Understanding the experiences of people with disfigurements: An integration of four models of social and psychological functioning

Psychosocial Interventions for Children and Young People With Visible Differences Resulting From Appearance-Altering Conditions, Injury, or Treatment Effects: An Updated Systematic Review

OBJECTIVE

Children and young people with visible differences can experience psychosocial difficulties, such as anxiety and teasing by others. Interventions targeting difficulties have previously been reviewed by Jenkinson et al. This review aimed to identify and critically assess recent studies evaluating the effectiveness of psychosocial interventions for children and young people with visible differences on psychosocial wellbeing, self-esteem, and social experiences and compare the findings with Jenkinson et al. using a replacement review process.

METHODS

Inclusion criteria are as follows: studies with participants aged 0-18 years with visible differences; investigating a psychosocial intervention; including comparison with an alternative intervention, control group, or pre- and post-intervention; and including a quantitative measure assessed pre- and post-intervention. Exclusion criteria are as follows: participants with body dysmorphic disorder or appearance changes due to eating disorders or obesity and studies not written in English. MEDLINE, AMED, and PsycInfo were searched and grey literature was included. Results were reviewed against eligibility criteria, data were extracted, and studies were evaluated using the Cochrane Risk of Bias 2 tool.

RESULTS

Using Jenkinson et al. as one source of studies, 24 studies were included evaluating a range of interventions such as social interaction skills training, residential social camps, and cognitive behavioral therapy. Risk of bias was high in 20 studies and of some concern in four studies.

CONCLUSION

There is some evidence of the effectiveness of hypnotherapy, a relaxation response resiliency program, integrative body-mind-spirit group, and therapeutic patient education, but more rigorous research is needed to confirm their impact on psychosocial outcomes.

Mechanism underlying a brief cognitive behavioral treatment for head and neck cancer survivors with body image distress

PURPOSE

Body image distress (BID) among head and neck cancer (HNC) survivors is a debilitating toxicity associated with depression, anxiety, stigma, and poor quality of life. BRIGHT (Building a Renewed ImaGe after Head & neck cancer Treatment) is a brief cognitive behavioral therapy (CBT) that reduces BID for these patients. This study examines the mechanism underlying BRIGHT.

METHODS

In this randomized clinical trial, HNC survivors with clinically significant BID were randomized to receive five weekly psychologist-led video tele-CBT sessions (BRIGHT) or dose-and delivery matched survivorship education (attention control [AC]). Body image coping strategies, the hypothesized mediators, were assessed using the Body Image Coping Skills Inventory (BICSI). HNC-related BID was measured with the Inventory to Measure and Assess imaGe disturbancE-Head and Neck (IMAGE-HN). Causal mediation analyses were used to estimate the mediated effects of changes in BICSI scores on changes in IMAGE-HN scores.

RESULTS

Among 44 HNC survivors with BID allocated to BRIGHT (n = 20) or AC (n = 24), mediation analyses showed that BRIGHT decreased avoidant body image coping (mean change in BICSI-Avoidance scale score) from baseline to 1-month post-intervention relative to AC (p = 0.039). Decreases in BICSI-Avoidance scores from baseline to 1-month resulted in decreases in IMAGE-HN scores from baseline to 3 months (p = 0.009). The effect of BRIGHT on IMAGE-HN scores at 3 months was partially mediated by a decrease in BICSI-Avoidance scores (p = 0.039).

CONCLUSIONS

This randomized trial provides preliminary evidence that BRIGHT reduces BID among HNC survivors by decreasing avoidant body image coping. Further research is necessary to confirm these results and enhance the development of interventions targeting relevant pathways to reduce BID among HNC survivors.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03831100 .

An ACT self-help intervention for adults with a visible difference in appearance: A pilot feasibility and acceptability randomized controlled study

Individuals living with a visible difference in appearance experience high levels of social anxiety, yet self-help interventions for this heterogeneous population are not available. We conducted a pilot trial of a novel Acceptance and Commitment Therapy (ACT) based self-help intervention.Individuals with anxiety about having a visible difference in appearance (n = 284) were randomized to an ACT-based four-week intervention (n = 145) or a waitlist control condition (n = 139). We collected pre and follow-up (four-weeks after the completion of the intervention) data. Primary outcomes included social anxiety and impairments in functioning. Psychological flexibility (PF) was also examined. ANCOVAs, controlling for pre scores, indicated significant improvements in functioning by the intervention group. No significant differences were observed for anxiety and PF between conditions at follow-up. Drop out was 68% for the intervention and 41% for the control group, with no differences in the groups in age, origin, gender, or type of visible difference. Participants in the intervention group found the intervention almost equally, useful (77%) and helpful (73%). An ACT-based self-help intervention can alleviate distress related to visible difference in appearance. More sophisticated designs are needed now, to collect idiographic and longitudinal data and examine personalized changes across time in this population.

Do congenital and acquired causes of visible difference predict distinct appearance-related psychosocial outcomes?

Having a visible difference caused by an appearance-altering condition or injury can impact psychosocial wellbeing. It remains unestablished whether the time at which a visible difference manifests, namely pre-memory (congenital) or later (acquired), predicts psychosocial outcomes associated with adjustment. In this survey study of 331 adults with visible differences, we tested whether their type, congenital (n = 161) or acquired (n = 170), would predict four key psychosocial outcomes: Appearance satisfaction, social appearance anxiety, life disengagement and intimacy distress. To account for other potential predictors and to test whether other variables would moderate any predictive effect found from the type of visible difference, the analyses also included demographic variables, visible difference characteristics and history, and interpersonal and intrapersonal factors. Four regression models were tested. With all variables entered, we found no evidence of type of visible difference as a significant predictor of any psychosocial outcome. Instead, the only consistent predictors of outcomes were optimism, social support and the extent to which participants felt able to disguise their difference. Overall, findings do not support the idea that there is a psychosocial advantage to having a congenital nor acquired visible difference, and broadly reinforce commonalities in adjusting to any cause.

Prosthesis use among individuals with lower limb amputation in Bangladesh

OBJECTIVE

This study aimed to assess factors related to prostheses use among individuals with lower limb amputation in Bangladesh.

METHODS

Data related to prosthesis use, functional capabilities (as measured with the Locomotor Capabilities Index [LCI]), and user satisfaction were collected using telephone interviews between January 2014 and October 2016. Descriptive and regression analyses were performed.

