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Holistic News
| Music: A Healing Art |
January 1, 2007
A recent study by researchers at the University of Pavia in Italy concludes that music therapy (MT) may have a beneficial effect on relieving the suffering of those with Parkinson's disease and in maximizing their quality of life. These same benefits may extend to other chronic and incurable diseases, such as:
- Patients with physically and mentally handicapping conditions
- Patients before and after surgery and invasive medical procedures
- Following heart attack, respiratory failure and advanced cancer
- Patients with Alzheimer's disease
- Patients in geriatric care facilities
MT is an active therapy: meaning you, the patient, are the one who creates the music, as opposed to passively listening to music. The key to the therapy rests in your efforts. Creative genius is definitely not required. Researchers claim that the making of music helps to achieve a more relaxed and happy state of mind. Often MT is used along with physical or other therapies, nutritional and psychological counseling, all aimed at achieving optimal physiological and emotional function.
The creative arts are becoming more widely used in the care of patients with chronic illnesses of many kinds.
However, MT is not a new therapy. According to medical literature, MT is the longest established of the creative healing arts in the United States. MT heals through increasing endorphin neuropeptide release, enhancing immune function, reducing corticosteroid hormonal levels, and modifying brain wave activity. Many of the physiological effects resemble those achieved with meditation, yoga, t'ai chi, biofeedback, and other holistic approaches that emphasize overall well being.
Engaging in other creative arts may produce the results similar to those from MT. Studies in diverse settings have recorded significant benefits in physical, mental, spiritual, and social health from the active involvement in the creative activity, as opposed to being simply passive recipients. Another particular benefit of MT is the way it brings groups of people together. This makes it a valuable tool for encouraging communal as well as personal health, something most cultures have long recognized and valued.
Incorporating MT into your treatment can be very simple, inexpensive and straightforward, once you have reassured you doctor and his or her staff that you want to do it. Music therapists are increasingly able to bill insurance companies for their services, making it easy at least for larger general practices to hire such practitioners without any financial outlay. The rising cost of healthcare and prescription drugs, it becomes important to seek out cost-effective and nontoxic therapies. The skills required are readily available through motivated musicians. The point of becoming actively involved in music making is not to achieve a particular skill standard but to simply experience the creative process of music and rhythmic movement for its own sake.
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Graham-Pole, J. Making Music. The Integrative Consult. August 2000. |
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| Review Date: December 2000 |
Reviewed By: Integrative Medicine editorial
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Copyright © 2004 A.D.A.M., Inc
The publisher does not accept any responsibility for the accuracy of the information or the consequences arising from the application, use, or misuse of any of the information contained herein, including any injury and/or damage to any person or property as a matter of product liability, negligence, or otherwise. No warranty, expressed or implied, is made in regard to the contents of this material. No claims or endorsements are made for any drugs or compounds currently marketed or in investigative use. This material is not intended as a guide to self-medication. The reader is advised to discuss the information provided here with a doctor, pharmacist, nurse, or other authorized healthcare practitioner and to check product information (including package inserts) regarding dosage, precautions, warnings, interactions, and contraindications before administering any drug, herb, or supplement discussed herein. |
See more in our Holistic Articles Area |
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| You're Getting Verrrrry ... Healthy |
January 1, 2007
You're Getting Verrrrry ... Healthy. The Healing Powers of Hypnotherapy
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When you hear the word "hypnosis" do you immediately picture a shady character swinging a watch in front of your face trying to make you do something you don't want to do? If so, it's time you learned the facts about this growing alternative therapy.
Hypnotherapy is the name given to hypnosis when it's used for medical purposes. The medical community recognizes hypnotherapy as helpful for a number of health conditions. Most commonly, hypnotherapists treat anxiety and stress, pain, smoking, and overeating. There are other uses for hypnotherapy, however, including help with asthma, childbirth, diabetes, eczema, irritable bowel syndrome, sleep problems, surgical procedures, tics, and Tourette's syndrome. A study in 1999 suggested that hypnosis may help bone fractures heal faster. And it may reduce the need for pain medication during the healing time.
In a hypnotherapy session, a hypnotherapist will work to bring you into a trance-like state. This state is a normal part of human consciousness. It is not, contrary to popular belief, an unnatural psychological state that can be suddenly brought on. In fact, many of us enter this state on our own on a regular basis—we refer to it as "drifting off into space" or "spacing out." A hypnotized person is fully aware of what's going on and can end the session if feeling uncomfortable. About 20 percent of people take to hypnotic suggestion easily and enter deeply into this state. If you are one of these, you may not remember a therapy session after it's done. Another 20 percent may not respond to a hypnotherapist's suggestions at all. The rest of us fall somewhere in between. Children (over 5 years of age) generally respond well to hypnotherapy.
The most common technique used by hypnotherapists is to repeat a direct command in a low, steady tone of voice. Once a trance-like state is achieved, a hypnotherapist can suggest how you should feel about something when you wake up. For example, if you're trying to quit smoking, he or she may suggest to you that in the future you will be disgusted by the taste of cigarettes.
Hypnotherapy may be a good choice if you want to learn how to relax or if you have a stress-related health problem. However, if you have a strong desire to remain in control of your circumstances you may not be able to find help in hypnotherapy. It's also important that you feel comfortable working with a hypnotherapist. You will need to be an active partner and commit yourself to regular self-hypnosis, which your therapist will teach you. You will benefit most by practicing 15 to 20 minutes of self-hypnosis every day.
You should only see a hypnotherapist who is professionally qualified. Preferably, find someone who also has training in psychiatry or psychology. Hypnotherapy is a powerful tool; you need to feel confident that your therapist understands your goals and will direct you appropriately. To find a therapist, go to the National Board for Certified Clinical Hypnotherapists' Web site at www.natboard.com or the International Registry of Professional Hypnotherapists' site at www.hypnosis.org. And discuss your hypnosis plans with your doctor. |
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| References |
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Hypnosis. The World Book Rush-Presbyterian St. Luke's Medical Center Medical Encyclopedia. Available at http://content.health.msn.com.
Kohen DP, Olness KN, Colwelll SO, Heimel A. The use of relaxation-mental imagery (self-hypnosis) in the management of 505 pediatric encounters. J Dev Behav Pediatr. 1984;5(1):21-25.
Loitman J. Pain management: Beyond pharmacology to acupuncture and hypnosis. JAMA Online. Available at http://www.ama-assn.org.
