘primary modes of therapeutic action/
influence’ (PMTA), separating BY into chemical and
biomechanical modes, and BS into psychological and ‘non-
local’ (=spiritual) (see Table 1)[2]. Most CAM (and
allopathic!) therapies can be sorted into these PMTA
frames, which serve to clarify the basic theories underlying
the therapy, both for practitioners and patients.
All three classifications/models embrace a holistic
health perspective—i.e. that humans function as integrated
units and, consequently, changes at one point may have
synergistic effects at another point, another level or even
on the whole person. To detect holistic changes, it seems
appropriate to use well-known health-related quality of life
(HRQOL) and sense of coherence (SOC) measures in
CAM research.
During the last decades, new training centres have been
established where courses are held that are directed
towards a holistic health approach to life. A recent study of
a group of people just starting on a course at one centre in
Sweden showed that these individuals scored significantly
lower on the emotional health scale within the HRQOL and
had more long-term sick leave than the general population,
despite normal physical health and advanced education [5].
These findings raise the question of whether MBM/BE
training can change the HRQOL, healthcare utilisation or
even sick leave patterns, and if so, whether there any
variables predictive for outcome?
The aim of this study was to follow changes in HRQOL
and SOC [33], medication, sick leave and utilisation of
alternative and allopathic health care in a group of partic-
ipants at a MBM training center over a period of 6 months.
At the start of this study, we had two hypotheses: (1) that
the individuals of the control group (CG) would maintain
stable scores at a normal, high level; (2) that the individuals
of the study group (SG) would show improved scores after
the course intervention.
Methods
Setting
The setting, the participants and the Swedish population
samples have been defined by Fernros et al. [5], but are
summarised here. This study was carried out at one specific
training centre in Sweden which holds courses teaching
health self-management. The principal course includes
MBM and BE techniques, if categorised according to Jones
PMTA or Tataryn [2,32], and the process is, according to
Wilber, ‘individual’ and ‘interior’ [31].
The centre has been holding the same MBM/BE courses
since 1985; each course is 7 days long, lasts 14 hours a day
and has room for 24 people. The price is euro 3055 per
person, which includes the costs of the 7-day course, lod-
ging, food and phone contacts (preparations and follow-
up). The participants join the courses mainly on their own
initiative or on a friend’s recommendation, but only rarely
by medical referral. About 5000 people have attended the
courses to date.
The therapists have attended various educational courses
on a holistic health management that is equivalent to 2–3
full-time years in counselling and MBM/BE techniques,
including guided and active meditation approaches, non-
judgemental mindfulness, body awareness, liberating dance,
breathing therapy and facilitating honest emotional expres-
sions. The staff includes one doctor, a course leader, a doctor
(one therapist and one assistant per four participants).
368 Qual Life Res (2008) 17:367–376
123
Table 1 Periodic table of healthcare systems and practices: based on the ‘‘primary modes of therapeutic action’ (PMTA) by Jones [2]
(published with permission from Curtis H. Jones). The publisher for this copyrighted material is Mary Ann Liebert, Inc Publishers
1) Bio-chemical 2) Bio-mechanical 3) Mind–body 4) Energy flow 5) Psychological 6) Non-local
Synthetic products
a
Personal activity
a
Mind-body
a
Bio-energy
a
Individual
a
Religious
a
Pharmaceuticals Exercise Bio-feedback
training
Acupuncture
CTM
Counseling Distance healing
Some vitamins Hatha yoga Behavioral
medicine
Acupressure
CTM
Hypnotherapy Faith practices
Guided imagery Healing touch Neurolingustic
programming
Prayer
Natural products
a
Physical/psychological
a
Mindfulness
meditation
Qi Gong, Tai
Chi
Art therapies (drama,
painting, music)
Some dietary
supplements
Pancha karma (Ayur.) Psychoneuro-
immunology
Ayurvedic
medicine,
Psychotherapy Extra- religious
a
/
spiritual
b
Nutrition Pilates Placebo Reiki, Shiatsu, Psychosynthesis
b
Distance healing
Western herbal
medicine
Alexander technique Rebirthing Jin shin jyutsu
b
Positive intention
practices
Colonics Hellerwork Visualisation Prayer
Death exercise
b
Non-human
field
a
Animistic practices.
