Personality features, caring burden and mental health of cohabitants of partners with chronic obstructive pulmonary disease or dementia

Locus of Control and Its Associations with Depressive Symptoms amongst People with Dementia

INTRODUCTION

Depression is common amongst people with dementia. This study examines whether locus of control (LoC), a perceived control construct influential in the coping process, is related to depressive symptoms in this population.

METHODS

In this prospective observational study, 257 community-dwelling older adults with a confirmed dementia diagnosis were included. At baseline, measures of depressive symptoms, LoC, cognition, independent functional ability, general health, dementia severity, and dementia disease insight were collected. At follow-up, measures of depressive symptoms and cognition were collected. Multiple linear regression using degree of depressive symptoms as measured with Montgomery-Asberg Depression Rating Scale as a dependent variable was applied to assess whether LoC was associated with depressive symptoms at baseline and follow-up while controlling for covariates.

RESULTS

LoC (p < 0.001), general health (p = 0.003), and insight (p = 0.010) were associated with severity of depressive symptoms at baseline, accounting for 28% of the variance. LoC (p = 0.025) and depressive symptoms (p < 0.001) at baseline were associated with severity of depressive symptoms at follow-up, accounting for 56.3% of the variance.

CONCLUSION

LoC was significantly associated with severity of depressive symptoms in people with dementia at baseline and at follow-up. Attention to LoC may be valuable for our understanding of depression in people with dementia, and interventions targeting depression could benefit from including a focus on internalizing perceived control. However, these findings are novel, and more research is needed.

One-Year Change in Locus of Control among People with Dementia

INTRODUCTION

Knowledge of how perceptions of personal control change over time may provide valuable insights into how people cope with having dementia. The present study aimed to examine change in locus of control over a 12-month period in persons with dementia.

METHOD

The study included 52 participants with dementia. Locus of control was measured with the Locus of Control of Behavior Scale (LoCB), with higher scores indicating a more external locus of control, interpreted as perceiving less personal control. A ≥5% change on the LoCB was considered clinically meaningful. We recorded sociodemographic characteristics and assessed dementia severity, cognition, ability to function independently in daily activities and physical self-maintenance, depressive symptomatology, and number of prescribed medications. Analyses were performed to examine differences between those with increases (more external) or decreases (less external) in the LoCB score after 12 months and to examine associations between baseline variables and change in the LoCB score.

RESULTS

The mean LoCB score for the total sample did not change after 12 months (baseline mean 29.33 vs. follow-up mean 30.33, p = 0.553); however, 2 subgroups emerged. Using the ≥5% cutoff revealed that the LoCB score changed for 92.3% of the sample, becoming less external (lower LoCB) for 21 participants and more external (higher LoCB) for 27 participants. At baseline, the mean LoBC score was higher in the group that became less external (33.81 vs. 24.56), p = 0.006, while this was reverse at follow-up (23.57 vs. 34.41), p = 0.001. Dementia severity and dependence in physical self-maintenance increased during the 12 months in both groups. Among those becoming more external, we also found a decline in cognition (p = 0.002), an increase in dependence in daily activities (p = 0.003), an increase in the use of prescribed medication, and a decrease in depressive symptomatology (p = 0.003). The baseline LoCB score was the only variable associated with 12-month change in LoCB scores (p = 0.001).

CONCLUSION

Most participants showed a clinically meaningful change in locus of control after 12 months. Those with more signs of dementia progression reported a decrease in personal control but also a decrease in depressive symptoms. These findings are interesting for our understanding of coping but must be replicated with a larger sample.

Informal caregivers and persons with dementia's everyday life coping

This qualitative study explores informal caregivers' experiences of supporting persons with dementia's everyday life coping. In the future, there will be fewer health personnel, increased dementia prevalence and limited nursing home availability. Accordingly, close relatives may be compelled to assume greater care responsibilities. Knowledge concerning persons with dementia's everyday coping from the perspective of informal caregivers remains insufficient, despite these people's importance for those with dementia. This investigation analyses informal caregivers' perceived challenges and pleasures in providing care, how home health care affects everyday life coping and the factors that are most important to informal caregivers in supporting care receivers.

Applicability of the locus of control of behaviour scale for people with dementia

OBJECTIVE

To investigate the applicability of the Locus of Control of Behaviour scale (LoCB) for people with dementia.