Olness K. Hypnotherapy: A cyberphysiologic strategy in pain management. Pediatr Clin North Am. 1989;36(4):873-884.
Peck P. Relaxation technique cuts time and cost. Web MD Medical News. Available at http://content.health.msn.com.
Shealy, CN. The Complete Family Guide to Alternative Medicine: An Illustrated Encyclopedia of Natural Healing. New York, New York: Barnes & Noble, Inc.; 1996.
Sugarman LI. Hypnosis in a primary care practice: developing skills for the "new morbitities." J Dev Behav Pediatr. 1996;17(5):300-306.
Sugarman LI. Imaginative Medicine: Hypnosis in pediatric practice (videotape). Rochester, NY: Imaginative Medicine; 1997.
Telephone interviews with Daniel Kohen, M.D. and Laurence Sugarman, M.D.
Ginandes CS, Rosenthal DI. Using hypnosis to accelerate the healing of bone fractures: a randomized controlled pilot study. Altern Ther Health Med. 1999:5(2):67-75. |
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| Review Date: January 2000 |
Reviewed By: Integrative Medicine editorial
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Copyright © 2004 A.D.A.M., Inc
The publisher does not accept any responsibility for the accuracy of the information or the consequences arising from the application, use, or misuse of any of the information contained herein, including any injury and/or damage to any person or property as a matter of product liability, negligence, or otherwise. No warranty, expressed or implied, is made in regard to the contents of this material. No claims or endorsements are made for any drugs or compounds currently marketed or in investigative use. This material is not intended as a guide to self-medication. The reader is advised to discuss the information provided here with a doctor, pharmacist, nurse, or other authorized healthcare practitioner and to check product information (including package inserts) regarding dosage, precautions, warnings, interactions, and contraindications before administering any drug, herb, or supplement discussed herein. | |
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| See more in our Holistic Articles Area |
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| Dealing with Domestic Violence |
January 1, 2007
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As many as one in five women who visit emergency rooms are victims of domestic violence. In total, about two to four million women in the United States are victims of domestic violence each year. And every day, four of them die. Still, many doctors and medical staff do not ask their patients about domestic violence.
Domestic violence is one family member harming another family member. Anyone, no matter what their sex, age, or social status, may be a victim. Most commonly, but not always, domestic violence involves a man abusing a woman. The abuse may be physical, sexual, or emotional. Physical abuse includes hitting, kicking, pushing, and choking. Sexual abuse is forced sexual participation. This includes participation when one person is unconscious or afraid to say no. Psychological abuse includes yelling at, threatening, blaming, and making someone feel inferior or stupid. Often more than one kind of abuse happens in domestic violence. Domestic violence usually continues over a long time and gets more frequent and severe over time.
If you suffer from domestic violence, you may visit your doctor because you are also having difficulty sleeping, are anxious, depressed, or drinking too much. Your doctor may quickly diagnose your sleep disorder, depression, eating disorder, or alcohol abuse. However, he or she may not ask you if these are related to domestic violence. A recent study shows that about half of physicians, physician assistants, and nurse practitioners think that domestic violence is very rare. Even more nurses feel this way. Almost half of the medical professionals surveyed said that when they meet a patient with injuries that might be due to domestic violence they seldom or never ask direct questions about domestic violence.
If you feel you are a victim of domestic violence, speak up. Visit your doctor right away, and tell them your concerns. If you know someone who might be abused, talk to him or her and urge that person to get help. Anyone can get help from the National Domestic Violence Hotline at 1-800-799-SAFE. If you see domestic violence happening or hear a violent fight, call 911. You may save someone's life. |
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| References |
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American Academy of Family Physicians, Commission on Special Issues and Clinical Interests. Family violence: an AAFP white paper. Am Fam Physician. 1994;50:1636-1646.
Freund KM, Bak SM, Blackhall I. Identifying domestic violence in primary care. J Gen Intern Med. 1996;1:44-46.
Freidman LS, Samet JH, Roberts MS, et al. Inquiry about victimization experiences: a survey of patient preferences and physician practices. Arch Intern Med. 1992;152:1186-1190.
Hamberger LK, Saunders DG, Hovey M. Prevalence of domestic violence in community practice and rate of physician inquiry. Fam Med. 1992;24:283-287.
Rodriguez MA, Bauer HM, McLoughlin E, Grumbach K. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA 1999;282(5):468-474.
McFarlance J, Parker B, Seeken K, Bullock L. Assessing for abuse during pregnancy. Severity and frequency of injuries and associated entry into prenatal care. JAMA 1992;267(23):3176-3178.
Sugg NK, Thompson RS, Thompson DC, Maiuro R, Rivara FP. Domestic violence and primary care: attitudes, practices, and beliefs. Arch Fam Med. 1999;8:301-306.
Wiist WH, McFarlance J. The effectiveness of an Abuse Assessment Protocol in Public Health Prenatal Clinics. Am J Public Health 1999;89(8):1217-1221.
Violence Against Women section on the American College of Obstetricians and Gynecologists' Web site at www.acog.org.
"Domestic Violence" on AMA Health Insight on the AMA Web site, www.ama-assn.org.
"Domestic Violence and Primary Care: Attitudes, Practices, and Beliefs," Archives of Family Medicine, July/August 1999. On the AMA Web site, www.ama-assn.org. |
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| Review Date: March 2000 |
Reviewed By: Integrative Medicine editorial
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Copyright © 2004 A.D.A.M., Inc
The publisher does not accept any responsibility for the accuracy of the information or the consequences arising from the application, use, or misuse of any of the information contained herein, including any injury and/or damage to any person or property as a matter of product liability, negligence, or otherwise. No warranty, expressed or implied, is made in regard to the contents of this material. No claims or endorsements are made for any drugs or compounds currently marketed or in investigative use. This material is not intended as a guide to self-medication. The reader is advised to discuss the information provided here with a doctor, pharmacist, nurse, or other authorized healthcare practitioner and to check product information (including package inserts) regarding dosage, precautions, warnings, interactions, and contraindications before administering any drug, herb, or supplement discussed herein. |
See more in our Holistic Articles Area |
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| On Cleansing the Body |
August 9, 2006
How many of you have thought of and/or tried a cleanse? If you have, you know how confusing the products and belief systems are that are out there. From fasting to using cleansing products, the options are endless, but what does cleansing mean for you? That is what this article is about.