RESULTS

This study involved 183 participants (89.6% male); the mean (SD) age was 49.5 (10.7) years. Most of the participants (95.6%) used prostheses daily, and the mean (SD) duration of use was 7.0 (4.1) hours per day. The mean (SD) basic LCI score, advanced LCI score, and total LCI score were 25.1 (4.9), 20.8 (8.3), and 45.9 (12.2), respectively. Among them, 36.7% were dissatisfied with the weight of the prosthesis. Having a below knee amputation (odds ratio 2.6 and confidence interval 1.3, 5.3) and absence of comorbidities (odds ratio 2.1; confidence interval 1.0, 4.4) were associated significantly with an increased use of prosthesis.

CONCLUSION

Factors such as weight of the prosthesis, amputation level, and presence of comorbidities are important considerations while planning for prosthetic rehabilitation and optimize utilization of the prosthetic devices.

Patient-reported outcomes in childhood head and neck rhabdomyosarcoma survivors and their relation to physician-graded adverse events-A multicenter study using the FACE-Q Craniofacial module

INTRODUCTION

Adverse events (AE) of treatment are prevalent and diverse in head and neck rhabdomyosarcoma (HNRMS) survivors. These AEs are often reported by physicians; however, patients' perceptions of specific AE are not well known. In this study, we explored patient-reported outcomes measuring appearance, health-related quality of life (HRQOL), and facial function in HNRMS survivors. Second, we assess the relationship between physician grading of AE and patient reporting.

MATERIALS AND METHODS

Survivors of pediatric HNRMS, diagnosed between 1993 and 2017, who were at least 2 years after completing treatment were invited to an outpatient clinic as part of a multicenter cross-sectional cohort study. At the outpatient clinics, survivors aged ≥8 years filled out the FACE-Q Craniofacial module; a patient-reported outcome instrument measuring issues specific to patients with facial differences. AE were systematically assessed by a multidisciplinary team based on the Common Terminology Criteria of Adverse Events system.

RESULTS

Seventy-seven survivors with a median age of 16 years (range 8-43) and median follow-up of 10 years (range 2-42) completed the questionnaire and were screened for AEs. Patient-reported outcomes varied widely between survivors. Many survivors reported negative consequences: 82% on appearance items, 81% on HRQOL items, and 38% on facial function items. There was a weak correlation between physician-scored AEs and the majority of patient-reported outcomes specific for those AEs.

CONCLUSIONS

Physician-graded AEs are not sufficient to provide tailored care for HNMRS survivors. Findings from this study highlight the importance of incorporating patient-reported outcome measures in survivorship follow-up.

"My body…tends to betray me sometimes": a Qualitative Analysis of Affective and Perceptual Body Image in Individuals Living with Endometriosis

Background

Endometriosis is a chronic reproductive disease manifesting in physical symptoms including pain, abdominal swelling, altered bowel and bladder function, and fatigue. These symptoms potentially threaten body image regarding subjective perceptions of functional, appearance, and sensory aspects of one’s body. The aim of this study was to qualitatively understand how endometriosis impacts on affective and perceptual aspects of body image.

Method

Participants (N = 40) were recruited through endometriosis consumer organizations. In an online survey, participants completed demographic and health history questions, then provided written narratives about body image–related impacts of their endometriosis in response to open-ended questions. These data were thematically analyzed using the template approach.

Findings

The majority of participants (M_age = 28.3 years) were employed part-time, diagnosed on average for 4.2 years, and reported pelvic pain and bloating, fatigue, and nausea symptoms. Thematic analysis yielded three themes including My Body is a Barrier, Needing to Hide Myself, and Body as Healer and Teacher, all of which reflected affective and perceptual aspects of body image.

Conclusion

These findings highlight wide-ranging body image–related impacts of endometriosis, suggesting the need for targeted interventions to address these concerns.

Motives, Means, and Belonging in a Strange Land: Female International Students Navigating a Racially and Ethnically Homogeneous Korean Society

Using Mandelbaum’s (1973) life history analysis framework, this study analyzed the intersection of female experience, social wellbeing, gender role, and the cost of migration as a female international student in an ethnically homogenous and ethnical nationalist host country, South Korea. A cross-cultural comparison also followed to understand factors affecting belongingness and the ability to incorporate. As a result, immigrant life course dimensions are affected by extremities of cultural nearness or distance, cultural fluency or disfluency, positive cultural experience, intense ethnic and cultural contact, and the existence of a diaspora. The emigration to Korea and structural systems significantly turn the female immigrants’ course of life. Adaptation and belongingness are also affected by a desire for an abundant “Korean” cultural experience, rare cultural contact, code-switching, or indifference for a cultural experience. A comparative look at the experiences also produced common and different patterns based on the cultural origin of the students. Overall, the distinct ethnic characteristics of Korea as a host not only created a demanding assimilation (a strong pull to Korean ethnic identity assumed roles) but it also brought a unique and transforming female and belongingness experience. As migration may redirect or reward female gender roles, this study points to a proper discussion to understand the relativity of female experience within a distinctive and culturally demanding host country.

Cultural Bereavement and Mental Distress: Examination of the Cultural Bereavement Framework through the Case of Ethiopian Refugees Living in South Korea

In South Korea, a mono-ethnic nation, refugees and asylum seekers from culturally distant countries are exposed to cultural bereavement, cultural identity shock, and cultural inconsistency for themselves and their children. Along with biological, psychological, and social factors, this phenomenon is hypothesized as playing a major role in an increased rate of distress among refugees. This study explored the experiences of 11 Ethiopian refugees living in South Korea, and their relevance to cultural bereavement while affirming and suggesting an update for the cultural bereavement framework. The analysis showed the refugees experiencing a slight continuation of dwelling in the past; a sense of guilt due to the fading of one’s culture; different types of anger; and anxiety with relation to the cultural identity of themselves and of their young children. Strong religious beliefs, a continuation of religious practice, informal gatherings within the Ethiopian diaspora, and organized community activities provided an antidote for cultural bereavement. The implication of the result hopes to assist and direct practitioners to identify complex manifestations of mental distress that often get wrongfully labeled as to their causation as well as methods and sources of diagnosis. Any update on the cultural bereavement framework also needs to consult the setting and peculiar circumstances of the displaced people in question.