METHOD

A sample of 534 participants with dementia (78.4 mean age, 58% female) were included. Assessment included the LoCB, the Montgomery-Aasberg Depression Rating Scale (MADRS), the Mini-Mental Status Examination Norwegian revised (MMSE-NR) and the Instrumental Activities of Daily Living (I-ADL). Completion percentages and internal reliability of LoCB were examined for predefined MMSE-NR groups (0-4, 5-9, 10-14, 15-19, 20-24, 25-27, and 28-30). Factors associated with completion were analysed, and a principal component analysis (PCA) of the LoCB was performed. Sum score and component subscale scores were compared to MADRS and MMSE-NR scores.

RESULTS

In total, 234 participants completed the LoCB. Completion percentages ranged from 74% (MMSE-NR 28-30) to 0% (MMSE-NR 0-9). Internal reliability was between 0.80 and 0.72 in groups with MMSE-NR > 9, except in MMSE-NR 20-24 (0.52). Age, MMSE-NR and education were associated with completion. The PCA yielded three components - powerful others, internal, and luck/fate - with explained variance of 41.3%. Participants with MADRS > 7 scored higher on the LoCB sum score, powerful others and internal subscale scores. No difference was found regarding the luck/fate subscale score. MMSE-NR did not affect LoCB scores.

CONCLUSION

Older age, less education, and more cognitive impairment decreased the likelihood of completion. However, psychometric test results indicate that those who completed the LoCB understood the questions, even with severe cognitive impairment. We conclude, therefore, that the LoCB is applicable for investigating control orientation among people with dementia.

Characteristics, Burden of Care and Quality of Life of Next of Kin of People with Dementia Attending Farm-Based Day Care in Norway: A Descriptive Cross-Sectional Study

Purpose

Caring for people with dementia is often associated with burden of care and may influence the quality of life of the next of kin. The aim of this study was to describe the characteristics of the next of kin to people with dementia attending farm-based day care service (FDC) and identify characteristics associated with burden of care and quality of life (QoL) of next of kin.

Participants and Methods

Ninety-four dyads of people with dementia and their next of kin were included from 25 FDCs in Norway in this descriptive cross-sectional study. The Relative Stress Scale (RSS) and the QoL–Alzheimer’s Disease Scale (QoL-AD) were used as outcomes measures.

Results

The participants consisted of those who lived with a person with dementia (spouse/partner, 62%) and those who did not (children), with significant differences in age, education level, work employment, perceived social support, depression symptoms, burden of care, and QoL. In multiple regression models, RSS and QoL were associated with living with the person with dementia, anxiety symptoms and perceived social support. In addition, RSS was associated with neuropsychiatric symptoms (NPS) in the people with dementia.

Conclusion

Our findings underline the importance of obtaining knowledge about the next of kin’s burden of care and QoL, of people with dementia attending an FDC. This knowledge is essential for those responsible for providing the best possible services for the next of kin and for developing targeted interventions to support the next of kin.

Nurses striving to provide caregiver with excellent support and care at a distance: a qualitative study

Background

In Norway, changes in life expectancy have led to increased attention to older people who are ageing at home, by means of home care services, adapted technology and informal caregivers. The caring situation has become difficult for many caregivers. The use of telecare has now offered them the possibility to receive support at home. The purpose of this study was to explore how nurses provide support and care at a distance, using a web camera and a web forum in a closed telecare network for caregivers to persons suffering from stroke and dementia.

Methods

The study had an explorative design with a qualitative approach. The data sources consisted of interviews with nurses and excerpts from posts in a closed telecare network. Content analysis was used to analyse the text from the interviews and the text from the web forum.

Results

The main theme, “Balancing asymmetric and symmetric relationships” described nurses’ relationship with caregiver. Two categories, “Balancing personal and professional qualities” and “Balancing caregivers’ dependence versus independence” were identified. The first describing the tension in their dialogue, the second describing how nurses provided the caregivers with a sense of security as well as strengthening them to master their daily lives.

Conclusions

The nurses provided long distance support and care for the caregivers, by using computer-meditated communication. This communication was characterized by closeness as well as empathy. To strengthen the caregivers’ competence and independence, the nurses were easy accessible and provided virtual supervision and support. This study increases the knowledge about online dialogues and relationship between nurses and caregivers. It contributes to knowledge about balancing in the relationship, as well as knowledge about bridging the gap between technologies and nursing care as potential conflicting dimensions. Maintenance of ethical principles are therefore critical to be aware of.