When someone comes to me and asks me how they should cleanse, I ask them four things:
- Why are they cleansing? For example, are they having digestive problems, is it something spiritual for them or is there another reason.
- What type of cleanse are they referring to? Many people find cleansing to be mostly about taking products, others, mostly about fasting/ juicing and still others find bodywork an integral part. Understanding what my client is wanting is key in my helping them.
- Are there any physical challenges they currently have that could interfere with the cleanse or that the cleanse could be too much for. Contrary to popular belief, a cleanse isn't always healthy for the system. In fact, if someone's immune system is weak, cleansing could cause physical problems, especially if they use products that further weaken them.
- How much time are they planning to spend on the cleanse? For some, they just want a day. For others, a week. I need to know this to help them with their cleanse.
Once I have this information, I can assist them in finding a cleanse that works for their unique system. I start by:
- Checking their ayurvedic type through pulse testing. If someone is dominant in Kapha energy, I would offer solutions much different than a dominant Pitta.
- Take a full intake of foods they currently eat, sleep habits, health conditions and mental/physical well-being.
Once I have that information, I can then begin developing a plan for them. Here is an example of a recent client that I assisted through a cleanse that met his needs.
We'll call him Mitchell. Mitchell is 43, about 40 lbs overweight and had been dealing with major fatigue and sadness issues. He has constipation, lethargy and feels like sleeping all the time. He was also on various heart and thyroid meds which weren't working very well.
I tested his doshas and his Ayurvedic type is Kapha dominant with Vata. His Kapha energy was very imbalanced and conflicting with his Pitta flow. Vata was off a bit but it seemed more related to the other energies.
Mitchell confided in me that his main problem was the constipation. He felt that if he could just go to the bathroom normally, he wouldn't feel so sad. He had tried laxatives but they only made him cramp up. He had also tried some of the products on the market but they made him more constipated. I explained to him that these products actually had too many things in them to work for his bodytype. For example, the psyllium bulked him up which made him feel worse and the senna wasn't strong enough to actually do anything more than bloat him.
I told him rather than a quick cleanse, it would be best to bring his body into a balanced state.
We started by getting his constipation in check. I did some energy work on him and it showed that his large intestine and liver were not working at optimum flows so we began with using triphala (ayurvedic herb) and a tablespoon of high-grade castor oil at night. I also offered specific food and food-combining options. Within a week he was coming back and within two, he felt much better and the bloating had come down dramatically.
Next, I kept feeling that his meds were fighting is system. He was taking levoxl and when I muscle tested him for it, it wasn't doing anything for him. I asked that he talk to his doctor about trying synthroid instead as my inner guidance was telling me. He did and he began on synthroid the next week.
While he was changing meds, I focused more on energy work and his continuing with the program we'd laid out. I also began incorporating pranayama(breathing) techniques, yoga and some NLP work for releasing stress from his body and mind.
About 3 weeks later, he was feeling much better and the synthroid was having a much better affect in his system than the other med did. He had also lost 11 lbs and a lot of bloated weight. We decided that he wanted to try a juice fast for a few days to see how it would feel so we planned out a fast and incorporated wheatgrass juice and a few products. He did it for 3 days over a weekend and then I offered a clear plan to bring his body back to balance.
After the fast and balancing, he felt he had received what he needed in the form of a cleanse and had new ways of eating, breathing and looking at cleansing options for his unique system which he could do for himself in the future. He also decided to take a weekly yoga class at a local studio which he was really enjoying.
I hope that offers you an idea of the uniqueness of the cleansing process and some new options for deciding for yourself what you need.
Many Blessings, Jenifer |
Related link: http://www.theempowermentcentre.com |
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| Protecting Holistic Remedies - BHRT |
March 2, 2006
A recent petition by Wyeth is causing quite a stir in the holistic industry, with good reason.
Wyeth's goal is to restrict the manufacturing of BHRT at compounding pharmacy's. Their recently filed Citizen’s Petition tells the FDA to impose restrictions on the compounding and dispensing of bio-identical hormone replacement therapy (BHRT). This could have dramatic effects, not only on BHRT, but also, in the future, on the availability of compounded products at any compounding pharmacy.
For more on the petition itself, click here to view the petition http://www.fda.gov/ohrms/dockets/dockets/05p0411/05p-0411-cp00001-01-vol1.pdf.
To file a comment directly to the FDA - click here http://www.accessdata.fda.gov/scripts/oc/dockets/comments/commentsmain.cfm?EC_DOCUMENT_ID=794&SUBTYP=NEXT&CID=&AGENCY=FDA
For information on what you can do, see the following link which will take you to the website for The International Academy of Compounding Pharmacists... http://www.iacprx.org/site/PageServer?pagename=Action_Alert
Also, check out the following link with Women's International for more information and resources at ... http://www.womensinternational.com/bhrt.html
Spread the word!
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Related link: http://www.theempowermentcentre.com |
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| Taking the Journey for Ourselves |
February 19, 2006
Being on a spiritual and/or empowerment path means that we practice being present for our lives, our emotions, each other and the struggles that occur throughout our lives that lead us to new awarenesses and places within. Sometimes that practice means taking a breath at the grocery store to realize the man in front of you who dropped his keys and is now taking an extra several minutes finding his wallet is not intentionally making you late for your meeting, and sometimes it means taking a longer, deeper look within.
One practice that I like to do is to reflect on the aspects of my life that are causing struggle, and those that bring me happiness and peace as a reminder of what my mind does to me ;) and what I truly value.
To practice: Take a few moments and a pen and paper and sit with the following.
Begin by sitting quietly for a few moments and putting forth an intention of release and renewal. Breathe into your heart and your entire being and ask those who love you to give you alone time.
Now write the following at the top of a blank page. "My main causes of concern right now are:" and stop there for a moment. (The first time you do this exercise you may want to begin with "My main 3 causes of concern right now are" in order to familiarize yourself both with the exercise and with the amount of time it may take you.) Sit with yourself and allow each one to come up on it's own and list them, leaving space in between for the solutions but not thinking of solutions yet. Thinking only of the language that will explain the concern and writing that down - getting it out of you and onto the paper.
When you have written everything, close your eyes and see the rest of the tensions that you may have been holding about these concerns flowing from you into the paper. Then sit with yourself without these concerns and feel the lightness within you.