e.g. shamanism
Injection
a
Non-invasive/
manipulation
a
Chinese herbs Group
a
Fire walking
b
Cell therapy Chiropractic medicine Body-mind
a
Homeopathy Family therapy
Chelation therapy Kinesiology (applied) Art therapies
(dance, pottery)
Support groups
(e.g. AA, NA)
Feldenkrais Body posture/
straining therapy
b
Emitted energy
a
Rituals
Ingestion
a
Massage Aromatherapy Colour & light
therapy
Internal (incl. gut
b
)
cleansing products
Birth exercise
b
Diathermy
Invasive methods
a
Liberating dance
b
Magnets,
Radiation
Surgery Chakra
experiencing
b
(Ultra) Sound
therapy
Dentistry Conduction/
convection
a
Hydrotherapy,
sauna
Warm/ cold
objects
Laser
Systems
a
Systems
a
Systems
a
Systems
a
Systems
a
Systems
a
Allopathic medicine Allopathic medicine Mind–body
medicine
Ayurvedic
medicine
Psychotherapy
systems (Freudian,
Jungian, humanistic)
Religious healing
Herbal medicine
(and others)
Naprapathic medicine Chakra body
energy centres
b
Chinese Trad.
Medicine
Traditions
Osteopathy Energy flow
medicine
Ayur, Ayurvedic medicine.
a
Each subheading has many more methods than given here; the few methods presented in this table are only a few examples
b
Practices/ therapies added as interpreted by author
Qual Life Res (2008) 17:367–376 369
123
The focus of the course is on personal development
through self-knowledge, using all of the techniques
described in the previous paragraph, supplemented with
information to help the participants understand the BE
centres in the body, namely the seven Chakras: 1, ‘sur-
vival/breeding/sexuality’ in the pelvis; 2, ‘relating’ in the
belly; 3, ‘power’ in the solar plexus; 4, ‘heart’ in the
chest; 5, ‘creativity’ in the throat; 6, ‘intuition’ in the
forehead; 7, ‘spirituality’ at the top of the head. A dif-
ferent teaching method has been established, that relies
more on experiencing, feeling and expression, and less on
verbal learning.
The course contains many different and exclusive body
exercises, meditations, reflections and relating practices on
themes such as birth, death, freedom and bully–victim
roles. The founder of the training centre describes these in
his book [34]. The aims of this intense 1-week course is to
provide repeated opportunities to join in with engaged
curiosity about one’s self. In this well-staffed milieu, 7
days and nights in a row, participants are invited to explore
themselves outside of their normal emotional comfort zone,
reaching new experiences and feelings of suppressed fear,
sadness, anger, joy and love, enhancing integrity and
insights. Some previous participants have commenced on
the course with serious personal problems, such as
depression with suicide thoughts, sexual abuse, cancer
disease, family relation difficulties, as well as less serious
ones. Many of them are asked to bring a husband/ family
member into the course for mutual support. The course
curriculum is not suitable for schizophrenic patients, but
the centre has had experience dealing with people with
brief reactive psychosis symptoms in the course (outside of
this study).
The study reported here is an experimental, prospective,
case–control study of a compound intervention (the
course). The study group (SG) was recruited through an
invitation during a personal visit to the training centre at
the very start of all seven courses over a 1-year period
(Fig. 1). In all, 50 men and 57 women agreed to participate.
The mean age of participants of the SG was 42.1 years,
with no gender difference.
The control group (CG) represented people who had
attended the same course 1–3 years previously (Fig. 1).
The main reason for including CG in this study was to
avoid the bias of the course attendant subpopulation, which
has been clearly shown in a comparison of entry data and
data on the general Swedish population [5]. Among those
individuals who had previously taken the course and eli-
gible to participate in this study, we chose 126 people from
previous enrollment lists; these individuals were informed
of the study and invited by mail to participate. Of these, 39
men and 47 women agreed to participate in the study. The
mean age of the CG was 44.1 years (2 years old than that of
the SG), which assures that they had their course experi-
ences at about the same ages as the SG.
The study started in January 2000, and all follow-up
questionnaires were collected no later than August 2001.
Assessments
Three questionnaires were used to assess HRQOL, SOC
and socio-demographic background.
The HRQOL questionnaire SWEDQUAL 1.0 was cho-
sen; this a nationally well-known, validated and reliable
instrument with a Cronbach’s alpha reliability coefficient
of B78% [35]. SWEDQUAL 1.0 was developed from the
Medical Outcomes Study, as was the Short-Form (SF-36),
and is similar the SF-36 although it contains more items on
sleep, cognitions, personal relations and sexual function-
ing. SWEDQUAL consists of 61 items of self-assessment
distributed into 13 scales (Table 2). Two random samples
(n=2366) of the Swedish population were tested with
SWEDQUAL. These samples have been used in studies on
conditions as disparate as diabetes, glaucoma, angina
pectoris and, here, MBM-users [5,3638].
