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Wang X, Liu Y, Liu Y, Zhang J, Liu L, Matarese M, Wang L. Exploring patients with COPD self-care behaviours and self-efficacy and their interconnections: A network analysis. J Clin Nurs 2024. [PMID: 39041386 DOI: 10.1111/jocn.17378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 05/16/2024] [Accepted: 07/11/2024] [Indexed: 07/24/2024]
Abstract
AIM The aim of this study was to investigate self-care behaviours of patients with chronic obstructive pulmonary disease (COPD), understand their complex interconnections and identify key behaviours influencing self-care and self-efficacy. DESIGN An observational, cross-sectional study design. SETTING(S) The outpatient department of two tertiary hospital. METHODS A convenience sample of patients with a diagnosis of COPD were included (n = 222). Self-care behaviours were assessed using the Chinese version of self-care of chronic obstructive pulmonary disease inventory based on the Middle-Range Theory of Self-Care of Chronic Illness. Patient self-care efficacy was evaluated using Chinese version of Self-Care Self-Efficacy Scale in Chronic Obstructive Pulmonary Disease. Employing network analysis, associations between behaviours (nodes) and their interrelationships (edges) were deciphered. The study was reported following the STROBE checklist. RESULTS Among the spectrum of self-care behaviours, patients exhibited the most pronounced deficiencies in behaviours directed to enhancing breathing, monitoring extra-respiratory symptoms and problem-solving. Within the network, the most central emerging behaviour was the modification of prescribed therapy at the worsening of symptoms, as suggested by healthcare providers, which drives all self-care behaviours. The confidence in being able to do something to relieve symptoms, despite difficulties, was a bridging activator of self-care. The network structure underscored the prominence of self-care self-efficacy in driving self-care maintenance, monitoring, and management behaviours. CONCLUSIONS Education programs for COPD should prioritise enhancing breathing, symptom monitoring and problem-solving skills. The crucial self-care behaviour in COPD involves adjusting treatments in response to symptom changes. Patient confidence in symptom alleviation acts as a catalyst for self-care engagement. Targeted assessments addressing these aspects could enhance educational interventions, ultimately improving COPD patient outcomes. REGISTRATION This study has been registered in the Chinese Clinical Trials Registry (registration number: ChiCTR2200059764; registration date: 11 May 2022).
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Affiliation(s)
- Xinyu Wang
- School of Nursing, Tianjin Medical University, Tianjin, China
- TianJin Eye Hospital, Tianjin, China
| | - Yuan Liu
- Tianjin Medical University General Hospital, Tianjin, China
| | - Yong Liu
- School of Nursing, Tianjin Medical University, Tianjin, China
| | | | - Ling Liu
- School of Nursing, Tianjin Medical University, Tianjin, China
| | - Maria Matarese
- Research Unit of Nursing Sciences, Faculty of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Lan Wang
- School of Nursing, Tianjin Medical University, Tianjin, China
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Wang X, Zhang L, Liu Y, Liu L, De Maria M, Matarese M, Wang L. Psychometric properties of the Chinese version of the Self-Care in Chronic Obstructive Pulmonary Disease Inventory based on the Middle-Range Theory of Self-Care of Chronic Illness. Int J Nurs Pract 2024; 30:e13230. [PMID: 38123159 DOI: 10.1111/ijn.13230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 05/30/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023]
Abstract
AIMS To test the psychometric properties of the Chinese version of the Self-Care in Chronic Obstructive Pulmonary Disease Inventory on a sample of patients with chronic obstructive pulmonary disease in China. BACKGROUND Measuring the self-care of patients with chronic obstructive pulmonary disease is vital to promote the performance of effective self-care behaviours. However, few instruments have been developed to measure self-care in chronic obstructive pulmonary disease, and the existing instruments lack theoretical support and satisfactory psychometrics properties. The Self-Care in Chronic Obstructive Pulmonary Disease Inventory based on Middle-Range Theory of Self-Care of Chronic Illness has been developed and tested previously in Italian and US population. DESIGN A cross-sectional instrument development study. METHODS Construct validity was tested by confirmatory factor analysis and hypothesis testing, and reliability internal consistency using factor score determinacy coefficients. RESULTS A convenience sample of 185 patients with chronic obstructive pulmonary disease was recruited from September 2020 to January 2022. The instrument consists of three scales: self-care maintenance, self-care monitoring and self-care management. Confirmatory factor analysis performed on the three scales produced good fit indices. The internal consistency was adequate with factor score determinacy coefficients ranging from 0.891 to 0.953 in Self-Care Maintenance Scale, 0.990 to 0.993 in Self-Care Monitoring Scale and 0.750 to 0.976 in Self-Care Management Scale. CONCLUSIONS The Chinese version of the Self-Care in Chronic Obstructive Pulmonary Disease Inventory has acceptable reliability and validity. Some differences from the original instrument were identified. Further validation studies should be conducted to confirm the psychometric properties of the instrument in Chinese population.