From this light space, look at the first one on the list, and sit with it until you decide on the right actions to take to take care of it. It might be that you decide no action other than to let it be is what you need to do. When you have finished the first one, write down your decisions and then come back to the space of lightness for a moment, breathing into it to expand the light throughout you. When you are ready, take the next one and continue this way with your list.
When you complete your list, come back to the light space and begin to bring into this space all of the things you enjoy in your life and are grateful for. Allowing your heart to expand and delight in each new item, being, thought. For example, you might really enjoy your morning expresso, bring that in. You might enjoy hugging your daughter or taking that morning drive to the park on Saturdays. You might get joy out of your dog running to meet you at your front door or the feeling of opening that occurs when your read a book that changes you in some way. Take the time to spend with what you enjoy. Remember that you don't need to share this with others, this is about you so no need for any judgment here. For instance, if you really enjoy chocolate, release the urge to judge in any way the sugar or calorie content and just enjoy the reality that it has been present in your life and offered enjoyment. This practice is about allowing yourself to enjoy your life, rather than trying to create a life based on what you think is acceptable. See how it feels to simply enjoy it.
When you complete this, take the time to write a bit on what you enjoy and maybe even some goals of enjoyment for the week ahead.
I hope you *enjoy* this exercise and that it assist you in making your life what you truly desire.
In light,
Jenifer |
Related link: http://www.theempowermentcentre.com |
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| On Healing Digestion |
February 19, 2006
Over the years I have seen poor digestion cause anger, fatigue, malnourishment, stress, anxiety, and more. One of the key components of enhancing our digestion is to allow our amazing bodies to digest our food as easily as possible. I'm going to offer four ways you can increase your power of digestion.
1) Don't drink anything with or close to meals.
That means water as well as soda (which really slows down or halts digestive juices both through carbonation and through the sugar/additives/caffeine). If you choose you can drink water up to 10 minutes prior to a meal but no liquids within 2-3 hours after a meal. (Exact digestive times differ based on what you are eating, how you are food combining, and the amount of food you take in.)
Why does this matter? There are three main reasons. First, because there is an enzymatic process to breaking down foods and liquids can dilute the process, causing the food not to break down properly and causing gastrointestinal distress(have you ever felt uncomfortably bloated after a meal where you drank a lot?). Second, because when we drink as we eat, we have a tendency not to chew food thoroughly, which causes digestion problems as well. Third, when you drink a lot with a meal, it may cause you, due to the digestive challenges, not to be able to truly feel when you are full. I've seen individuals who, simply by not drinking with meals, have learned how much food is enough for their bodies and have found it easier to listen to that internal knowing. Try this step and see how it affects your eating and digestion.
2) Don't talk about anything stressful during or around a meal.
I am consistently amazed with the amount of anger and stress expressed at dinner tables - and honestly in relationships in general. I have traveled quite a bit and it seems that many people connect on what went wrong with their day instead of the blessings that occurred. Perhaps this is due to how our media expresses news as being only negative for the most part, however, you have the power to change how you talk, especially during meals.
When you sit down to the table with others, ask that everyone either eat in silence or only discuss good things that either happened or that they are wanting to happen/ making happen in their lives. You may even want to put a jar on the table that each time someone says something that isn't positive, they have to put a nickle in the jar and find a creative way to reward positive thinking (for example, who ever comes up with the most positive thinking that month gets to purchase something yummy for a future family meal with the money).
If you are eating alone, make it an enjoyable experience for yourself as well. Turn off the tv, light a candle, make food that you enjoy, and think on beautiful things as you eat. Sometimes I think on how many people came together to create the meal that I am eating. I am pretty much a vegan and eat a lot of veggies so I enjoy thinking of those who picked the vegetables, those who sprouted the seeds, those who packaged everything in a way that kept it fresh.
I think you will be amazed at how much both your digestion and your overall energy will change when you have a positive-centered meal experience!
3) Get Closer to Your Food
So what do I mean by this? I mean two things. First, buy locally grown produce (hopefully organic). It just makes sense that something grown closer to home will be easier to digest. It lives and breathes in the same environment that you live and breathe in and it goes through the same seasons as you do. Second, get to know the food that you like, that your body likes, and how to make it most appetizing for you. This may sound simple but I want you to think for a moment about the food you ate today so far. First of all, did you enjoy the food? Was it presented in a way that was most pleasing for you (versus eating out of a container at the fridge - I've done it too, I'm speaking from personal experience)? Also, did you eat it in the form that you like the most and do you know what other forms are available. For example, I have never really liked corn. I always ate it growing up but I always felt like it was cooked too much and had a bit of a hard time digesting it. Yet, I'd never seen someone eat it any other way so I just took it out of my diet as an adult.
Then one day I was at a raw food retreat and they served us raw corn. I looked at it debating on whether to try it and I did and WOW! I loved it AND I digested it perfectly fine. I was amazed. So THIS could be corn! Now, if someone asks if I like corn, I say yes but it has to be raw. They usually kind of look at me funny to see if I'm kidding, even more so after I explain that I can't digest 'cooked corn'. I just smile as I'm sure there are things they eat that would be new for me too.;)
Anyway, back to the meaning here. Try this, one meal per week purchase all of the foods you would make a meal with. Lay them out and don't start until you really take a look at what you are using. This isn't about judging anything. It's about really seeing your food and knowing more intimately what you are putting in your body. Then try something new with it. If you are cooking beans, try them less cooked and cut them a different way. If you are cooking meat or dairy, make sure you cook it thoroughly, and you could try a different variation on doing a rub instead of a sauce or something else. Then take each dish individually. Eat the beans alone and when you are finished try the next dish. See what they each taste like on their own and enjoy them. At the end of the meal, you may just have a new appreciation for new ways that you enjoy foods AND your digestion will have enjoyed taking in one food at a time in a slower, more deliberate fashion.
and lastly ... 4) Chew your food thoroughly to aid your digestion. |
Related link: http://www.theempowermentcentre.com |
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| Overcoming Depression on the Internet |
August 15, 2005
Overcoming Depression on the Internet (ODIN) (2): A Randomized Trial of a Self-Help Depression Skills Program With Reminders
Greg Clarke, PhD; Donna Eubanks; Ed Reid; Chris Kelleher; Elizabeth O'Connor, PhD; Lynn L DeBar, PhD; Frances Lynch, PhD; Sonia Nunley; Christina Gullion, PhD
Kaiser Permanente Center for Health Research, Portland, OR, USA
Corresponding Author:
Greg Clarke, PhD Kaiser Permanente Center for Health Research 3800 N. Interstate Ave Portland, OR 97227-1098 USA Phone: +1 503 335 6673 Fax: +1 503 335 6311 Email:
greg.clarke [at] kpchr.org
Background: Guided self-help programs for depression (with associated therapist contact) have been successfully delivered over the Internet. However, previous trials of pure self-help Internet programs for depression (without therapist contact), including an earlier trial conducted by us, have failed to yield positive results. We hypothesized that methods to increase participant usage of the intervention, such as postcard or telephone reminders, might result in significant effects on depression.