In addition, the participants completed a socio-demo-
graphic questionnaire on level of education, marital status,
medication as well as the number of visits to doctors, CAM
providers and sick leave during the preceding 6 months.
The socio-demographic and SWEDQUAL data from the
subpopulation attending this MBM course have been
compared in an earlier study to population data collected
from several national authorities [5].
Training centre
MBM/BE
Attendants previous
three years (n=273).
Invited by mail
n=126
Attendants
present year
n=122
Excluded: Declined
participation n=4
repeated attendance
n=4, language=7
Address unknown
n=15, declined
participation n=6,
no reply n=19.
CG Entry n=86
Non-responding
at six months n=16,
death n=1
SG Entry n=107
Non-responding at
six months n=23,
death n=1
Control group
n=69
Study group
n=83
Fig. 1 Flow chart of recruitment of individuals from the training
centre MBM/BE. SG Study group, CG control group
370 Qual Life Res (2008) 17:367–376
123
The SOC scale short form was also used (13 items, with
a Cronbach’s alpha of 0.74–0.91). This scale measures
comprehensiveness, meaningfulness and manageability in
life [33]. Swedish national medians have been presented in
studies by Langius’ group and Nilsson [3941].
The three entry questionnaires were completed by the
members of the SG on arrival at the centre, before the start
of the course. The members of the CG were sent the same
questionnaires by mail at the same time. Both the SG and
CG were sent the follow-up questionnaire by mail 6
months later. A response time within 8.5 months was
achieved by 94% of SG and 82% of the CG. For logistic
and dropout data, see Fig. 1.
The CG subjects were matched to the study group
subjects by sex and age ±4 years (intention was 2 years).
A 5- to 9-year difference was accepted in a few (six) people
aged over 50 years in order to maximise data utilisation.
Statistical methods
We have used the paired ttest and v
2
test. No difference
was found between Pearson and Spearman correlations, or
between the ttest and Wilcoxon sign rank test. The sample
size of the SG was assessed to 88 subjects. This assessment
was based on an expected intervention difference with 80
and 72.5 points, respectively, on the scale ’General Health
Perceptions’ (SD 25) by the paired ttest, with an
alpha =0.05 and power =0.8. A SWEDQUAL difference
of 7.5 points =9% correlates to an Effect size [0.3 and
was judged to be the clinically significant level [5]. Sta-
tistical significance is accordingly chosen to p\0.01,
owing to multiple comparisons. This is valid also for SOC,
who was shown to have significantly adjusted changes of
2.4–4.9 in 6 months [42]. The analyses were carried out on
STATA ver. 8 software (Stata Corp, College Station, TX),
updated January 2005.
The study was approved by the local Ethics Committee
of Karolinska Institutet at Karolinska University Hospital
in Huddinge.
Main outcome measures
1. Changes in HRQOL measured by SWEDQUAL 1.0 at
6 months after intervention, especially ‘general health
perceptions’, ‘sleep’, ‘pain’, ‘negative affectivity’,
‘positive affectivity’, ‘role limitation due to emotional
health’ and ‘cognitive functioning’.
2. Changes in SOC 6 months after intervention.
Results
The SWEDQUAL results on HRQOL in SG and CG are
shown in Table 3. The SG had overall HRQOL improve-
ment, especially on the six co-correlated scales: ‘Role
Table 2 Quality of life items in SWED-QUAL 1.0
Scale Description
Psychological
Emotional well-being Negative and positive affectivity altogether
Negative affectivity (6) Felt nervous, tense, down, sad, impatient, annoyed
Positive affectivity (6) A happy person, harmonic, feel liked, optimistic
Role limitation due to emotional health (3) Extent to which emotional problems interfere with activities of daily living (ADL)
Cognitive functioning (6) Concentration, memory, decisions, confusion
Physical
General health perceptions (8) Prior and current health, resistance to illness, health concern
Sleep quality (7) Sleep initiation, maintenance, somnolence
Pain frequency, intensity (6) Pain interference with ADL, sleep and mood
Physical functioning (7) Perform activities (work, sports, stairs, dressing)
Satisfaction with physical ability (1) Satisfaction with ability to do what wanted
Role limitation due to physical health (3) Extent to which physical problems interfere with ADL
Social/relationships
Family functioning (4) Satisfaction with cohesiveness, talking things over, understanding
Marital functioning (6) Express wishes, sharing feelings, being supportive
Sexual functioning (5) Lack of interest, inability to enjoy sex, having orgasm (women), getting/maintaining erection
(men)
Number in parenthesis indicates the number of items of self-assessment for that scale
Qual Life Res (2008) 17:367–376 371
123
limitation due to emotional health’, ‘Positive’ and ‘Nega-
tive affectivity’, together with ‘Cognitive functioning’,
‘Sleep quality’ and ‘General health’, Table 2. Starting from
statistically significant low HRQOL assessments before the
course (all p\0.01), the SG reached average population
mean values after the course intervention, only differences
are shown; for population values, see [5].