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Affiliation(s)
- Xinyu Wang
- School of Nursing, Tianjin Medical University, Tianjin, China
| | - Lujing Zhang
- School of Nursing, Tianjin Medical University, Tianjin, China
| | - Yuan Liu
- Tianjin Medical University General Hospital, Tianjin, China
| | - Ling Liu
- School of Nursing, Tianjin Medical University, Tianjin, China
| | - Maddalena De Maria
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Maria Matarese
- Research Unit of Nursing Sciences, Faculty of Medicine, Campus Bio-Medico University of Rome, Rome, Italy
| | - Lan Wang
- School of Nursing, Tianjin Medical University, Tianjin, China
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Lee JE, Nguyen HQ, Fan VS. Inflammatory Markers and Fatigue in Individuals With Moderate to Severe Chronic Obstructive Pulmonary Disease. Nurs Res 2024; 73:54-61. [PMID: 38064303 PMCID: PMC10751060 DOI: 10.1097/nnr.0000000000000695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
BACKGROUND Fatigue, a prevalent complex symptom among patients with chronic obstructive pulmonary disease (COPD), is considered an important clinical indicator of disease severity. However, the underlying mechanisms of COPD-related fatigue are not fully understood. OBJECTIVES This analysis explored the relationships between peripheral inflammatory markers and COPD-related fatigue in people with moderate to severe COPD. METHODS This is a secondary analysis of a longitudinal observational study of individuals with COPD examining the biological causes and functional consequences of depression. The data used in this study were collected at baseline. Systemic inflammation markers included C-reactive protein (CRP) and three pro-inflammatory cytokines consisting of interleukin-6 (IL-6), IL-8, and tumor necrosis factor-α. COPD-related fatigue was self-reported using the Chronic Respiratory Questionnaire. Covariates included age; gender; smoking status; disease severity; symptoms of depression, anxiety, and pain; and social support. Multivariable linear regression analyses were conducted. RESULTS The sample included 300 adults living with COPD; 80% were male, and the average age was 67.6 years. Modest correlations were found between two systemic inflammatory markers (CRP and IL-8) and COPD-related fatigue. CRP was the only inflammatory marker significantly associated with fatigue symptoms after adjusting for covariates in multivariable analyses. Depression, pain, and education level were also significant predictors of COPD-related fatigue. DISCUSSION The findings suggest that altered immune response based on CRP may contribute to COPD-related fatigue. Management of depression and pain may work as an effective treatment strategy for COPD-related fatigue. Further longitudinal studies with a broader range of inflammatory markers and multidimensional measures of fatigue symptoms are warranted.