Objectives: This paper presents a second randomized trial of a pure self-help Internet site, ODIN (Overcoming Depression on the InterNet), for adults with self-reported depression. We hypothesized that frequently reminded participants receiving the Internet program would report greater reduction in depression symptoms and greater improvements in mental and physical health functioning than a comparison group with usual treatment and no access to ODIN.
Methods: This was a three-arm randomized control trial with a usual treatment control group and two ODIN intervention groups receiving reminders through postcards or brief telephone calls. The setting was a nonprofit health maintenance organization (HMO). We mailed recruitment brochures by US post to two groups: adults (n = 6030) who received depression medication or psychotherapy in the previous 30 days, and an age- and gender-matched group of adults (n = 6021) who did not receive such services. At enrollment and at 5-, 10- and 16-weeks follow-up, participants were reminded by email (and telephone, if nonresponsive) to complete online versions of the Center for Epidemiological Studies Depression Scale (CES-D) and the Short Form 12 (SF-12). We also recorded participant HMO health care services utilization in the 12 months following study enrollment.
Results: Out of a recruitment pool of 12051 approached subjects, 255 persons accessed the Internet enrollment site, completed the online consent form, and were randomized to one of the three groups: (1) treatment as usual control group without access to the ODIN website (n = 100), (2) ODIN program group with postcard reminders (n = 75), and (3) ODIN program group with telephone reminders (n = 80). Across all groups, follow-up completion rates were 64% (n = 164) at 5 weeks, 68% (n = 173) at 10 weeks, and 66% (n = 169) at 16 weeks. In an intention-to-treat analysis, intervention participants reported greater reductions in depression compared to the control group (P = .03; effect size = 0.277 standard deviation units). A more pronounced effect was detected among participants who were more severely depressed at baseline (P = .02; effect size = 0.537 standard deviation units). By the end of the study, 20% more intervention participants moved from the disordered to normal range on the CES-D. We found no difference between the two intervention groups with different reminders in outcomes measures or in frequency of log-ons. We also found no significant intervention effects on the SF-12 or health care services.
Conclusions: In contrast to our earlier trial, in which participants were not reminded to use ODIN, in this trial we found a positive effect of the ODIN intervention compared to the control group. Future studies should address limitations of this trial, including relatively low enrollment and follow-up completion rates, and a restricted number of outcome measures. However, the low incremental costs of delivering this Internet program makes it feasible to offer this type of program to large populations with widespread Internet access.
(J Med Internet Res 2005;7(2):e16)
doi:10.2196/jmir.7.2.e16
KEYWORDS
Internet; depression; cognitive therapy; self-help; randomized trial
Several Internet interventions have emerged in recent years to treat mental and behavioral health problems. These interventions provide some of the basic skills training traditionally offered in face-to-face psychotherapies, particularly cognitive behavioral therapy (CBT). This recent trend extends the tradition of bibliotherapy with books, videos [1–3], and computer programs [4]. Mental health Internet interventions have targeted panic disorder [5,6], distress associated with tinnitus [7], and depression [8,9]. Nearly all of these “guided self-help” interventions [10] incorporate the Internet skills training with simultaneous professional staff counseling typically delivered by telephone or email.
Our Internet program, ODIN (Overcoming Depression on the InterNet) [11], shares a CBT approach with these other interventions. However, it is “pure self-help” [10] because it relies solely on skills training delivered by the Internet and eschews the therapist-delivered mental health counseling typical of the other programs. Both guided and pure self-help approaches merit consideration, but the much lower cost of the latter is a significant advantage.
Several of these interventions have been evaluated in randomized trials, with generally positive results on depression symptomatology for guided self-help programs [5,7,8]. However, initial trials of pure self-help Internet programs failed to impact depression symptoms [9], including our first investigation of the ODIN program [11]. In this earlier study, we randomized 299 adults with highly elevated depression symptoms to either access to the ODIN site, or no access. Participants in both conditions were free to receive treatment as usual (TAU) health care services, including depression medication and psychotherapy. This TAU control condition, consisting principally of antidepressant medication, distinguishes our research from that of most other trials of Internet mental health interventions, which have employed a waitlist control condition. Subjects reported depression symptoms at enrollment and at 4-, 8-, 16-, and 32-weeks follow-up. However, in that trial we found that participants in the intervention group used the ODIN Internet site very infrequently after their initial enrollment session, which may have contributed to the overall negative effects. We concluded that future studies should focus on increasing participant use of the Internet site.
This paper presents the second trial of our pure self-help ODIN program. This time, we added telephone and postcard reminders to the intervention group aimed at increasing participant use of ODIN, and we compared the intervention against a “no access” TAU control condition. We had no hypotheses regarding different website usage attributable to postcard or telephone reminders. However, the latter method required so much more staff time that we wanted to test whether brief telephone contact increased website usage beyond the less expensive postcard reminder. We hypothesized that persons randomized to the ODIN group would report greater reductions in depression symptoms and greater improvements in mental and physical health functioning. We also report general medical and mental health care service utilization data of participants in the 12 months following randomization.
Subjects and Recruitment
We conducted the study in the Kaiser Permanente Northwest HMO, which has about 440000 members in northwest Oregon and southwest Washington. Our research center is located within the HMO and is scientifically autonomous. The Human Subjects Committee for the HMO approved study procedures.
We employed the HMO's electronic medical record to identify two recruitment groups in 2000: a “depressed” group of adults (n = 6030), who received depression medication or psychotherapy in the previous 30 days and had a chart diagnosis of depression; and a “nondepressed” group of adults (n = 6021), who did not receive such services and did not have an HMO diagnosis of depression but who was age and gender matched to the first group. We included the latter group to determine whether persons with previously undetected cases of depression might enroll in the study.
We mailed all potential participants a study recruitment brochure in a plain envelope. The brochure explained the study and provided the Internet address. It was up to the initiative of invited individuals to visit the study Internet site.