The CG maintained normal HRQOL levels on all 13
scales and did not differ from the Swedish population in
general. Those members of the CG who did not return
questionnaires (dropouts) had a pattern of entry assessment
levels between those of the SG and CG, but all SWED-
QUAL results showed only small differences in terms of
dropouts, age or gender among all data in both groups.
The SOC levels, changes and reference data are pre-
sented in Table 4. The mean SOC scores of the SG
increased significantly by about 10% after the course
intervention (p\0.01), thus reaching the mean SOC levels
of the average population. The lowest initial assessments in
the SG were seen among individuals aged up to 35 years
(data not shown), and there were large individual variations
in how much the score changed (-20 to +41, SD =13.0).
The CG maintained SOC means at about the levels of the
average population, but here also, there was individual
variation (-22 to +34, SD =12.1). Dropouts from the CG
had SOC assessments similar to the entry values of the SG.
The SOC scores also co-correlated with the eight increased
SWEDQUAL scores mentioned above (Pearson corr [0.4).
Socio-demographic data are shown in Table 5. Self-
assessed number of sick leave days showed an irregular
pattern. The women in the SG had more sick leave at both
entry and follow-up than the general Swedish population,
both in percentage of individuals and in number of days.
The men in the SG and all individuals of the CG had a sick
leave similar to that of the average population, again both
in percentage of individuals and in number of days [5]. The
sick leave was inversely and significantly correlated to the
General Health (p\0.01) scale, but not to the other scales.
Two of three subjects were very healthy.
‘Psychoactive drugs’ (PD) stands for selective seroto-
nin reuptake inhibitors (SSRI), depression medication,
tranquillisers and/or sleeping pills, and antipsychotics were
not used in our SG and CG. Both the SG and CG groups
together, including dropouts, had a medication usage rate
Table 3 SWED-QUAL health-related quality of life (HRQOL) results in the study group before the course intervention, the control group at the
same time and in both groups and 6 months later
HRQOL scales SWEDQUAL:
0 (worst)–100 (best)
Study group (n=83) pvalue for
HRQOL
Difference
Control group (n=69) pvalue
forHRQOL
difference
Baseline Six months Baseline Six months
HRQOL
(SD)
Difference HRQOL
(95% CI)
HRQOL
(SD)
Difference
HRQOL(95% CI)
Psychological
Emotional well-being
(neg +pos):
50.5 (20.7) 17.6 (12.3; 22.8) \0.001 70.6 (22.0) 0.9 (-3.7; 5.6) ns
Negative affectivity 45.0 (24.6) 20.4 (14.0; 26.8) \0.001 69.9 (25.2) -0.9 (-6.4; 4.7) ns
Positive affectivity 55.9 (22.8) 14.7 (9.3; 20.2) \0.001 71.4 (22.3) 2.7 (-2.4; 7.7) ns
Role limitation due to emotional
health
53.3 (31.1) 11.8 (3.2; 20.4) \0.01 74.9 (25.3) -1.5 (-7.8; 4.7) ns
Cognitive functioning 58.4 (27.1) 13.9 (8.0; 19.9) \0.001 79.7 (20.9) -3.6 (-8.7; 1.5) ns
Physical
General health perceptions 73.7 (25.4) 7.0 (3.5; 10.5) \0.001 86.4 (18.1) 1.1 (-1.8; 3.9) ns
Sleep quality 66.6 (21.3) 10.3 (5.8; 14.8) \0.001 76.9 (21.3) -1.1 (-5.3; 3.0) ns
Pain frequency- intensity 77.4 (23.6) 7.4 (3.1; 11.8) \0.001 82.4 (21.9) 3.4 (-3.0; 9.8) ns
Physical functioning 94.0 (8.9) 0.4 (-1.0; 7.2) ns 96.6 (5.4) -2.1 (-5.0; 0.9) ns
Satisfaction with physical
functioning
66.0 (25.7) 6.1 (0.1; 12.1) \0.05 78.4 (22.0) 0.2 (-4.6; 4.9) ns
Role limitation due to physical
health
72.0 (30.7) 3.8 (-3.2; 10.7) ns 80.7 (27.4) 1.7 (-5.4; 8.9) ns
Social/relationships
Family functioning 57.3 (29.6) 8.9 (2.8; 14.9) \0.01 70.7 (28.3) 2.4 (-2.6; 7.4) ns
Marital functioning 67.9 (23.0) 5.8 (1.4; 10.3) \0.05 76.6 (25.6) 2.7 (-3.8; 9.1) ns
Sexual functioning 80.4 (23.2) 3.1 (-1.0; 7.2) ns 81.5 (21.4) -1.0 (-5.1; 3.1) ns
ns, Not significant; CI, confidence interval; SD, standard deviation
All values represent scale mean scores for HRQOL [range: 0 (worst)–100 (best possible)]
372 Qual Life Res (2008) 17:367–376
123
of about 10%, which is similar to that of the average
population. In the SG, the PD use started as average and
decreased by the end of the course (p\0.01). There were
relatively more PD users (17%) among dropouts from the
course than among both the SG and CG (6%), which was a
significant difference (p=0.03).