Can depression in psychogeriatric inpatients at one year follow-up be explained by locus of control and coping strategies?

OBJECTIVES

Treatment of depression (in late life) is good. The short-term, but not long-term prognosis after treatment of depression in late life is good. To identify modifiable factors, we wanted to examine whether coping in terms of locus of control and coping strategies in depressed patients were associated with the prognosis of depression at follow-up, adjusted for sociodemographic information and health variables.

METHOD

In total, 122 patients (mean age 75.4 years; SD = 6.6) were followed up (median 13.7 months, Q1-Q3 386-441) with a diagnostic evaluation(ICD-10) for depression and assessment of depressive symptoms (MADRS). Coping was assessed using Locus of Control of behavior (LoC-scale) and Ways of Coping questionnaire (WoC-scale).

RESULTS

At follow-up, 37.7% were diagnosed with a depressive episode. A stronger external LoC and lower MMSE-NR score at baseline were in adjusted linear regression analysis significantly more associated to higher depressive symptom scores (MADRS). More use of problem-focused coping, a lower I-ADL functioning, but not emotion-focused coping at baseline were significantly associated with being depressed (ICD-10), at follow-up in adjusted logistic regression analysis.

CONCLUSION

LoC and coping strategies at baseline were associated with the prognosis of depression at follow-up, and may further be studied as indicators for choice of baseline intervention strategies.

Relation Among Anxiety and Family Burden in Primary First-Degree Caregivers of Outpatients with Mental Disorders in Turkey

The aim of this study was to determine the relation among anxiety and family burden in primary first-degree relative caregivers of outpatients with mental disorders in Turkey. Data were collected with patients' primary first-degree relative caregivers via the Information Form, Beck Anxiety Inventory (BAI), and Perceived Family Burden Scale (PFBS). In all, 481 caregivers (325 women and 156 men) participated in this study. Based on this study's results, primary caregivers of patients with mental disorders had a moderate level anxiety, and as anxiety increased, family burden also increased. Those results suggest that mental health nurses should plan interventions not only for patients, but also for their family member or their caregivers to decrease anxiety level.

Self-assessment of the mental health status in older adults in Poland: a cross-sectional study

BACKGROUND

Demographic aging of society poses numerous challenges, including the provision of health care to the elderly population. According to World Health Organization data, the most frequent mental disorders in the senior population are: dementia, depression, and drug and alcohol addiction. The aim of this study was to subjectively assess mental health status (the severity of non-psychotic symptoms of mental functions and depressive symptoms) in older adults of Bialystok (Poland).

METHODS

The study included 300 people - inhabitants of Bialystok and its surrounding areas - aged over 60: 100 residents of a nursing home, 100 senior students of the University of the Third Age in Bialystok, and 100 senior students of the University of a Healthy Senior. Two standardized psychometric scales were used in the study: the General Health Questionnaire (GHQ-28) and the Beck Depression Inventory (BDI).

RESULTS

The median GHQ total point value equaled 26 points, which indicated possible non-psychotic mental disorders. The overall BDI score showed that respondents had a subjective feeling of depressive symptom intensification at the level of 11 points out of 63 points, which indicated minor depressive disorders. Positive and statistically significant correlations were observed between suspicion of non-psychotic mental disorders and the occurrence of depressive symptoms both without distribution into groups and with distribution into sex, group affiliation, and age.

CONCLUSIONS

Subjective assessment of mental health status in older adults, inhabitants of Bialystok, was negative. Social and demographic characteristics (sex, group affiliation, age) analyzed in the study, played no significant role in the assessment of depressive and non-psychotic mental symptom occurrence. Residents of the nursing home were characterized negatively in terms of subjective assessment mental health status from the other two study groups.

Associations between the psychological health of patients and carers in advanced COPD

Objective

Anxiety and depression are highly prevalent in patients with COPD and their informal carers, and associated with numerous risk factors. However, few studies have investigated these in primary care or the link between patient and carer anxiety and depression. We aimed to determine this association and factors associated with anxiety and depression in patients, carers, and both (dyads), in a population-based sample.