Assessing the usability and acceptability of Face IT@home: an online CBT intervention for people with visible differences

To increase access to support, an online psychosocial support tool for adults with visible differences was adapted for use without referral or supervision. This intervention combines a cognitive behavioural and social skills model of support. This study aimed to assess the usability and acceptability of Face IT@home as a self-help intervention. Eighty-one participants were recruited (32 with visible differences). Stage 1 included 14 participants (11 female, all with visible differences) who viewed two sessions of Face IT@home and undertook a semi-structured telephone interview. Stage 2 consisted of 14 think-aloud sessions (13 female, none with visible differences) with participants, supervised by researchers. Stage 3 employed 53 participants (47 female; 19 with visible differences), to view one session of Face IT@home and complete an online survey to evaluate usability and acceptability. User interviews, think-aloud studies and questionnaires identified usability and acceptability factors of Face IT@home that make it fit for purpose as a self-help tool. Participants suggested some changes to the Face IT@home program to improve usability. Participants reported that Face IT@home was a useful tool for people with visible differences and could be effective. The CBT-based model was considered a useful approach to addressing psychosocial concerns. The online self-help format will increase access to psychological support for adults with visible differences.

Key learning aims

(1)

Psychosocial Effects of Vitiligo: A Systematic Literature Review

Background

Patients with vitiligo experience reduced quality of life.

Objective

To comprehensively describe the available evidence for psychosocial burden in vitiligo.

Methods

A systematic review of observational studies and clinical trials identified using PubMed, EMBASE, Scopus, and the Cochrane databases was performed through 1 March, 2021, to assess psychosocial comorbidities in vitiligo. Two independent reviewers performed an assessment of articles and extracted data for qualitative synthesis.

Results

Included studies (N = 168) were published between 1979 and 1 March, 2021; 72.6% were published since 2010. Disorders including or related to depression (41 studies, 0.1–62.3%) and anxiety (20 studies, 1.9–67.9%) were the most commonly reported. The most prevalent psychosocial comorbidities were feelings of stigmatization (eight studies, 17.3–100%), adjustment disorders (12 studies, 4–93.9%), sleep disturbance (seven studies, 4.6–89.0%), relationship difficulties including sexual dysfunction (ten studies, 2.0–81.8%), and avoidance or restriction behavior (12.5–76%). The prevalence of most psychosocial comorbidities was significantly higher vs healthy individuals. Factors associated with a significantly higher burden included female sex, visible or genital lesions, age < 30 years (particularly adolescents), and greater body surface area involvement, among others. The most commonly reported patient coping strategy was lesion concealment.

Limitations

Available studies were heterogeneous and often had limited details; additionally, publication bias is possible.

Conclusions

The results of this systematic review show that vitiligo greatly affects psychosocial well-being. The extent of psychosocial comorbidities supports the use of multidisciplinary treatment strategies and education to address the vitiligo-associated burden of disease.

Protocol Registration

PROSPERO (CRD42020162223).

Graphic Abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40257-021-00631-6.

The psychosocial impact of losing an eye through traumatic injury and living with prosthetic restoration: A thematic analysis

This study aims to explore the psychosocial factors and challenges affecting the lives of those who wear an ocular prosthesis following a traumatic eye injury. Thematic analysis of semi-structured interviews with eight individuals resulted in five themes: emotional devastation in the aftermath; moving forward; fear of negative social evaluation; keeping it normal - protecting self and close others; and threat of injury & blindness. Enucleation or evisceration of an eye causes significant emotional stress. Despite successful prosthetic restoration, many individuals continue to experience ongoing psychosocial challenges, as a consequence of their experiences of visible difference and visual impairment.

Body image concerns in individuals diagnosed with benign gynaecological conditions: scoping review and meta-synthesis

Background

Benign gynaecological conditions (BCGs) and body image-related concerns are commonly experienced by reproductive-aged female-identified individuals. Qualitative evidence from cancer populations identifies a link between diseases of the sexual organs and body image distress encompassing appearance, sensory and functional aspects. Most BCGs and the impacts on body image have been studied separately. However, commonalities exist between these conditions including chronicity, diagnostic delays, and menstrual-related social stigma. This systematic scoping review and meta-synthesis aimed to compare and contrast the experience of body image in the benign conditions of endometriosis, polycystic ovarian cysts, uterine fibroids, and vulvar intraepithelial neoplasia.

Method

Electronic databases (MEDLINE, PsycINFO, Scopus, CINAHL, Embase, and Allied and Complementary Medicine) were searched in February 2020 and relevant articles were examined to identify papers that qualitatively explored the relationship between body image and BCGs. Meta-synthesis was used to analyse the 17 papers that met the inclusion criteria.

Results

Six main themes evolved from this iterative analysis: loss of control; regained control; silence – menstrual concealment; cultural differences; feeling abnormal, and functional impairment. Body image concerns were widespread although impacts on individual’s lives were dependent on the unique symptom profile of each disease which interacted with socio-cultural factors, daily functioning, and feminine identity. Body image concerns were a common, but hidden, experience rarely screened in routine clinical settings despite causing significant distress.

Conclusions

The chronicity and severity of individuals unique symptom profile often determined the intensity and type of body image concerns individuals described. Across conditions, body image concerns were often left untreated, were concealed, and were associated with reduced quality of life.

Conceptualizing "Family" and the Role of "Chosen Family" within the LGBTQ+ Refugee Community: A Text Network Graph Analysis

This study analyzed meaning attributions regarding “family” and “chosen family” by Lesbian, Gay, Bisexual, Pansexual, Transgender, Gender Queer, Queer, Intersex, Agender, Asexual, and other Queer-identifying community (LGBTQ+) refugees. The meaning and significance of a chosen family in the newly established life of the refugees was also pin-pointed for its value of safekeeping the wellbeing and settlement process. We analyzed narrative statements given by 67 LGBTQ+ refugees from 82 YouTube videos. Using InfraNodus, a text graph analysis tool, we identified pathways for meaning circulation within the narrative data, and generated a contextualized meaning for family and chosen family. The conceptualization process produced a deduction within family relationships, exploring why people, other than in biological relationships, appear to be vital in their overall wellbeing and settlement, as well as the process through which this occurs. Biological family is sometimes associated with words that instigate fear, danger, and insecurity, while the concept of chosen family is associated with words like trusting, like-minded, understanding, welcoming, loving, committed, etc. The results of the study are intended to add knowledge to the gap by showing the types and characteristics of family relationships in LGBTQ+ refugee settings. It is also a call for the relevant research community to produce more evidence in such settings, as this is essential for obtaining a better understanding of these issues.

Cancer and Stress: Does It Make a Difference to the Patient When These Two Challenges Collide?

Simple Summary

Head and neck cancers are the sixth most common cancer in the world. The burden of the disease has remained challenging over recent years despite the advances in treatments of other malignancies. The very use of the word malignancy brings about a stress response in almost all adult patients. Being told you have a tumour is not a word anyone wants to hear. We have embarked on a study which will investigate the effect of stress pathways on head and neck cancer patients and which signalling pathways may be involved. In the future, this will allow clinicians to better manage patients with head and neck cancer and reduce the patients’ stress so that this does not add to their tumour burden.