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Reizes Z, McNamara RJ, Dale M, McKeough Z. Establishing the Validity of Using the COPD Assessment Test to Screen for Fatigue in People With Chronic Obstructive Pulmonary Disease Referred to Pulmonary Rehabilitation. Phys Ther 2023; 103:pzad064. [PMID: 37329503 PMCID: PMC10471199 DOI: 10.1093/ptj/pzad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 02/20/2023] [Accepted: 03/28/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE Fatigue is the second most prevalent symptom in chronic obstructive pulmonary disease (COPD), yet it is often undetected in pulmonary rehabilitation. The aim of this study was to assess the validity of using a health status questionnaire (COPD Assessment Test [CAT] and CAT-energy score) to detect fatigue in people with COPD referred to a pulmonary rehabilitation program. METHODS This study was a retrospective audit of people with COPD referred to pulmonary rehabilitation. The validity of the CAT-total score and CAT-energy score for detecting fatigue was analyzed compared to a validated fatigue questionnaire, the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F). Cut-off values defining fatigue included a CAT-total score ≥ 10, a CAT-energy score ≥ 2, and a FACIT-F score ≤ 43. Data were analyzed using 2 × 2 tables from which accuracy, sensitivity, specificity, and likelihood ratios were calculated. RESULTS Data from 97 participants with COPD (age in years mean [SD] = 72 [9]; FEV1% predicted mean [SD] = 46% [18]) were used. The FACIT-F score ≤ 43 classified 84 participants (87%) as fatigued. A CAT-total score ≥ 10 yielded an accuracy of 0.87, sensitivity of 0.95, specificity of 0.31, and positive and negative likelihood ratios of 1.38 and 0.15, respectively. A CAT-energy score ≥ 2 yielded an accuracy of 0.85, sensitivity of 0.93, a specificity of 0.31, and positive and negative likelihood ratios of 1.34 and 0.23, respectively. CONCLUSION The CAT-total score is an accurate and sensitive measure for fatigue, and the CAT could be an appropriate tool to screen for fatigue in people with COPD referred to pulmonary rehabilitation. IMPACT Use of the CAT as a screening tool for fatigue has the potential to improve clinician awareness of fatigue, simplify the pulmonary rehabilitation assessment process by reducing survey burden, and inform fatigue management, which may subsequently reduce the symptomatic burden of fatigue in people with COPD.
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Affiliation(s)
- Zoe Reizes
- Sydney School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Renae J McNamara
- Department of Physiotherapy, Prince of Wales Hospital, Randwick, New South Wales, Australia
- Woolcock Institute of Medical Research, Glebe, New South Wales, Australia
| | - Marita Dale
- Sydney School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Zoe McKeough
- Sydney School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
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Stability of distinct symptom experiences in patients with chronic obstructive pulmonary disease (COPD). Respir Med 2022; 201:106944. [PMID: 35970058 DOI: 10.1016/j.rmed.2022.106944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/06/2022] [Accepted: 07/24/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE This study aimed to examine reclassification rates among classes of chronic obstructive pulmonary disease (COPD) patients based on their distinct symptom experiences and to assess how these subgroups differed in symptom scores and health-related quality of life (HRQoL) outcomes over one year. Moreover, we wished to assess how these subgroups differed in demographic and clinical characteristics at 12 months. PATIENTS AND METHODS This is a follow-up study of 267 patients with moderate, severe, and very severe COPD. Based on their distinct symptom experiences using the Memorial Symptom Assessment Scale (MSAS), three subgroups (i.e., "high", "intermediate", and "low") were identified at baseline. In the present study, transitions between the subgroups at three, six, nine, and 12 months were investigated and calculated as reclassification rates. Differences among the subgroups in symptom scores and HRQoL at each time point and demographic and clinical characteristics at 12 months were evaluated using analysis of variance with post hoc comparisons. RESULTS Almost 65% were still in the "high" class after 12 months. At 12 months, pairwise comparisons for respiratory function measurements were not significantly different. Compared to the "intermediate" and "low" class, patients in the "high" class were more likely to be women and had significantly more comorbidities, reported a significantly higher number of symptoms at all time points, and worse HRQoL scores. CONCLUSION Our findings suggest that the pattern of a high symptom burden in COPD is consistent over time. The patients' individual symptom experiences should be the primary focus of treatment.