The number of individuals who recently had participated
in (other) self-development activities/courses increased
from 16 to 38% after the course intervention, a rate still
’kept up’ in the CG.
Discussion
The main finding of this study was that the intervention has
a strong positive effect on HRQOL, especially in terms of
emotional health. This result indicates that this MBM/BE
course is an effective approach for normalising reduced
HRQOL. Emotional health is here fairly well correlated
(0.26–0.57) to self-assessed general health which, in turn,
is well known to be correlated to health prognosis. We
assume here that simply following the course curriculum is
the reason for the increased emotional QOL as this course
has a strong focus on awareness of feelings during the
exercises. Qualitative comments at follow-up have inclu-
ded: ‘My long-lasting anxiety is slowly diminishing.’’ ‘I
have terminated a relationship that was destructive for
me.’ ‘I have opened myself to the world, 2 months ago,
after 21 years in a closed body.’’ There were, however, also
a few negative comments: ‘I feel as if I don’t need such a
strong course, but I do need an increase in self confidence.’’
‘My tendency for depression has increased (after the
course), I have had panic anxiety for the first time, I am
now sick listed.’ ‘I was sick listed 25% for 2 months
because the course brought up so much from my past.’’
The reliability of the results is strengthened by the high
response rates, the long inclusion time (an entire year), the
equal gender distribution in the SG and the use of previ-
ously validated questionnaires [SWEDQUAL (61 items),
SOC-13]. Other generic QOL measures, such as QOL5
(five items), would have been too endpoint focused for this
new research area. It was considered important at the time
of designing the study (1999) to obtain as wide view as
possible, thus the requirement for many scales. The
WHOQOL-100 [43] or the WHOQOL-BREF [44] would
have suited our purpose as well. These include 26 items in
four domains and, like SWEDQUAL, also have the phys-
ical, psychological and social/relationship aspects
(Table 2).
The results on the two groups (SG and CG) confirmed
the initial two hypotheses: (1) the stability of the CG scores
and (2) the clinically significant improved scores of the SG,
which reached population average levels after 6 months.
Table 4 Sense of coherence in study and control groups expressed in two different ways (data published with permission from Va
˚rd I Norden Ann Langius, 1996. For more Swedish references,
see Discussion)
SOC-13
measures
(13–91 points
possible)
Study group Control group Swedish population
Start value
SOC (%)
n=83
Start rates,
within
Langius’
frame (%)
Six-month
value
SOC (%)
n=83
Six-
month
rates,
within
Langius’
frame (%)
SOC
median
difference
(pvalue)
a
Start value
SOC (%)
n=69
Start rates,
within
Langius’
frame (%)
Six-month
value SOC
(%) n=69
Six-month
rates, within
Langius’
frame (%)
SOC
median difference
(pvalue)
a
Langius’
samples-96
n=19–268,
total [640
Langius’
Reference
rates (%)
SOC median 59*** 62 3 (\0.01)
a
64 64.5 0.5 (ns)
a
64–71 Reference!