Abstract

A single head and neck Cancer (HNC) is a globally growing challenge associated with significant morbidity and mortality. The diagnosis itself can affect the patients profoundly let alone the complex and disfiguring treatment. The highly important functions of structures of the head and neck such as mastication, speech, aesthetics, identity and social interactions make a cancer diagnosis in this region even more psychologically traumatic. The emotional distress engendered as a result of functional and social disruption is certain to negatively affect health-related quality of life (HRQoL). The key biological responses to stressful events are moderated through the combined action of two systems, the hypothalamus–pituitary–adrenal axis (HPA) which releases glucocorticoids and the sympathetic nervous system (SNS) which releases catecholamines. In acute stress, these hormones help the body to regain homeostasis; however, in chronic stress their increased levels and activation of their receptors may aid in the progression of cancer. Despite ample evidence on the existence of stress in patients diagnosed with HNC, studies looking at the effect of stress on the progression of disease are scarce, compared to other cancers. This review summarises the challenges associated with HNC that make it stressful and describes how stress signalling aids in the progression of cancer. Growing evidence on the relationship between stress and HNC makes it paramount to focus future research towards a better understanding of stress and its effect on head and neck cancer.

Traumatic Stress Among Children After Surgical Intervention for Congenital Melanocytic Nevi: A Pilot Study

BACKGROUND

Hospitalization and surgery are traumatic experiences that can result after traumatic stress symptoms (PTSS). Surgical interventions for congenital melanocytic nevus (CMN) can be very stressful, but their potential for causing PTSS has not been studied. We aim to determine prospectively whether children undergoing surgery for CMN develop PTSS and what are the specific risk factors for such an event.

OBJECTIVE

The authors aim to determine prospectively whether children undergoing surgery for CMN develop PTSS and what the specific risk factors for such an event are.

METHODS

Thirty children who were consecutively hospitalized in a pediatric surgery ward for CMN removal during the study period were recruited voluntarily. About 4 months after discharge from the hospital, the children and their parents were assessed for psychological distress.

RESULTS

At the assessment 4 months after hospitalization, the children displayed a significant increase in symptoms of distress in comparison with baseline levels. Moreover, 33.3% met full post-traumatic stress disorder (PTSD) diagnostic criteria. The number of invasive procedures, family resources, and parental distress predicted 40% of the variance in PTSS, with parental distress predicting it most significantly.

CONCLUSION

The high prevalence of PTSS among children undergoing CMN removal and among their parents emphasizes the importance of actions for prevention and early treatment of psychological distress.

Handling traumatic experiences in facially disfigured female burn survivors

BACKGROUND

This research deals with the impact of resilience, perceived stigmatization, social comfort and coping strategies on quality of life among female burn survivors with facial disfigurement, man many of which are found in Asian countries.

METHODS

Using cross-sectional research design, female burn survivors with severe facial disfigurement (N = 100) were drawn by using purposive sampling strategy from a public sector hospital and an organization working in Lahore, Pakistan. Perceived Stigmatization Questionnaire (PSQ) (Lawrence et al., 2006), Social Comfort Questionnaire (SCQ) (Lawrence et al., 2006), State-Trait Resilience Scale, Coping with Burns Questionnaire (CBQ) (Willebrand et al., 2001) and World Health Organization Quality of Life Brief Questionnaire (WHOQOL-BREF Questionnaire; World Health Organization, 2014) were used for assessment.

RESULTS

The analyses showed a significant positive relationship among resilience, coping with burns and social comfort. A significant negative relationship was found between perceived stigmatization and coping with burns, resilience and social comfort. All these variables were tested for differentiation on the basis of survivor's age (less vs. more than 30 years), occupation (housewife vs. gainfully employed), education (less vs. more than matriculation), social status (low vs. middle class), family system (nuclear vs. joint), siblings (yes vs. no), residence (living in home vs. shelter home) and psychological help received or not after the burn injury. Results indicate a mixed type of phenomenon among variable's differentiation. Path analysis through AMOS resulted into a model showing no direct relationship of quality of life with coping with burns, perceived stigmatization and resilience; however, social comfort mediates the relationship between quality of life and coping with burns, perceived stigmatization and resilience.

CONCLUSION

It is found that quality of life is dependent on coping with burns, perceived stigmatization and resilience through social comfort. The findings hold implications for the mental health professionals and rehabilitation service providers to emphasize on the restorative strategy for burn survivors to elevate their social comfort, to assist them in handling their injuries and develop a curative plan to support them in their coping skills.

Australian health professionals' perspectives of psychosocial adjustment to visible differences: A qualitative analysis of pediatric populations

Living with a visible difference (e.g., disfigurement) can compromise a child's psychological wellbeing. Although some children can adjust well, others can develop a range of appearance-related issues such as social anxiety, low self-esteem, and body dissatisfaction. However, current research fails to confirm what factors contribute to appearance-related distress, and what factors buffer the consequences of living with a visible difference. Semi-structured qualitative interviews were conducted with 16 Australian specialist health professionals who care for children with visible differences. Interviews explored the type of appearance-related psychosocial concerns presented to a pediatric hospital, perspectives on the impact of appearance-related distress, as well as factors and processes that health professionals perceive influence adjustment. Data were subjected to inductive thematic analysis. Rich evidence was offered by health professionals, which demonstrated deep understanding of the psychological wellbeing of their patients. Three themes were identified: Mind, Body, and Soul; Stages of Life; and Individual Differences. Findings highlighted the complexity of appearance-related distress, with individual differences in adjustment, and the powerful impact it can have on a child's short and long-term psychosocial wellbeing. The importance of reaching consensus in the conceptualisation and measurement of psychological wellbeing is stressed, and key domains associated with adjustment are proposed.

No Need to Worry? Anxiety and Coping in the Entrepreneurship Process

Understanding experiences of and responses to anxiety is foundational to developing robust theories of entrepreneurial behavior. Using open-ended, vignette and graphical elicitation interviews with 77 entrepreneurs, we inductively investigate the experience of and coping responses to anxiety during the entrepreneurship process. We develop a comprehensive and dynamic goal-striving model to explain experiencing and coping with entrepreneurial anxiety by integrating empirical findings with appraisal and control theories. In doing so, we theorize that entrepreneurial anxiety is endogenous to a cyclical conception of goal-striving, such that various sources of anxiety make sense only in consideration of the goals, standards or values to which they pertain. In this regard, entrepreneurs' coping responses influence four different points of an iterative goal-striving cycle-an insight that moves beyond problematic static and binary coping classifications.