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Rantala HA, Leivo-Korpela S, Lehtimäki L, Lehto JT. Assessing Symptom Burden and Depression in Subjects With Chronic Respiratory Insufficiency. J Palliat Care 2021; 37:134-141. [PMID: 34841962 PMCID: PMC9109583 DOI: 10.1177/08258597211049592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objectives: Patients with chronic respiratory insufficiency suffer
from advanced disease, but their overall symptom burden is poorly described. We
evaluated the symptoms and screening of depression in subjects with chronic
respiratory insufficiency by using the Edmonton symptom assessment system
(ESAS). Methods: In this retrospective study, 226 subjects with
chronic respiratory insufficiency answered the ESAS questionnaire measuring
symptoms on a scale from 0 (no symptoms) to 10 (worst possible symptom), and the
depression scale (DEPS) questionnaire, in which the cut-off point for depressive
symptoms is 9. Results: The most severe symptoms measured with ESAS
(median [interquartile range]) were shortness of breath 4.0 (1.0-7.0), dry mouth
3.0 (1.0-7.0), tiredness 3.0 (1.0-6.0), and pain on movement 3.0 (0.0-6.0).
Subjects with a chronic obstructive pulmonary disease as a cause for chronic
respiratory insufficiency had significantly higher scores for shortness of
breath, dry mouth, and loss of appetite compared to others. Subjects with DEPS
≥9 reported significantly higher symptom scores in all ESAS categories than
subjects with DEPS <9. The area under the receiver operating characteristic
curve for ESAS depression score predicting DEPS ≥9 was 0.840
(P < .001). If the ESAS depression score was 0, there was an
89% probability of the DEPS being <9, and if the ESAS depression score was
≥4, there was an 89% probability of the DEPS being ≥9. The relation between ESAS
depression score and DEPS was independent of subjects’ characteristics and other
ESAS items. Conclusions: Subjects with chronic respiratory
insufficiency suffer from a high symptom burden due to their advanced disease.
The severity of symptoms increases with depression and 4 or more points in the
depression question of ESAS should lead to a closer diagnostic evaluation of
depression. Symptom-centered palliative care including psychosocial aspects
should be early integrated into the treatment of respiratory insufficiency.
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Affiliation(s)
- Heidi A Rantala
- Department of Respiratory Medicine, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Sirpa Leivo-Korpela
- Department of Respiratory Medicine, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Juho T Lehto
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Oncology, Palliative Care Unit, Tampere University Hospital, Tampere, Finland
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Nishimura K, Nakayasu K, Mori M, Sanda R, Shibayama A, Kusunose M. Are Fatigue and Pain Overlooked in Subjects with Stable Chronic Obstructive Pulmonary Disease? Diagnostics (Basel) 2021; 11:diagnostics11112029. [PMID: 34829376 PMCID: PMC8620334 DOI: 10.3390/diagnostics11112029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 11/19/2022] Open
Abstract
Although there have been many published reports on fatigue and pain in patients with chronic obstructive pulmonary disease (COPD), it is considered that these symptoms are seldom, if ever, asked about during consultations in Japanese clinical practice. To bridge this gap between the literature and daily clinical experience, the authors attempted to gain a better understanding of fatigue and pain in Japanese subjects with COPD. The Brief Fatigue Inventory (BFI) to analyse and quantify the degree of fatigue, the revised Short–Form McGill Pain Questionnaire 2 (SF-MPQ-2) for measuring pain and the Kihon Checklist to judge whether a participant is frail and elderly were administered to 89 subjects with stable COPD. The median BFI and SF-MPQ-2 Total scores were 1.00 [IQR: 0.11–2.78] and 0.00 [IQR: 0.00–0.27], respectively. They were all skewed toward the milder end of the respective scales. A floor effect was noted in around a quarter on the BFI and over half on the SF-MPQ-2. The BFI scores were significantly different between groups regarding frailty determined by the Kihon Checklist but not between groups classified by the severity of airflow limitation. Compared to the literature, neither fatigue nor pain are considered to be frequent, important problems in a real-world Japanese clinical setting, especially among subjects with mild to moderate COPD. In addition, our results might suggest that fatigue is more closely related to frailty than COPD.