After receiving the study recruitment brochure, participants entered confirmed HMO membership numbers at the study home page and proceeded to the online consent form and baseline assessment battery. Subsequently, participants were automatically randomized by the website (using random sequence software) to one of the three groups. Participants in the TAU control group were denied access to the ODIN intervention. Instead, they were linked to an HMO health information website which provided information about depression but no interactive skills training. Participants in the remaining two intervention groups were given immediate access to the ODIN intervention and received either US mail postcards or brief (< 5 minutes) telephone reminders from non-clinician study staff at 2, 8, and 13 weeks after enrollment. The telephone reminder calls were scripted to convey information identical to that included on the postcard reminders. Staff first identified themselves and the study, then reminded participants of the ODIN website address and gave instructions for looking up forgotten passwords. They read a brief description of a feature of the website designed to entice the participant to make a return visit and then concluded the call. The reminder staff had no mental health background, and they were prohibited from engaging in any therapy-like activity. Staff were capable of, and limited to, answering questions only about basic website troubleshooting (eg, difficulty logging on or accessing questionnaires). Figure 1 provides a summary of the study process.
Participants in all conditions were free to obtain any traditional mental or physical health care services and access any Internet health resources. Participants were not blind to their study condition.
Assessment Battery
At baseline and at each follow-up, participants completed an online version of the Center for Epidemiological Studies Depression Scale (CES-D) [12], a self-report measure of 20 depressive symptoms. Participants also completed the Short Form 12 (SF-12), a measure of health-related functioning [13,14]. A Physical Component Summary (PCS) scale and a Mental Component Summary (MCS) scale were computed from the SF-12 items [15].
Computerized depression instruments generally yield psychometrics equivalent to paper versions [16]; both versions of the CES-D correlate highly (r = .96) [17]. Patients often prefer computerized methods for reporting sensitive health topics [16].
Subjects in all conditions were sent email reminders to complete the online follow-up questionnaires at 5, 10, and 16 weeks after enrollment. Study staff telephoned participants who failed to respond to two email reminders for any assessment. Participants received US $5, $10, $15, and $20 gift certificates to Amazon.com for completing the baseline and subsequent assessments.
Intervention
The ODIN Internet intervention (www.feelbetter.org) was a pure self-help program offering training in cognitive restructuring [18,19]. (See the Multimedia Appendix of our previous report [11] for screenshots.) We did not employ any behavioral therapy or behavioral activation techniques. Intervention content was adapted from CBT psychotherapy manuals [20,21] successfully employed in randomized trials [22–25]. The intervention was organized in seven “chapters,” each presenting a new technique via interactive examples and practice opportunities. Tutorials included the self-assessment of mood, identification of unrealistic thoughts, and generation of realistic counter-thoughts. Participants randomized to the intervention conditions were able to use the program at any time.
A representative module was the “Thought Helper.” Participants typed their personal negative or irrational thought into a text box and then clicked on a search button. The Web server searched a predefined list of 300 negative thoughts for examples that best matched the negative thought submitted by the participant and returned a list of the most likely matches. Participants selected the displayed negative thought that they thought was closest to their original. The program then returned a list of several possible realistic counter-thoughts relevant to that belief. Users were encouraged to create a personalized counter-thought using relevant portions of the provided examples and enter it into the website for storage. Users could later retrieve their own personal counter-thoughts, unrealistic beliefs, and activating situations.
We did not actively monitor the participant interactions for suicidal thoughts or behaviors, but instead provided links to the non-research HMO psychiatric emergency services staffed by professional mental health providers.
Health Care Utilization
HMO computer systems provided data for inpatient and outpatient services, prescriptions, emergency room visits, and other utilization. Non-HMO health care services were not assessed.
Analysis Plan
We examined CES-D and SF-12 scores using random effects regression analyses, modeling an unstructured covariance matrix, with slope and intercept as random effects. The test of difference between groups is a test of the difference in these slopes over time. The random effects modeling includes all data on all participants (an intent-to-treat analysis), but it preserves the measurement time for each observed response (rather than carrying last observations forward). It does so by computing maximum likelihood estimates of the slope over time given the data observed and the covariance structure within subjects. This method, which conditions out the missing data, is called restricted (or residual) maximum likelihood estimation (REML). The REML methods for dealing with missing data are superior in efficiency and are considered less biased than the last observations carried forward (LOCF) method [26,27]. For all outcomes analyses (except for health care utilization), we conducted planned comparisons of (a) the two intervention conditions combined versus the control condition; and (b) the mail versus the telephone intervention conditions. We ran separate models for each predictor/outcome combination: the linear slope, both linear and quadratic trends, and a third that included linear, quadratic, and cubic trends. The linear trend indicates the direction and rate of change, while the quadratic and cubic trends indicate how the rate of change increased or decreased at some point during the observation period. We report results from the best fitting of these three models for each predictor/outcome combination. All tables and figures present observed unimputed data.
For health care utilization data, we employed chi-square analyses to compare proportions of participants in each condition who had at least one instance of each type of health care service. We then conducted logistic regression analyses predicting use of each type of health care service from study condition and baseline CES-D score.
Recruitment, Randomization, and Follow-Up
Of 12051 total study recruitment brochures mailed to depressed and nondepressed HMO members, 291 participants (2.4%) entered confirmed HMO membership numbers at the study home page and proceeded to the online consent form and baseline assessment battery. Subsequently, 255 members (87.6%) were automatically randomized by the website (using random sequence software) to one of three groups: 100 to the TAU control group, 75 to the ODIN intervention with postcard reminders group, and 80 to the ODIN intervention with telephone reminders group.
Fifty-five of the 255 enrolled participants were from the nondepressed recruitment group (0.9% of those invited), and 200 were from the depressed recruitment group (3.3% of those invited). The randomized sample was more likely to be female (77% vs 71% of the non randomized sample, P = .03) and older (64% were 45 years or older vs 52% of the non randomized sample, P < .001).
Follow-up completion rates for all groups combined were 64% (n = 164) at 5 weeks, 68% (n = 173) at 10 weeks, and 66% (n = 169) at 16 weeks. Overall, 209 participants (82%) completed at least one post-baseline assessment. Compared to participants completing at least one follow-up (baseline CES-D mean = 28.9, SD = 13.0), subjects who were lost to follow-up had higher baseline CES-D scores (mean = 33.3, SD = 12.6; t = 2.08, P = .04) and were slightly older (average age 47.7 vs 42.9, P = .006), but they did not differ with respect to gender (P = .08). Participants in the control condition were more likely to have completed at least one follow-up assessment (93%) than participants in either the telephone reminder intervention (76%) or the mail reminder intervention conditions (73%, P = .001).