Low SOC range 29–49 (25) (59.0) 36–53 (25) (44.6) 33–56 (25) (37.3) 32–56 (25) (33.3) 40–60 Reference! Reference! (25)
Middle SOC range 50–69 (50) (32.5) 54–74 (50) (39.8) 57–73 (50) (46.3) 57–73 (50) (49.3) 61–75 Reference! Reference! (50)
High SOC range 70–83 (25) (8.4) 75–85 (25) (15.7) 74–85 (25) (16.4) 74–86 (25) (17.4) 76–88 Reference! Reference! (25)
***Significantly low compared to reference values by Langius
The ‘value’ columns give the participants’ median self-rated SOC and the quartile range of the observed values. The ‘rate’’ columns show the percentage of the observed values that fall within
the corresponding quartile range reported in Langius’ study of standard Swedish populations
a
Wilcoxon sign rank test
Qual Life Res (2008) 17:367–376 373
123
A previous study by Mulkins, using a similar study
design, evaluated an integrative (=CAM) intervention in
Vancouver and showed HRQOL improvement (SF-36) after
6 months [45]. In a review from 2003, Clark found a strong
relationship between overall satisfaction among hospita-
lised patients and the degree to which staff addressed
emotional/spiritual needs, independent of diagnosis [46].
Another Canadian study defined six benefits from integra-
tive healthcare via interviews and focus groups. These
benefits included ‘improved physical and emotional well-
being’, ‘personal transformation’, ‘feeling connected’ and
‘improved quality of life’ [47]; as such, they were similar to
the results shown by our SWEDQUAL and SOC scales.
There was a significant improvement (=salutogenesis)
in median SOC values reported by the SG after interven-
tion (Table 5). The SOC showed an individual variability,
in terms of both degree of change and correlation (Pear-
son [0.3) to the improved SWEDQUAL health, emotional,
sleep and cognitive scales, but not to the physical ones
(function, pain). This separated correlation is described by
Flensborg-Madsen et al. [48] in their questioning of SOC’s
association to health. Still, we found a correlation (0.36) to
general health, indicating that people
´s health experience is
not only physical. According to Antonovsky’s definition
from the 1980s, results obtained with SOC-13 approximate
those obtained with SOC-29 (items) in showing stable
values for adults [33]. In Sweden, SOC-13 has shown
stable levels over time in different Swedish populations
ranging in age from 30 to 65 years in the early 1990s [39]
as well as a statistically significant decline in both men and
women over a 5-year period in the late 1990s [41]. Fur-
thermore, Holmberg recently demonstrated large individual
changes in SOC-29 scores (25% had more than a 1 SD
change) after 12 years of assessment among middle-aged
Swedish men, despite stable median values [49].
These findings and those of Larsson and Kallenberg [42]
and Volanen et al. [50] support the findings of our study:
adjusted SOC can still change significantly by as much as
1–8% in either direction as a result of life experience(s),
therapeutic intervention(s), life crises and aging, making it
a useful intervention variable [42,50].
The sick leave rates are only self-assessed data, which
makes interpretation difficult. Although the sick leave rates
among women in the SG seemed high, the CG women had
a lower sick leave rate (close to the average rate for the
Swedish population) 2 years after their intervention. Use of
registry data and one additional year of study time may
have provided a clearer picture of this aspect of the study.
‘Doctor’s appointments’ was only an average population-
associated variable and is not further discussed.
Conclusions
This study shows that this MBM/BE intervention gives
significant improvement of (emotional) HRQOL and SOC.
The study also contributes to the original validation of
therapeutic CAM interventions for which there is as yet
little scientific documentation.