Materials and methods

This was a prospective, cross-sectional study of 119 advanced COPD patients and their carers. Patient and carer scores ≥8 on the Hospital Anxiety and Depression Scale defined symptoms of anxiety and depression, χ² tests determined associations between patient and carer symptoms of anxiety/depression, and χ² and independent t-tests for normally distributed variables (otherwise Mann–Whitney U tests) were used to identify other variables significantly associated with these symptoms in the patient or carer. Patient–carer dyads were categorized into four groups relating to the presence of anxious/depressive symptoms in: both patient and carer, patient only, carer only, and neither. Factors associated with dyad symptoms of anxiety/depression were determined with χ² tests and one-way analysis of variance for normally distributed variables (otherwise Kruskal–Wallis tests).

Results

Prevalence of symptoms of anxiety and depression was 46.4% (n=52) and 42.9% (n=48) in patients, and 46% (n=52) and 23% (n=26) in carers, respectively. Patient and carer symptoms of anxiety/depression were significantly associated. Anxious and depressive symptoms in the patient were also significantly associated with more physical comorbidities, more exacerbations, greater dyspnea, greater fatigue, poor mastery, and depressive symptoms with younger age. Symptoms of carer anxiety were significantly associated with being female and separated/divorced/widowed, and depressive symptoms with younger age, higher educational level, and more physical comorbidities, and symptoms of carer anxiety and depression with more unmet support needs, greater subjective caring burden, and poor patient mastery. Dyad symptoms of anxiety/depression were significantly associated with greater patient fatigue.

Conclusion

Symptoms of anxiety and depression in COPD patients and carers are significantly associated. Given their high prevalence, considerable impact on mortality, impact on quality of life and health care use, and associations with each other, screening for and addressing patient and carer anxiety and depression in advanced COPD is recommended.

Depression in individuals with chronic obstructive pulmonary disease and their informal caregivers

OBJECTIVE

Individuals with chronic obstructive pulmonary disease (COPD) and their caregivers are at high risk for developing depression. Depression can adversely affect the quality of life of patients and caregivers; however, studies in COPD have largely examined predictors of patient and caregiver depression in isolation. This dyadic study examined individual-level predictors of patient and caregiver depression in COPD (i.e. actor effects) as well as how dyad members effect each other's depression (i.e. partner effects).

METHODS

Survey data were collected from 89 patient-caregiver dyads that were enrolled in a multi-site cohort study.

RESULTS

Participants were predominantly women (61% of patients and 76% of caregivers) and racial/ethnic minorities (65% of patients and 63% of caregivers). Based on PHQ9 cutoffs, 30% of patients and 20% of caregivers had mild depression; 30% of patients and 8% of caregivers had moderate to severe depression. Multilevel models with the dyad as the unit of analysis showed that less frequent patient self-management, higher levels of caregiver burden, and being in poorer health were associated with higher levels of depression for both dyad members. Higher levels of depression in a partner were also associated with higher levels of depression for women, regardless of whether women were patients or caregivers.

CONCLUSION

Findings suggest that similar factors predict patient and caregiver depression in COPD and that women are at increased risk for developing depression when their partners are depressed. Dyadic psychosocial interventions that target patients and their caregivers may thus be beneficial in terms of addressing depression in this this vulnerable population.

Locus of control and coping strategies in older persons with and without depression

OBJECTIVES

To compare locus of control and coping strategies in older persons with and without depression.

METHOD

This cross-sectional study included 144 depressed in-patients from seven psychogeriatric hospital units, and 106 community-dwelling older persons without depression. All participants were 60 years and older. Locus of control was assessed by a 17-items self-report questionnaire with six response categories. Coping strategies were assessed by a 26-items self-report questionnaire with five response categories. For analytical purposes, age (<75 years vs. ≥75 years), level of education (<10 years vs. ≥10 years) and general medical health (poor vs. not poor) were categorized.

RESULTS

In linear regression analysis, controlling for demographics, health, and social variables, the depressed in-patients showed a higher external locus of control orientation and a less frequent use of problem-focused coping strategies compared with the non-depressed group. No differences in use of emotion-focused strategies were found between the two groups.

CONCLUSION

Compared with the non-depressed old persons, the depressed hospitalized older persons were characterized by perceptions of less personal control, and less use of problem-focused strategies, what also might have brought positive alterations into their situation.