Comparability of Conditions
Table 1 presents the frequency of participant log-ons for the mail and telephone reminder intervention conditions and the same data from our earlier randomized trial [11]. Participants in the two intervention groups with different reminder modes did not differ in the number of log-ons to the website (t = .45, P = .65), but both groups together did access the website significantly more often (t = 5.74, P < .001) than participants in our initial study [11], which was nearly identical in design except for the lack of reminders.
Study conditions did not differ with respect to recruitment group, gender, or baseline CES-D and SF-12 scores; however, participants in the control group were more likely to be college graduates and were significantly older (Table 2).
Depression
Figure 2 shows that participants in the intervention conditions improved more than those in the control group on self-reported depression (F1,523 = 4.93, P = .03 for the linear slope), with an estimated difference in effect size of 0.277 standard deviation units. The graph displays the group means for each participant's change in CES-D from their baseline score, across all assessment points. The random effect regression parameter estimate was 0.25 (95% CI = 0.03–0.58). This effect held up even when controlling for baseline differences in age and education. We did not find any difference between the two treatment conditions.
We tested clinical significance [28] by examining how many cases moved over time from the “disordered” to the “non disordered” CES-D ranges. The CES-D has two cutoff scores: a score of ≥ 16 is considered “moderately depressed,” and a score of ≥ 28 is considered “severely depressed” [12,29]. We compared the intervention conditions (combined) against the control condition using these categories. A total of 211 participants were above the lower of the two CES-D cutoff scores (≥ 16) at baseline (75 control and 136 treatment). Of these moderately depressed participants, 137 completed the 16-week follow-up. At that final follow-up, 56% (n = 42/75) of these participants in the treatment group were still in the moderately depressed range, compared to 76% (n = 47/62) of the control sample (chi2 = 5.8, P = .02).
We also examined the 149 participants who were above the severely depressed cutscore (CES-D ≥ 28) at baseline (53 control and 96 treatment). Of these, 93 participants completed the 16-week assessment; 42% (n = 20/48) of the intervention cases were still in the severely depressed range at this final follow-up, compared to 62% (n = 28/45) of the control cases (chi2 = 3.9, P = .05). Using either moderate or severely depressed scoring criteria, significantly more treatment participants (20%) moved from the clinical to normal range by the end of the study.
Because control participants were more likely to have completed at least one follow-up assessment than intervention participants, we examined whether the significant outcome results may have been a function of bias in the followed sample. This is a consideration because random effects regression methods yield unbiased estimates of missing follow-up data only if the missingness is ignorable (ie, can be predicted from patient characteristics and is unrelated to the study outcome). If loss to follow-up is a function of study outcome, the analyses conducted with imputed but possibly biased data may not accurately reflect the true outcomes. Therefore, we ran a repeated measures analysis predicting follow-up completion at each time point from baseline depression severity, age, sex, recruitment group, and educational attainment. In this model, younger age, male gender, and ODIN intervention assignment all increased the likelihood of missing a follow-up assessment. None of these factors predicted treatment outcome, suggesting they would be unlikely to contribute to the treatment outcomes that we found. However, it is not possible to completely prove that imputed follow-up data are unbiased. Therefore, our results clearly need replication in a sample with minimal and nonsystematic attrition.
Table 3 presents depression results for several subgroups, to generate hypotheses for future studies. We limited these exploratory analyses to subgroups with larger samples. These included female participants (n = 197; linear model fit best, time × treatment F1,419 = 1.92, P = .17); participants with higher baseline CES-D scores (CES-D > 20; n = 191; quadratic model fit best, time × time × treatment F1,381 = 5.14, P = .02; effect size = 0.537 standard deviation units); and participants recruited from among HMO members with depression diagnoses in their medical records (n = 200; linear model fit best, time × treatment F1,403 = 3.09, P = .08).
Functioning
We did not find any statistically significant intervention effects on the physical components (PCS) or mental components (MCS) subscales of the SF-12 (Table 4).
Dose-Adjusted Effects
We failed to find statistically significant interactions between the total number of ODIN sign-ins (our measure of dose) and CES-D or SF-12 outcomes (data not shown).
Health Care Utilization
In the 12 months following randomization, we found no differences in the use of mental health or general medical services or psychoactive medications across all conditions (Table 5).
We detected a modest but statistically and clinically significant advantage for the two treatment conditions relative to the control group on self-reported depression, but not on functioning. To the best of our knowledge, this study is the first to find significant effects for a pure self-help or “unattended” Internet program, where the intervention was delivered without any adjunct person-to-person contact.
This study is also the first to find Internet intervention effects in the context of a TAU control condition. TAU was essentially another potentially active treatment, with 93% of participants receiving at least some traditional mental health care in the year following randomization (84% through the week 16 follow-up), the majority of which was antidepressant medication. This high background level of depression treatment and other health care had the potential to obscure differences between conditions. Nonetheless, we still observed an advantage for the ODIN intervention.
While the magnitude of this outcome was relatively modest, it compares favorably with other traditional, stand alone bibliotherapy interventions such as self-help books [3]. More importantly, the potential public health implications of these findings are considerable. The low incremental costs of delivering this Internet program makes it feasible to offer this or similar programs to very large populations (health plans, large employer groups, universities) where Internet access is widespread. Interventions with a small average effect may have substantial public health impact when applied to a large number of people, as a modest but meaningful number of patients will not develop the target disorder as a result of this small, average improvement [30].
Is the observed effect size of 0.277 standard deviation units (0.537 in cases with higher baseline depression) of sufficient magnitude to merit much enthusiasm? In meta-analyses of depression evidence-based psychotherapy efficacy randomized controlled trials (where the control condition is typically an easily surmounted no treatment or waitlist control), the difference in effect size is typically much higher, averaging around 1.56 standard deviation units [31]. However, when (as in this randomized controlled trial) the evidence-based psychotherapy is provided in the context of TAU [32], this effect size advantage typically shrinks substantially. Gaffan [31] and Gloaguen [33] find only small to medium mean effect sizes favoring CBT when it is compared to behavioral therapy (0.27), “other” psychotherapy (0.23), or pharmacotherapy (0.27). In this context, our TAU control condition is best thought of as a blend of evidence-based and non-evidence-based psychosocial and pharmacotherapy treatments [34]. Therefore, the observed effect size of 0.277 standard deviation units is roughly consistent with the effect sizes of this meta-analysis when traditional, face-to-face CBT is compared to these other treatments.