Further research
The WHOQOL-BREF questionnaire from 2004 may have
been a more modern and global health questionnaire,
Table 5 Socio-demographic and medical data among the SG compared to official Swedish population statistics from 1999–2000 (NBH, NSIB,
StSw; source: Statistics Sweden)
Socio-demographics Population
values (%)
SG
a
(n=83) CG
a
(n=69)
Entry Follow-
up
Diff (CI) p(diff)\Entry Follow-
up
Diff (CI) p(diff)\
Doctor’s appointments (mean)
a
1.4
a
1.7 1.4 -0.3 (-0.8; 0.1) ns 1.1 0.8 -0.3 (-0.7; 0.1) ns
Sick leave none, n(%) 57 (69) 51 (62) 52 (75) 50 (73)
Sick leave 1–92 days, n(%) 13 (16) 14 (17) 7 (10) 10 (15)
Sick leave [90 days
a
,n(%) (3.4)
b
13 (16) 18 (22) 10 (15) 9 (13)
Sick leave (mean days)
a
All 23.8
a
32.5 40.4 7.8 (-2.5; 8.2) ns 29.3 26.2 -3.1 (11.6; 5.4) ns
Men 19.7
a
22.0 21.2 22.6 24.3
Women 28.0
a
41.4 56.5 36.2 28.1
Psychotropic medication (%)
b
All *10%
b
9.6 6.0 3.6 \0.01 2.9 2.9 ns
Men *5%
b
10.5 7.9 2.9 2.9
Women
a
*13%
b
8.9 4.4 3.0 3.0
a
Half-year values
b
Cumulative prevalence over a 1-year period
374 Qual Life Res (2008) 17:367–376
123
adding Spirituality, Energy and Medication and the new
fourth domain, Environment with Safety, Finance,
Healthcare and Leisure assessments. The CAM training
centre setting, where individual skills are practiced toge-
ther in a group, is likely to be of interest for future cost–
benefit analyses. The addition of registry data on sick
listing may have enhanced interpretation. The presence of
emotional health problems indicates that further studies
may benefit from adding interviews and/or focus groups to
the study design. In search of possible reasons to the ini-
tially reduced HRQOL scores, our interpretation may have
been strengthened if we had used a validated depression
scale. On the other hand, the experiences from the training
centre, the physical functioning and the PD use indicated
only average population depression rates.
Physiological parameters, such as blood pressure and
levels of stress hormones, may have provided useful
information, but these were not measured for logistic rea-
sons. An interesting bridge between soft data (assessments)
and hard data (cytokines) has recently been reported by
Kelley and Lekander who found associations between low
self-assessed general health and an increase in pro-
inflammatory cytokines (the brain mediators of sickness
behaviour). Such measurements may have been useful in
this study, but they were not available during the time
interval of this study [41,51,52].
The categorisation of PMTA is quite different from the
diffuse MESH-term ‘mind–body relations’ (MBR). We
would welcome an unbiased revision of the MESH-term
system for CAM towards PMTA, with the aim of
increasing clarity and comparability for future research.
Acknowledgements This study was supported by separate grants
from the Stockholm County Council and it’s Center for Family and
Community Medicine, Huddinge, Sweden.
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Some cancer patients use therapeutic massage to reduce symptoms, improve coping, and enhance quality of life. Although a meta-analysis concludes that massage can confer short-term benefits in terms of psychological wellbeing and reduction of some symptoms, additional validated randomized controlled studies are necessary to determine specific indications for various types of therapeutic massage. In addition, mechanistic studies need to be conducted to discriminate the relative contributions of the therapist and of the reciprocal relationship between body and mind in the subject. Nuclear magnetic resonance techniques can be used to capture dynamic in vivo responses to biomechanical signals induced by massage of myofascial tissue. The relationship of myofascial communication systems (called “meridians”) to activity in the subcortical central nervous system can be evaluated. Understanding this relationship has important implications for symptom control in cancer patients, because it opens up new research avenues that link self-reported pain with the subjective quality of suffering. The reciprocal body–mind relationship is an important target for manipulation therapies that can reduce suffering.
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Background: The paper reports on the development of the WHOQOL-BREF, an abbreyiated version of the WHOQOL-100 quality of life assessment. Method: The WHOQOL-BREF was derived from data collected using the WHOQOL-100. It produces scores for four domains related to quality of life: physical health, psychological, social relationships and environment. It also includes one facet on overall quality of life and general health. Results: Domain scores produced by the WHOQOL-BREF correlate highly (0.89 or above) with WHOQOL-100 domain scores (calculated on a four domain structure). WHOQOL-BREF domain scores demonstrated good discriminant validity, content validity, internal consistency and test-retest reliability. Conclusion: These data suggest that the WHOQOL-BREF provides a valid and reliable alternative to the assessment of domain profiles using the WHOQOL-100. It is envisaged that the WHOQOL-BREF will be most useful in studies that require a brief assessment of quality of life, for example, in large epidemiological studies and clinical trials where quality of life is of interest. In addition, the WHOQOL-BREF may be of use to health professionals in the assessment and evaluation of treatment efficacy.