Experiential avoidance and cognitive fusion mediate the relationship between body evaluation and unhelpful body image coping strategies in individuals with visible differences

Psychological flexibility, the capacity to be open to any internal stimuli and act in accordance with valued ends, has been identified as an explanatory variable in how people cope with body concerns. The role of psychological flexibility is unexplored in adults with an atypical appearance due to a health condition, injury, or medical treatment (collectively visible difference), who often encounter multiple day-to-day body image threats. Testing two core components of psychological flexibility, namely experiential avoidance (a desire to avoid or get rid of unpleasant internal experiences) and cognitive fusion (taking thoughts literally), can also provide a more precise theoretical model, with clearer implications for psychological intervention. This survey study investigated whether each psychological flexibility component mediated the relationship between body evaluation and two unhelpful body image coping strategies (behavioural avoidance and appearance-fixing behaviours) in 220 adults with various causes of visible difference. Controlling for demographic variables and subjective noticeability of visible difference, results suggest that cognitive fusion partially mediated the relationship for both body image coping strategies, and experiential avoidance partially mediated behavioural avoidance but not appearance-fixing behaviours. Cognitive fusion may be a particularly important cognitive process in the mechanisms underpinning unhelpful body image coping strategies in this population.

A Web-Based Self-Help Psychosocial Intervention for Adolescents Distressed by Appearance-Affecting Conditions and Injuries (Young Persons' Face IT): Feasibility Study for a Parallel Randomized Controlled Trial

BACKGROUND

Disfigurement (visible difference) from wide-ranging congenital or acquired conditions, injuries, or treatments can negatively impact adolescents' psychological well-being, education and health behaviours. Alongside medical interventions, appearance-specific cognitive behavioural and social skills training to manage stigma and appearance anxiety may improve psychosocial outcomes. YP Face IT (YPF), is a Web-based seven session self-help program plus booster quiz, utilising cognitive behavioural and social skills training for young people (YP) struggling with a visible difference. Co-designed by adolescents and psychologists, it includes interactive multimedia and automated reminders to complete sessions/homework. Adolescents access YPF via a health professional who determines its suitability and remotely monitors clients' usage.

OBJECTIVE

To establish the feasibility of evaluating YPF for 12-17 year olds self-reporting appearance-related distress and/or bullying associated with a visible difference.

METHODS

Randomized controlled trial with nested qualitative and economic study evaluating YPF compared with usual care (UC). Feasibility outcomes included: viability of recruiting via general practitioner (GP) practices (face to face and via patient databases) and charity advertisements; intervention acceptability and adherence; feasibility of study and data collection methods; and health professionals' ability to monitor users' online data for safeguarding issues. Primary psychosocial self-reported outcomes collected online at baseline, 13, 26, and 52 weeks were as follows: appearance satisfaction (Appearance Subscale from Mendleson et al's (2001) Body Esteem Scale); social anxiety (La Greca's (1999) Social Anxiety Scale for Adolescents). Secondary outcomes were; self-esteem; romantic concerns; perceived stigmatization; social skills and healthcare usage. Participants were randomised using remote Web-based allocation.

RESULTS

Thirteen charities advertised the study yielding 11 recruits, 13 primary care practices sent 687 invitations to patients on their databases with a known visible difference yielding 17 recruits (2.5% response rate), 4 recruits came from GP consultations. Recruitment was challenging, therefore four additional practices mass-mailed 3,306 generic invitations to all 12-17 year old patients yielding a further 15 participants (0.5% response rate). Forty-seven YP with a range of socioeconomic backgrounds and conditions were randomised (26% male, 91% white, mean age 14 years (SD 1.7)); 23 to YPF, 24 to UC). At 52 weeks, 16 (70%) in the intervention and 20 (83%) in UC groups completed assessments. There were no intervention-related adverse events; most found YPF acceptable with three withdrawing because they judged it was for higher-level concerns; 12 (52%) completed seven sessions. The study design was acceptable and feasible, with multiple recruitment strategies. Preliminary findings indicate no changes from baseline in outcome measures among the UC group and positive changes in appearance satisfaction and fear of negative evaluation among the YPF group when factoring in baseline scores and intervention adherence.

CONCLUSIONS

YPF is novel, safe and potentially helpful. Its full psychosocial benefits should be evaluated in a large-scale RCT, which would be feasible with wide-ranging recruitment strategies.

TRIAL REGISTRATION

ISRCTN registry ISRCTN40650639; http://www.isrctn.com/ISRCTN40650639.

A systematic review of body image measures for people diagnosed with head and neck cancer (HNC)

PURPOSE

Head and neck cancer (HNC) is a relatively common cancer which causes a significant health burden, impacting individuals physically and psychologically. HNC treatment may result in facial disfigurement, eating and communication difficulties, and body image disturbances. We aimed to (1) identify HNC-specific patient-reported outcome measures (PROMs) used to assess body image, (2) evaluate their conceptual coverage, (3) appraise their development process and psychometric properties, and (4) determine appropriate body image PROM(s) for use in the HNC setting.

METHODS

Online databases were searched (July 2007-July 2017) for studies that assessed body image in patients with HNC. Studies were screened for eligibility. In addition, we searched three PROM databases for relevant PROMs. From available body image frameworks, we compiled a conceptual schema consisting of 18 clinically relevant body image issues important in the HNC setting, against which PROMs were assessed. Selected measures were appraised for psychometric characteristics, content, and readability.

RESULTS

A total of 245 records were retrieved. 18 studies with PROMs met our inclusion criteria, reporting eight PROMs. The PROM databases searched yielded 62 measures. After screening, eleven measures were short-listed and appraised. The Derriford Appearance Scale (DAS)-59, DAS-24, and body image scale (BIS) cover > 55% of issues within the body image conceptual schema; were developed based on literature, patient interviews, and clinician opinions; and have evidence of internal consistency (Cronbach alpha > 0.7), validity, and responsiveness.

CONCLUSIONS

We recommend the DAS-24 and BIS as having adequate coverage of HNC-related issues, and suitable for use in future research.