The mail and telephone reminders similarly increased the frequency of visits to the ODIN site, relative to our first study with no reminders [11]. We are therefore inclined to use postcard reminders in the future because they are much less costly than telephone reminders.
Our failure to detect effects on health care utilization was not unexpected. A follow-up period of two years or more is typically needed to detect impacts of an intervention on health care utilization [35]. Further, because health care utilization typically has very high variance (a small number of patients use an extreme amount of health care), very large samples are typically needed for adequate power [36].
Limitations
This study had several limitations. First, despite providing gift certificates for completed assessments, follow-up rates averaged around 66%—although 82% of participants completed at least one follow-up assessment. These rates are comparable to the follow-up rates obtained in our earlier study [11] and are similar to, if not better than, rates seen in other Internet intervention trials (reviewed by Eysenbach [37]).
Second, subjects lost to follow-up were slightly more depressed, slightly older, and less likely to be in the control group. All these factors, but particularly the interaction between experimental condition and attrition, limit our confidence in our results, although post-hoc analyses suggest that confounding effects were unlikely to have accounted for the observed results.
Our enrollment rates were also quite low, with 3.3% of the “depressed” recruitment sample and 0.9% of the “nondepressed” recruitment sample enrolling in the study, respectively. We have no information on why so many declined to enroll. Because the majority of the “depressed” recruitment sample was receiving traditional depression care (all had depression diagnoses in their medical charts), perhaps they felt no need to augment their traditional care with our self-help program. Among the nominally “nondepressed” recruitment sample, we had hoped to enroll previously unrecognized cases of depression [38]. However, the 1% “nondepressed” enrollment rate suggests that only a small minority of these undetected cases found our study of interest. Perhaps some of these individuals did not recognize their own depression and thus would not have seen the program as applicable. Still others may have been receiving other depression care outside of this HMO, which we could not know about from the HMO records. Regardless of the reasons for the low enrollment, these rates are not an indication of the acceptability of this intervention or any Internet program offered outside of a research trial. The unique features of randomized trials (a chance of being assigned to the no-access control group, repeated reminders to complete assessments over time, burdensome questionnaires) create barriers to participants that likely contribute to lower research enrollment rates, but which have no counterparts in usual clinical care implementation of these types of programs.
This study was also limited by its reliance on a single, self-reported measure of depression. We decided against using research diagnostic interviews because the accompanying in-person or telephone interview contacts had the potential to impart quasi-therapeutic benefits that, in turn, might have swamped the small benefit expected from the ODIN intervention. Further, the target population for the ODIN website includes persons who may have low level or subdiagnostic depression symptoms, as well as individuals who meet full diagnostic criteria for major depression or other DSM mood diagnoses. Relying on DSM mood diagnosis as a primary outcome might have missed the effects of the ODIN intervention on depression symptoms below the level of a full diagnosis.
Finally, our follow-up period of 16 weeks was extremely brief. We must examine this intervention's longer term impacts on depression, health care utilization, and quality of life. Future studies should include a much longer follow-up and a broader range of assessment domains.
Conclusions
The lessons we have learned from this investigation are guiding our development of a completely new Internet intervention for depressed young adults. This new program emphasizes behavioral activation, or increasing pleasant activities, as the main therapeutic technique [39].
We are encouraged by the results of this study, while acknowledging the positive effects are modest in magnitude. Nonetheless, we view low intensity, widely available interventions as an important piece of an overall, population-based strategy for reducing depression disorder and symptomatology. The marginal costs of delivering this pure self-help Internet program to each additional individual are very minimal, given that there is no staff time associated with the delivery of the intervention content. Therefore, it is feasible to offer this type of program to entire populations where Internet access is widespread, such as universities and large employers.
Acknowledgments
This study was supported by a grant to the first author from the Garfield Foundation Depression Initiative Project. All authors are independent of this funding agency. The authors would like to thank Enid Hunkeler, Eric Stice, Scott Bull, Amanda Petrik, Fran Janda, Vicki Maxwell, Ted Trotman, Terri Haswell, Steve Hollon, and Jennifer Coury for their advice and assistance on this project.
Conflicts of Interest
None declared.
References
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- Mckendree-Smith NL, Floyd M, Scogin FR. Self-administered treatments for depression: a review. J Clin Psychol 2003 Mar;59(3):275-288. [CrossRef] [Medline]
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- Marks I. Computer aids to mental health care. Can J Psychiatry 1999 Aug;44(6):548-555. [Medline]
- Carlbring P, Ekselius L, Andersson G. Treatment of panic disorder via the Internet: a randomized trial of CBT vs. applied relaxation. J Behav Ther Exp Psychiatry 2003 Jun;34(2):129-140. [Medline] [CrossRef]
- Richards JC, Alvarenga ME. Extension and replication of an Internet-based treatment program for panic disorder. Cogn Behav Ther 2002;31(1):41-47. [CrossRef]
- Andersson G, Strömgren T, Ström L, Lyttkens L. Randomized
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| The Role of the Internet in Patient-Practitioner Relationships |
August 15, 2005
Angie Hart1, DPhil, MPhil, BA, Dip Psych Counselling; Flis Henwood2, BA (Hons), MSc, PhD; Sally Wyatt3, BA (Hons), MA, PhD
1Centre for Nursing and Midwifery Research, University of Brighton, UK
2School of Computing, Mathematical and Information Sciences, University of Brighton, UK
3Department of Communication Studies, University of Amsterdam, The Netherlands
Corresponding Author:
Angie Hart, DPhil, MPhil, BA, Dip Psych Counselling Principal Lecturer Centre for Nursing and Midwifery Research Faculty of Health University of Brighton Room 264, Mayfield House Falmer, East Sussex BN1 9RT UK Phone: +01273 644051 Email:
a.hart [at] brighton.ac.uk
Background: Studies suggest that there has been an increase in the use of the Internet by patients in many Western societies. However, despite the many texts available on health and the Internet, not much is known about how much patients actually use the Internet to look up health information in their daily lives. We know little about what meaning this activity has for their experience of health and illness, and for their relationship with health-care practitioners.
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