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This study explores the distribution of sense of coherence (SOC) in common demographic and sodoeconomic subgroups in a nation-wide representative sample. It also explores the relationship between SOC and these conditions, on the one hand and self-reported Indicators of health, on the other. The sample consisted of 2,003 Swedes; 976 men and 1,027 women. The mean age was 44.2 years (SD = 16.6 years). The sample was selected by SIFO, the biggest Swedish market research Institute, to be representative of the Swedish population between the ages of 15 and 75 years. All participants responded to a mailed questionnaire including Antonovsky's short SOC questionnaire, common sodoeconomic and sodal situation variables and hearth questions. The distribution of SOC scores in different subgroups was partly inconsistent with previous studies. A sex difference was found; men scored significantly higher on the SOC scale than women. Regarding age, SOC scores increased with increasing age. Btvariate statistics showed that SOC was more strongly related to general well-being and psychological symptoms than to overall physical hearth and somatic symptoms. SOC was also more strongly related to health among women than men. Multivariate statistics (separately for men and women) indicated that SOC was more strongly related to the health indicators than age, education and income levels, number of persons in the household and number of friends. The possibility of a conceptual overlap between SOC and self-assessments of health, well-being and psychological symptoms in particular is discussed.
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Nilsson M, Trehn G, Asplund K (University Hospital, Umeå, Sweden). Use of complementary and alternative medicine remedies in Sweden. A population-based longitudinal study within the northern Sweden MONICA Project. J Intern Med 2001; 250: 225–233. Objectives. Previous studies have shown a high prevalence of users of complementary and alternative medicine (CAM) remedies in Anglo-Saxon countries. We have explored the use of CAM remedies in Sweden, its distribution in different population groups and time trends during the years 1990–99. Design and subjects. Within the framework of the population-based northern Sweden Multinational Monitoring of Trends and Determinants of Cardiovascular Disease (MONICA) Project, randomly selected 25–74-year-old participants in risk factor surveys performed in 1990, 1994 and 1999 responded to questions about their use of CAM remedies. The participation rate was 72%. Results. Amongst 5794 respondents in the 1999 survey, 30.5% reported that they had taken a CAM product (vitamins, minerals or biological CAM remedy) in the preceding 2 weeks. Vitamins/minerals only had been taken by 11.7% and other CAM remedies (dominated by fish oil, ginseng and Q10) with or without vitamins/minerals by 18.8%. Use of CAM remedies was more frequent in women than in men and more frequent in people with high than with low level of education. The prevalence was unrelated to a history of severe cardiovascular disease or diabetes but significantly more common in subjects with poor self-perceived health, particularly so in women. During 1990–99, the use of CAM remedies increased, more in women than in men. Conclusions. The prevalence of CAM remedy use (other than vitamins and minerals) is high in Sweden. It has been increasing during the 1990s. Its use is particularly common in women, well-educated people and in those with poor self-perceived health.
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We present a Swedish Health-Related Quality of Life Survey (SWED-QUAL) that was adapted from measures used in the Medical Outcome Study (MOS). The development of these measures spans more than 20 years and their reliability and validity have been extensively tested. The SWED-QUAL consists of 61 items that form 11 multi-item scales tapping aspects of physical, mental, social and general health. The instrument was mailed in 1991 to a random stratified sample of 2,366 individuals from the Swedish general population aged 18-84 years and to a stratified random sample of 2,349 individuals who had been seriously injured in a traffic accident. The response rates were 61% and 59%, respectively. Telephone follow-up of non-responders indicate that most of those tended to have a better health-related quality of life than responders. The SWED-QUAL satisfied all of the psychometric criteria that were evaluated. Multitrait scaling provided strong support for item discrimination. Cronbach's alpha exceeded 0.78 for all scales. Scores tended to be lower among older than younger people, and among females compared to males. The good response rate indicates that the content of the SWED-QUAL is considered relevant by people at large, that the results from the general population sample could be used for comparisons with other samples and the instrument used for further studies of the effectiveness of a broad spectrum of medical interventions.
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The paper presents reference values of the questionnaires Sense of Coherence scale (SOC), measuring self‐rated prerequisite for coping ability, and Sickness Impact Profile (SIP), measuring self‐rated functional status. The sample used is randomly selected from a Swedish urban population consisting of 145 individuals (75 women, 70 men), divided into three age groups, 26–40, 41–55 and 56–70 years. The mean SOC score was 151 (SD 18) and was not related to gender or age. The total SIP score was low (median 0) as expected in a general population. However, again as expected, the results revealed the functional status being worse in the older group of individuals than in the younger ones. The results might give further validity to the test. The SOC scores were significantly correlated to the overall SIP scores and to the subscales of mental and social character and not to those of a physical nature. Thus, the weaker the SOC the worse the functional status. These findings are suggested to give the Sense of Coherence scale a discriminating validity. A single item concerning general health was also rated by the individuals showing the better the general health the stronger the SOC and the less the dysfunction.