The Use of a Brief Measure to Assess Longitudinal Changes in Appearance Concerns for Youth Recovering From Burn Injuries

Burns are among the most common injuries to children, and, although survival rates have improved, many burn survivors are left with scars and/or other visible differences, which may be associated with anxiety, depression, and/or low self-esteem. A better understanding of the prevalence and persistence of these problems in child and adolescent burn survivors might lead to an expanded paradigm of care and possibly to better outcomes. The present study provides longitudinal prevalence data for the Appearance Concerns (AC) subscale of the parent-reported Burn Outcomes Questionnaire (BOQ) for 5- to 18-year-old children and identifies patient characteristics associated with higher risk for appearance concerns. Subjects were 799 pediatric burn survivors who were assessed prospectively using the parent-reported BOQ5-18, which was administered soon after their discharge from acute care and again every 3 to 6 months for up to 4 years. Approximately 20% of all youth were reported to have appearance concerns over the first 2 years, after which the rate declined gradually, falling to around 10% after 3 years. This study showed that such concerns were prevalent and persistent years after burn injuries and suggested that larger burns, facial burns, and country of origin outside of the United States were all associated with higher scores on the AC subscale. These findings highlight the importance of assessing appearance concerns in the long-term care of young burn survivors and suggest that the BOQ5-18 AC subscale could be used to identify individuals with heightened appearance concerns and to measure their response to interventions.

Understandings and experiences of visible difference and romantic relationships: A qualitative exploration

The association between disfigurement ('visible difference') and romantic relationships has received relatively little consideration in the research literature. This qualitative research, conducted in the United Kingdom, explored participants' accounts of their visible difference and romantic life. Semi-structured interviews were conducted with 22 participants who had a variety of visible differences. Inductive thematic analysis demonstrated that participants understood their difference as having a pervasive and enduring impact. These encompassed challenges that must be negotiated in the formation of romantic relationships, including feeling unattractive to others and feeling personally devalued. Relevant physical and sexual sequelae were comprised of anxieties regarding informing partners of a difference, impacted sexual activity, and concerns about heritability. Finally, the potential for partner support and acceptance to positively impact romantic relationships was recognised. This research highlighted the need to extend our understanding of visible difference and intimate relationships and to develop effective interventions to ameliorate appearance-related concern.

Acceptance and Commitment Therapy for People Experiencing Appearance-Related Distress Associated With a Visible Difference: A Rationale and Review of Relevant Research

People may have a visibly different appearance due to various causes, such as congenital conditions, injury, disease, or medical treatment. Some individuals with a visible difference experience social anxiety and isolation, body image dissatisfaction, shame and self-stigma, psychological trauma, and challenges managing their condition. In this article, we synthesize the relevant literature and present the theoretical rationale for the application of Acceptance and Commitment Therapy (ACT), a third-wave behavioral therapy combining mindfulness skills and value-driven action, to those experiencing distress relating to an unusual or altered appearance. We also outline how ACT may be tailored to the specific considerations of this population and recommend next steps in researching its acceptability and clinical effectiveness.

Factors associated with negative observer responses towards individuals with visible differences: A scoping review

People with visible differences are often confronted with negative observer responses, including stares, disgust, and avoidance. Characteristics of negative observer responses are well-documented, but less is known about associated factors. We conducted a scoping review to map what is known about factors associated with negative observer responses. Web of Science, PubMed, PsycINFO, and CINAHL databases were searched, and 16 articles met inclusion criteria. Two general categories of factors were identified: (1) observer characteristics, including age, sex, and socioeconomic status, experiences with disfigurements, and personal beliefs or attitudes related to visible differences; and (2) evolved internal mechanisms, including threat-detection, disgust, and disease avoidance. Additionally, there was evidence that lack of anonymity influences lower reporting of observer reactions. Efforts that increase exposure to individuals with visible differences may ameliorate adverse reactions; however, due to the limited nature of evidence reviewed, further research is needed before more concrete recommendations can be made.

Factors affecting subjective appearance evaluations among patients with congenital craniofacial conditions: An application of Cash's cognitive-behavioural model of body image development

Satisfaction with appearance is of central importance for psychological well-being and health. For individuals with an unusual appearance, such as congenital craniofacial anomalies (CFA), appearance evaluations could be especially important. However, few, if any papers have presented a comprehensive synthesis of the factors found to affect subjective satisfaction with appearance among children, adolescents, and adults born with a CFA. Further, only a handful of craniofacial studies have applied psychological theories or models to their findings, resulting in an overall lack of guidance for researchers in the field. This paper summarises the literature pertaining to satisfaction with appearance among those affected by CFAs, and examines the extent to which Cash's cognitive-behavioural model of body image development (2012) fits with this literature. Given the overlap between factors of interest in the field of CFAs, and in the area of body image more broadly, a closer collaboration between the two research fields is suggested.

An evaluation of the impact of a burn camp on children and young people's concerns about social situations, satisfaction with appearance and behaviour

INTRODUCTION

This evaluation aimed to assess the impact of a burn camp on children and young people's concerns about social situations, satisfaction with appearance and behaviour.

METHODS

Young people completed the Perceived Stigmatisation Questionnaire (PSQ), Social Comfort Questionnaire (SCQ) and Satisfaction with Appearance Scale (SWAP) one month before camp (n=23), on the last day of camp (n=21) and at a three-month follow-up (n=13). Parents completed the Strengths and Difficulties Questionnaire (SDQ) one month before camp (n = 22) and at follow-up (n=12). Parents and young people also completed open-ended questions before camp and at the follow-up.

RESULTS

Results in this evaluation were mixed. While parents' reported scores on the SDQ were poorer after camp, young people's reported outcomes on all three measures improved at the end of camp. PSQ and SWAP scores were maintained and improved, respectively, at the follow-up. Qualitative responses were generally consistent with these scores. Significant improvements were found between the scores before camp and at the three-month follow-up for both the SWAP and PSQ. These results indicate that the burn camp may help to improve young people's satisfaction with their appearance and concerns about social situations. However, there was no comparison group and there was a significant loss of participants at follow-up.

CONCLUSION

Burn camps may therefore offer a range of psychosocial benefits to young people with burn injuries. This was the first evaluation to demonstrate a positive impact of a burn camp on satisfaction with appearance and concerns about social situations using outcome measures validated with the burns population.

Experiences of stigma over the lifetime of people with xeroderma pigmentosum: A qualitative interview study in the United Kingdom

This study explored experiences of stigma in 25 adults with xeroderma pigmentosum. Analysis of semi-structured interviews revealed the changing nature of stigma over the lifetime. Bullying occurred in childhood, whereas adults were questioned about both their photoprotection and skin damage, often resulting in internalised feelings of stigma. Resilience and rejection of feelings of stigma increased with age and experiences of stigma differed across cultures. Findings indicate a need to develop social skills training to help people reject feelings of stigma. Future research should explore perspectives of families, friends and formal institutions and their potential to cause or reduce feelings of stigma.