Influence of caregiver personality on the burden of family caregivers of terminally ill cancer patients

Objective:

To determine the influence of caregiver personality and other factors on the burden of family caregivers of terminally ill cancer patients.

Method:

We investigated a wide range of factors related to the patient–family caregiver dyad in a palliative care setting using a cross-sectional design. Caregiver burden was assessed using the seven-item short version of the Zarit Burden Interview (ZBI–7). Caregiver personality was assessed using the 10-item short version of the Big Five Inventory (BFI–10), which measures the following five personality dimensions: extroversion, agreeableness, conscientiousness, neuroticism, and openness. Patient- and caregiver-related sociodemographic and psychological factors were included in the analysis because of their potential association with caregiver burden. Clinical patient data were obtained from medical charts or by using other measures. Multivariate linear regression analysis was performed to identify the independent factors associated with caregiver burden.

Results:

We analyzed 227 patient–family caregiver dyads. The multivariate analysis revealed that caregiver extroversion was protective against caregiver burden, whereas depressive symptoms in caregivers were related to increased burden. Neuroticism was positively correlated with caregiver burden, but this relationship was nonsignificant following adjustment for depressive symptoms. Patient-related factors were not significantly associated with caregiver burden.

Significance of Results:

Evaluating caregiver personality traits could facilitate identification of individuals at greater risk of high burden. Furthermore, depression screening and treatment programs for caregivers in palliative care settings are required to decrease caregiver burden.

Characteristics of the relationship that develops from nurse-caregiver communication during telecare

AIMS AND OBJECTIVES

To explore the relationship between nurses and caregivers using a web camera and web forum as the communication methods.

BACKGROUND

In Norway and other European countries, there is an increased focus on ageing at home, which is aided by technology, as well as formal and informal care. The literature reveals that caregivers endure physical and mental burdens. With computer-mediated communication, such as telecare, it is possible for nurses to provide supportive care to caregivers in their homes.

DESIGN

An explorative design using qualitative content analysis.

METHOD

Six nurses and nine caregivers with residential spouses suffering from stroke or dementia were interviewed two times over a six-month period.

RESULTS

The nurses responded dynamically to the information they received and helped to empower the individual caregivers and to strengthen the interpersonal relationships between the caregivers. While some participants thought that meeting in a virtual room was close and intimate, others wanted to maintain a certain distance. The participants' altered their roles as the masters and receivers of knowledge and experience; this variation was based on a relationship in which mutual respect for one another and an interest in learning from one another allowed them to work together as partners to demonstrate the system and to follow-up with new caregivers.

CONCLUSIONS

The flexibility of the service allows the possibility of engaging in a close, or to some extent, a more distant relationship, depending on the participants' attitudes towards using this type of service.

RELEVANCE TO CLINICAL PRACTICE

Nurses can provide close care, support and information to caregivers who endeavour to master their everyday lives together with their sick spouses. The support seems to help the caregivers cope with their own physical and emotional problems.

Burden of care, social support, and sense of coherence in elderly caregivers living with individuals with symptoms of dementia

Family members are often the care providers of individuals with dementia, and it is assumed that the need for this will increase. There has been little research into the association between the burden of care and the caregiver's sense of coherence or receipt of social support. This study examined the relationship between the social support subdimensions and sense of coherence and the burden of care among older people giving care to a partner with dementia. The study was a cross-sectional observation study of 97 individuals, ≥65 years old and living with a partner who had symptoms of dementia. We used the Informant Questionnaire on Cognitive Decline in the Elderly, the Relative Stress Scale, the Social Provisions Scale, the Sense of Coherence Scale, and a questionnaire on sociodemographic variables. We used multiple regression analysis in a general linear model procedure. We defined statistical significance as p < 0.05. With adjustments for sociodemographic variables, the association with burden of care was statistically significant for the subdimension attachment (p < 0.01) and for sense of coherence (p < 0.001). The burden of care was associated with attachment and with sense of coherence. Community nurses and other health professionals should take necessary action to strengthen attachment and sense of coherence among the caregivers of people with dementia. Qualitative studies could provide deeper understanding of the variation informal caregivers experience when living together with their partner with dementia.

The effect of coping on the burden in family carers of persons with dementia

OBJECTIVES

This study explores the association between coping, measured by the extent of locus of control, and the burden of care on family carers of persons with dementia (PWD).