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Affiliation(s)
- Koichi Nishimura
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu 474-8511, Japan; (M.M.); (R.S.); (M.K.)
- Correspondence: ; Tel.: +81-562-46-2311
| | - Kazuhito Nakayasu
- Data Research Section, Kondo Photo Process Co., Ltd., Osaka 543-0011, Japan;
| | - Mio Mori
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu 474-8511, Japan; (M.M.); (R.S.); (M.K.)
| | - Ryo Sanda
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu 474-8511, Japan; (M.M.); (R.S.); (M.K.)
| | - Ayumi Shibayama
- Department of Nursing, National Center for Geriatrics and Gerontology, Obu 474-8511, Japan;
| | - Masaaki Kusunose
- Department of Respiratory Medicine, National Center for Geriatrics and Gerontology, Obu 474-8511, Japan; (M.M.); (R.S.); (M.K.)
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8
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Ebadi Z, Goërtz YMJ, Van Herck M, Janssen DJA, Spruit MA, Burtin C, Thong MSY, Muris J, Otker J, Looijmans M, Vlasblom C, Bastiaansen J, Prins J, Wouters EFM, Vercoulen JH, Peters JB. The prevalence and related factors of fatigue in patients with COPD: a systematic review. Eur Respir Rev 2021; 30:30/160/200298. [PMID: 33853886 DOI: 10.1183/16000617.0298-2020] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 01/04/2021] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Fatigue is a distressing symptom in patients with COPD. Little is known about the factors that contribute to fatigue in COPD. This review summarises existing knowledge on the prevalence of fatigue, factors related to fatigue and the instruments most commonly used to assess fatigue in COPD. METHODS Pubmed, PsycINFO, EMBASE, Cochrane and CINAHL databases were searched for studies from inception up to 7 January 2020 using the medical subject headings "COPD" and "Fatigue". Studies were reviewed in accordance with PRISMA guidelines. RESULTS 196 studies were evaluated. The prevalence of fatigue ranged from 17-95%. Age (r=-0.23 to r=0.27), sex (r=0.11), marital status (r=-0.096), dyspnoea (r=0.13 to r=0.78), forced expiatory volume in 1 s % predicted (r=-0.55 to r=-0.076), number of exacerbations (r=0.27 to r=0.38), number of comorbidities (r=0.10), number of medications (r=0.35), anxiety (r=0.36 to r=0.61), depression (r=0.41 to r=0.66), muscle strength (r=-0.78 to r=-0.45), functional capacity (r=-0.77 to r=-0.14) and quality of life (r=0.48 to r=0.77) showed significant associations with fatigue. CONCLUSIONS Fatigue is a prevalent symptom in patients with COPD. Multiple physical and psychological factors seem to be associated with fatigue. Future studies are needed to evaluate these underlying factors in integral analyses in samples of patients with COPD.
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Affiliation(s)
- Zjala Ebadi
- Dept of Medical Psychology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Joint first authors
| | - Yvonne M J Goërtz
- Dept of Research and Development, Ciro, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands.,Joint first authors
| | - Maarten Van Herck
- Dept of Research and Development, Ciro, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands.,REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
| | - Daisy J A Janssen
- Dept of Research and Development, Ciro, Horn, The Netherlands.,Dept of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Martijn A Spruit
- Dept of Research and Development, Ciro, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, The Netherlands
| | - Chris Burtin
- REVAL - Rehabilitation Research Center, BIOMED - Biomedical Research Institute, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
| | - Melissa S Y Thong
- Dept of Medical Psychology, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Jean Muris
- Dept of Family Medicine, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | | | - Milou Looijmans
- Dept of Medical Psychology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Christel Vlasblom
- Dept of Medical Psychology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Joëlle Bastiaansen
- Dept of Medical Psychology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Judith Prins
- Dept of Medical Psychology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Emiel F M Wouters
- Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,Ludwig Boltzmann Institute for Lung Health, Vienna, Austria
| | - Jan H Vercoulen
- Dept of Medical Psychology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Jeannette B Peters
- Dept of Medical Psychology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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