Pre-operative experiences and post-operative benefits of ptosis surgery: A qualitative study

This qualitative study sought to explore the experiences of patients who had undergone successful ptosis correction surgery. Participants were recruited from Bristol Eye Hospital. Nine participants were interviewed using a semi-structured interview schedule and open ended questions. Data were analysed using inductive thematic analysis. Four major themes were identified from patient accounts. Patients described the psychosocial and functional difficulties they experienced living with ptosis, and the subsequent benefits of surgery. Patients reported experiencing appearance related anxiety pre-operatively due to their condition and engaging in behaviours to avoid social encounters. Gender differences were noted in the internalization of perceived negative reactions from others, with men describing fewer adverse impacts. Patients described perceived barriers to seeking surgery including a lack of awareness of ptosis as a treatable condition, the perception that being concerned with their appearance could be seen as vain and the view that ptosis surgery is synonymous with cosmetic surgery. Following successful surgery patients outlined positive impacts on their vision, appearance and psychosocial well-being after successful surgery. This qualitative study highlights the complexities of the factors and processes contributing to the psychosocial impacts of ptosis and the potential benefits of surgery and/or psychosocial support. An increased awareness amongst people with ptosis of the potential positive impacts of surgery and an enhanced understanding of the reasons why patients may not seek treatment amongst health care professionals are likely to benefit this often overlooked patient group.

Guided internet-administered self-help to reduce symptoms of anxiety and depression among adolescents and young adults diagnosed with cancer during adolescence (U-CARE: YoungCan): a study protocol for a feasibility trial

INTRODUCTION

A subgroup of adolescents and young adults diagnosed with cancer during adolescence reports elevated levels of anxiety and depressive symptoms and unmet needs for psychological support. Evidence-based psychological treatments tailored for this population are lacking. This protocol describes a feasibility study of a guided-internet-administered self-help programme (YoungCan) primarily targeting symptoms of anxiety and depression among young persons diagnosed with cancer during adolescence and of the planned study procedures for a future controlled trial.

METHODS/ANALYSIS

The study is an uncontrolled feasibility trial with a pre-post and 3-month follow-up design. Potential participants aged 15-25 years, diagnosed with cancer during adolescence, will be identified via the Swedish Childhood Cancer Registry. 30 participants will be included. Participants will receive YoungCan, a 12-week therapist-guided, internet-administered self-help programme consisting primarily of cognitive-behavioural therapy organised into individually assigned modules targeting depressive symptoms, worry and anxiety, body dissatisfaction and post-traumatic stress. Interactive peer support and psychoeducative functions are also available. Feasibility outcomes include: recruitment and eligibility criteria; data collection; attrition; resources needed to complete the study and programme; safety procedures; participants' and therapists' adherence to the programme; and participants' acceptability of the programme and study methodology. Additionally, mechanisms of impact will be explored and data regarding symptoms of anxiety, depression, post-traumatic stress, body dissatisfaction, reactions to social interactions, quality of life, axis I diagnoses according to the Mini International Neuropsychiatric Interview and healthcare service use will be collected. Exploratory analyses of changes in targeted outcomes will be conducted.

ETHICS/DISSEMINATION

This feasibility protocol was approved by the Regional Ethical Review Board in Uppsala, Sweden (ref: 2016/210). Findings will be disseminated to relevant research, clinical, health service and patient communities through publications in peer-reviewed and popular science journals and presentations at scientific and clinical conferences.

TRIAL REGISTRATION NUMBER

ISRCTN97835363.

Study protocol of the YP Face IT feasibility study: comparing an online psychosocial intervention versus treatment as usual for adolescents distressed by appearance-altering conditions/injuries

INTRODUCTION

A significant number of adolescents suffer extensive and enduring difficulties such as social anxiety, body image dissatisfaction, low self-esteem and bullying as a result of conditions or injuries that affect their appearance (eg, craniofacial and skin conditions, treatment side effects and scarring). Evidence-based psychosocial interventions to meet their specific needs are currently lacking. YP Face IT, developed by the UK's Centre for Appearance Research in collaboration with clinical experts and young people, is an innovative online psychosocial intervention designed to offer this group immediate support, advice and coping strategies. It has been endorsed by young people, their parents/carers, GPs, clinical psychologists and health professionals working with those affected by appearance-related conditions.

METHODS AND ANALYSIS

Young people aged 12-17 with an appearance-altering condition/injury that self-identify as experiencing appearance-related distress, teasing or bullying will be invited to participate via GP practices and UK charities. Consenting participants will be randomised to the intervention (YP Face IT) or the treatment as usual (TAU) control group. Outcome measures will be completed by young people and their parents/carers at baseline, 13, 26 and 52 weeks. Primary outcome measures will be the Body Esteem Scale and the Social Anxiety Scale for Adolescents. Participants will complete other health-related outcome measures and resource use questionnaires for health economic analysis. We will assess recruitment rates, acceptability of the YP Face IT programme, adherence and retention to treatment, questionnaire completion rates, variation of TAU in Primary Care and the feasibility of GP practice staff supervising young people's use of YP Face IT.

ETHICS AND DISSEMINATION

This feasibility trial protocol (V.1, 3 March 2014), received a favourable ethical opinion from the NRES Committee South West-Frenchay (reference number 14/SW/0058). Findings will be disseminated through academic peer-reviewed publications, conferences and to participating GP practices and charities supporting those with conditions affecting appearance.

TRIAL REGISTRATION NUMBER

ISRCTN40650639; Pre-results.

An Attitudinal Study of Responses to a Range of Dermatological Conditions Using the Implicit Association Test

The Implicit Association Test (IAT) was used to explore implicit attitudes to dermatological conditions. The stimuli employed were photographs representing skin conditions and clear skin. Explicit attitudes were measured using rating scales and questions concerning participants’ experience of dermatitis. Participants ( N= 64) completed the IAT, explicit measures and demographics. The results showed a statistically significant implicit preference for people with clear skin and suggested that people who knew someone with a skin condition may exhibit stereotype inhibition. This concurs with earlier research into disfigurement, and in accord with previous IAT research, correlations between implicit and explicit measures were not significant.

Developing young person's Face IT: Online psychosocial support for adolescents struggling with conditions or injuries affecting their appearance

A participatory action approach with potential users and clinical experts was employed to design and evaluate the acceptability of young person’s Face IT (YP Face IT), an online intervention incorporating cognitive behavioural therapy and social skills training for adolescents with appearance-related anxiety as a result of a visible difference. Workshops with adolescents and clinicians informed a prototype YP Face IT which underwent a usability analysis by 28 multidisciplinary health professionals and 18 adolescents, before 10 adolescents completed it at home. Acceptability data obtained online and via interview were analysed using content analysis. Participants found YP Face IT acceptable and believed it would provide much needed and easy access to psychosocial support. They requested that it should be made widely available either as a self-management tool requiring minimal supervision from a health professional or to compliment therapist-led care.