METHOD

Two hundred thirty PWD living at home and their family carers were recruited from 20 Norwegian municipalities. The carers' burden was assessed by the Relatives' Stress Scale (RSS) and coping by the Locus of Control Behaviour Scale. The PWD were assessed by the Neuropsychiatric Inventory (NPI-Q), the Physical Self-Maintenance Scale (PSMS), the Instrumental Activities of Daily Living (IADL) scale, and the Mini Mental Status Examination (MMSE).

RESULTS

Locus of control (LoC) was found to be the most important factor associated with the burden on carers of PWD, even when we had controlled for the PWD variables, such as the NPI-Q score. The LoC and the carer's use of hours per day to assist the PWD were the only two variables the carers found that affected the extent of the burden. The NPI-Q was the most important variable in the PWD that affected the burden on the carers.

CONCLUSION

Carers who believe that what happens to them is the consequence of their own actions are likely to be less burdened than carers not expecting to have control. This finding gives a possibility to identify carers with a high risk of burden.

Predicting anxiety in carers of people with dementia: the role of trait emotional intelligence

BACKGROUND

Trait emotional intelligence (trait EI) is a personality dimension related to affect that has been shown to predict psychopathology. The objective of the present study was to examine the predictive validity of trait EI in explaining anxiety symptoms in family carers of people with dementia.

METHODS

A cross-sectional survey was conducted with a convenience sample of 203 dementia family caregivers. We used the Trait Emotional Intelligence Questionnaire - Short Form (TEIQue-SF) to measure trait EI in carers. The predictive validity of the scale in explaining anxiety was tested via regression analysis.

RESULTS

Bivariate correlational analysis indicated that lower levels of trait EI were related to higher perceived burden, higher anxiety and depression, and poorer self-rated health in carers. Multiple regression analyses indicated that trait EI was a significant predictor of anxiety symptoms after accounting for known factors influencing outcomes for caregivers. Trait EI also showed strong predictive validity in relation to psychosocial outcomes in carers.

CONCLUSIONS

Trait EI plays an important role in predicting anxiety in dementia caregivers. Theoretical models and interventions aimed at carers of people with dementia should take into account aspects of personality.

Personality of mental health caregivers

PURPOSE OF REVIEW

Caring for a family member with a chronic mental illness can be a major challenge with putting caregivers at risk of burden and depression. This review investigated the recent evidence on the role of personality traits and features for caregiver burden and depression in caregivers of care recipients with mental illness.

RECENT FINDINGS

Most of the evidence was found for caregivers looking after care recipients with dementia. Neuroticism was the personality trait showing the strongest association with caregiver burden and depression.

SUMMARY

Certain personality traits and features can increase the risk of caregiver burden and depression in caregivers looking after family members with a mental illness. More research is needed especially focusing on caregivers looking after care recipients with mental illnesses other than dementia as well as on interventions aiming to support vulnerable caregivers.

Conceptions of daily life in men living with a woman suffering from chronic obstructive pulmonary disease

AIM

To describe conceptions of daily life in men living with a woman suffering from chronic obstructive pulmonary disease (COPD) in different stages of the disease.

BACKGROUND

A chronic disease like COPD affects not only the person living with the illness, but also the spouse. Significant tasks and demands are placed on husbands. COPD has for a long time been considered more a man's disease than a woman's disease, but according to new evidence COPD is a vast problem in women, which requires support from their spouses. The literature review did not reveal any previous studies concerning conceptions of daily life in men living with women suffering from COPD in different stages.

METHODS

A phenomenographic study was conducted. Data were collected from October 2008 to October 2009 through semi-structured interviews with 19 men living with a woman suffering from COPD.

FINDINGS

Two main descriptive categories were found: (1) unchanged life situation where no support was needed; (2) changed life situation related to severity of COPD, where support was needed. The categories were described from the perspective 'ME and my spouse'. Even in their caregiving situation, the men continued with their own life and activities and did not put themselves in second place. No support was needed from healthcare or municipality when the women had mild COPD, but this changed when the COPD progressed. The men felt that daily life was burdened, restricted and the partner relationship was affected, even if the disease had not reached the final stage. The COPD forced them gradually into a caregiving role, and their daily life changed. They become more of a caregiver than a spouse. The men experienced lack of knowledge and support, and they felt that health professionals and municipality did not care about them.