The Effectiveness of Psychosocial Intervention for Individuals with Cleft Lip and/or Palate

Objective

The aim of this review was to assess the effectiveness of different psychological interventions for children and adults with cleft lip and/or palate and their parents.

Design

We searched six databases including MEDLINE and EMBASE to June 2013 and checked bibliographies. We included research that evaluated any psychological intervention in studies in which at least 90% of the participants had cleft lip and/or palate or were parents of those with cleft lip and/or palate. Studies containing less than 90% were excluded unless they reported results separately for those with cleft lip and/or palate, or raw data were available upon request from the authors. Inclusion assessment, data extraction, and risk of bias assessment were carried out independently by two reviewers.

Results

Seven studies were identified as inclusions, with only two studies being included in the full data analysis (one of which failed to meet the full inclusion criteria). The five remaining studies were included only in a narrative synthesis because data were available for people or parents of those with cleft lip and/or palate only. This highlights a distinct dearth of research into psychological intervention within the field of cleft lip and/or palate.

Conclusions

The review found no evidence to support any specific intervention. Key uncertainties need to be identified and addressed. Adequately powered, methodologically rigorous randomized controlled trials are needed to provide a secure evidence base for psychological intervention techniques in participants with cleft lip and/or palate and their parents.

Psychosocial interventions for adults with visible differences: a systematic review

Background. Some individuals with visible differences have been found to experience psychosocial adjustment problems that can lead to social anxiety and isolation. Various models of psychosocial intervention have been used to reduce social anxiety and appearance related distress in this population. The objective of this review was to update a previous systematic review assessing the efficacy of psychosocial intervention programs for adults with visible differences. The original review (Bessell & Moss, 2007) identified 12 papers for inclusion. Methods. A search protocol identified studies from 13 electronic journal databases.

METHODS

Studies were selected in accordance with pre-set inclusion criteria and relevant data were extracted. Results. This update identified an additional four papers that met the inclusion criteria. Two papers provided very limited evidence for the efficacy of a combined cognitive-behavioural and social skills training approach. None of the papers provided sufficient evidence for the optimal duration, intensity or setting of psychosocial interventions for this population. Discussion. The review concluded that a greater number of Randomised Controlled Trials and experimental studies were required to increase the methodological validity of intervention studies.

The Utility of Template Analysis in Qualitative Psychology Research

Thematic analysis is widely used in qualitative psychology research, and in this article, we present a particular style of thematic analysis known as Template Analysis. We outline the technique and consider its epistemological position, then describe three case studies of research projects which employed Template Analysis to illustrate the diverse ways it can be used. Our first case study illustrates how the technique was employed in data analysis undertaken by a team of researchers in a large-scale qualitative research project. Our second example demonstrates how a qualitative study that set out to build on mainstream theory made use of the a priori themes (themes determined in advance of coding) permitted in Template Analysis. Our final case study shows how Template Analysis can be used from an interpretative phenomenological stance. We highlight the distinctive features of this style of thematic analysis, discuss the kind of research where it may be particularly appropriate, and consider possible limitations of the technique. We conclude that Template Analysis is a flexible form of thematic analysis with real utility in qualitative psychology research.

Variáveis individuais e familiares na psoríase: um estudo com doentes e parceiros

Este trabalho avalia morbilidade, qualidade de vida, ajustamento de casal, coping familiar e imagem corporal em 101 doentes com psoríase e 78 parceiros. Os resultados revelaram uma relação positiva entre as variáveis dos doentes e parceiros no que diz respeito ao ajustamento, coping e morbilidade. Pior qualidade de vida e imagem corporal no doente estão associadas a mais morbilidade no parceiro. Os doentes em tratamento combinado e fototerapia apresentaram pior qualidade de vida e insatisfação com a imagem corporal. Melhor ajustamento de casal e menor ansiedade no parceiro predizem ajustamento de casal no doente. Satisfação com a imagem corporal prevê melhor qualidade de vida no doente. Os resultados enfatizam a necessidade de envolver os parceiros nos programas de intervenção. As implicações são apresentadas.

A qualitative analysis of acute skin toxicity among breast cancer radiotherapy patients

OBJECTIVES

One of the most common acute side effects of breast cancer radiotherapy is treatment-induced skin changes, referred to as skin toxicity. Yet no research to date has focused expressly on skin toxicity-related quality of life (QOL) in breast cancer radiotherapy patients. Therefore, our aim was to use qualitative approaches to better understand the impact of skin toxicity on QOL.

METHODS

Semistructured interviews were conducted with 20 women (Stage 0-III breast cancer), during their last week of external beam radiotherapy. Each interview was transcribed verbatim, and thematic analysis was performed.

RESULTS

Three themes were identified based on the interview responses: First, skin changes affect multiple dimensions of QOL. They cause physical discomfort, body image disturbance, emotional distress, and impair both day-to-day functioning and satisfaction with radiation treatment. Second, individual differences affect women's experiences. Generally African American women, younger women, women who are not currently in a relationship, women who are being treated during the summer, and women who are more invested in their appearance are more distressed by skin toxicity. Third, women use a variety of symptom management strategies including self-medication, complementary/alternative medicine approaches, and psychological strategies.

CONCLUSIONS

Implications of results are as follows: (1) skin toxicity affects numerous dimensions of QOL, and assessment approaches and psychosocial interventions should address this; (2) individual differences may affect the experience of skin toxicity and should be considered in treatment and education approaches; and (3) participants' own creativity and problem-solving should be used to improve the treatment experience.

Incorporating User Perspectives in the Design of an Online Intervention Tool for People with Visible Differences: Face IT

Background:Individuals with visible differences can experience social anxiety in relation to their appearance. Social skills-based psychosocial interventions have to date shown only limited effectiveness at addressing their concerns.Aims:To incorporate user perspectives in the development of an online psychosocial intervention, known as Face IT.Method and Results:Study one consisted of a needs assessment with 12 individuals with a visible difference and six health professionals in order to identify the difficulties experienced by those with visible difference and obtain feedback on the proposed content of Face IT. The findings demonstrated support for the social skills model and the use of an online intervention. Study two consisted of an empirical usability evaluation of Face IT with 14 potential users and 14 health professionals. Based on feedback from the participants, changes were made to the graphics and navigation of the programme. The clinical content has been made more acceptable.Conclusions:The findings indicate support for the importance of social skills-based psychosocial interventions for addressing the needs of those with a visible difference, and have allowed modifications to be made to Face IT ahead of a randomized controlled trial of effectiveness.