Effectiveness of psychosocial group intervention for reducing anxiety in women undergoing in vitro fertilization: a randomized controlled study

Effectiveness of psychosocial group intervention for reducing anxiety in women undergoing in vitro fertilization: a randomized controlled study Celia H. Y. Chan, M.S.W.,a Ernest H. Y. Ng, M.D.,b Cecilia L. W. Chan, Ph.D., P.C.,b Ho, M.D.,b and Timothy H. Y. Chan, B.Cog.Sc.a a Centre on Behavioral Health, and bDepartment of Obstetrics and Gynaecology, the University of Hong Kong, Hong Kong Special Administrative Region, People’s Republic of China

Objective: To evaluate the effect of the Eastern Body-Mind-Spirit (EBMS) group intervention on anxietyreduction of Chinese women undergoing IVF. Design: Randomized controlled study. Setting: Tertiary assisted reproduction unit. Participant(s): Two hundred twenty-seven women undergoing their first cycle of IVF treatment. Intervention(s): The intervention group (n ⫽ 69) received four sessions of EBMS group counseling, while the control group (n ⫽ 115) did not receive any intervention. Main Outcome Measure(s): State-Trait Anxiety Inventory. Result(s): Compared with the control group, the intervention group had a significant drop in State Anxiety mean score following intervention. A comparable number of embryos were transferred for each group, but there was a nonsignificant trend of a higher pregnancy rate in the intervention group. Conclusion(s): The Eastern Body-Mind-Spirit group intervention approach effectively reduces the anxiety level of women undergoing IVF treatment. (Fertil Steril威 2006;85:339 – 46. ©2006 by American Society for Reproductive Medicine.) Key Words: Infertility, IVF patients, holistic health, body-mind-spirit, psychosocial intervention, group psychotherapy

In vitro fertilization (IVF) is a medical treatment that requires a high level of active participation of the patient, who often finds the process both physically and emotionally exhausting. Studies have shown that IVF treatment can exert psychosocial impacts on both the patient and the couple (1). Women undergoing IVF treatment usually report higher levels of anxiety (2), depression (3), and emotional stress (4). Anxiety, in particular, is one of the most common emotional reactions among IVF patients. The patient’s anxiety level usually increases throughout the course of the treatment and peaks as she waits for the treatment outcome after oocyte retrieval and embryo transfer (5). The elevation of anxiety has many causes. Diagnostic and intervention procedures, which are often long and intrusive, induce physical pain, disturb the patient’s daily routine, and put strains on the sexual relationship of the couple (6). Moreover, patients often perceive IVF treatment as their very last chance of childbearing. Such an unrealistically high

Received November 3, 2004; revised and accepted July 14, 2005. This project was funded by a grant from the Committee on Research and Conference Grants (Grant No. EC1526-00) at the University of Hong Kong. Hong Kong Special Administrative Region, People’s Republic of China. Reprint requests: Centre on Behavioral Health, the University of Hong Kong G/F, Pauline Chan Building, 10 Sassoon Road, Pokfulam, Hong Kong Special Administrative Region, People’s Republic of China (Telephone: (852) 2859-0502) (FAX: 852-2816-6710; E-mail: chancelia@ hku.hk).

0015-0282/06/$32.00 doi:10.1016/j.fertnstert.2005.07.1310

expectation of the treatment is reflected by the fact that patients often report they have frequent ruminations on treatment outcome (3). Due to the stigma of sterility in Chinese communities, many Chinese women choose to conceal their condition, and go to great lengths to keep their friends and relatives from knowing they are receiving the treatment, especially the patient’s parents-in-law. With limited social support, patients might not have enough mental capacity to endure the treatment procedures. In response to psychological distress, IVF patients sometimes somatize and report bodily discomfort. Complaints, such as pain, fatigue, muscle tension, and loss of appetite, are common among women undergoing IVF treatment (7). Physical discomforts may reflect the individual’s underlying psychological status, and these symptoms have been usually associated with people who have depression and a high level of anxiety (8). Much interest has been focused on investigating the association between psychological responses and pregnancy rate or pregnancy outcomes after IVF. Demyttenaere and his colleagues demonstrated that a relatively high level of trait anxiety in women was predictive of a lower chance of conception in normal spontaneous cycles (9). Several years later, they studied 40 women undergoing IVF treatment and found that a high level of trait anxiety in terms of high active coping (i.e., trying over and over again), high avoidance, and high expression of

Fertility and Sterility姞 Vol. 85, No. 2, February 2006 Copyright ©2006 American Society for Reproductive Medicine, Published by Elsevier Inc.

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emotion were associated with a lower pregnancy rate (10). Stoleru and his colleagues demonstrated that women’s perceptions of the degree of marital harmony toward the project to conceive a child was a statistically significant predictor of the success throughout the course of IVF such as fertilization, implantation, and even the birth of a child (11). To allay the anxiety of IVF patients and enhance their psychological well-being, psychosocial intervention has been developed in Western countries (12, 13). These interventions usually take the form of a support group, during which the group facilitator or the therapist provides stress-reduction training and fosters peer support among patients and their partners (14, 15). The effectiveness of this form of psychosocial counseling is well established in the literature. (12, 13, 16 –19). Couples who had undergone psychosocial intervention of relaxation training, stress management, and psycho-education had a higher pregnancy rate of IVF treatment, especially for those women with unexplained infertility (11). To provide more culturally relevant psychosocial interventions for Chinese patients, we have developed an Eastern BodyMind-Spirit (EBMS) approach (20). The EBMS intervention takes the form of psycho-educational group counseling. Therapeutic components include: 1. mini-lectures on Traditional Chinese Medicine, which views health as a state of mind-body harmony; 2. stress-reduction training coupled with tai-chi exercises, meditation, and breathing techniques; 3. activities, such as singing, journal writing, and drawing, to encourage the discovery of positive meaning from negative experiences; and 4. reading materials excerpted from ancient Chinese philosophical writings on suffering and the meaning of life. It should be noted that the therapeutic goal of the EBMS intervention is not treatment compliance; instead, the EBMS intervention attempts to provide a “safety zone” for IVF patients to reexamine the meaning of childbearing to them. By being more aware of the hidden values behind their decisions leading to the treatment, we believe that the patients can then reduce their own anxieties by facilitating personal growth and transformation, and learning to let go of their high expectations of treatment outcome. The EBMS intervention has been applied into different populations, such as divorced women, bereaved families, and cancer patients, who have had traumatic experiences throughout their lives (21). The purpose of this prospective controlled study was to evaluate the effect of an EBMS intervention on the anxiety reduction of Chinese IVF patients. It was hypothesized that women who received the EBMS intervention would experience a lower level of anxiety during the IVF treatment and therefore have better mental adjustment and psychosocial functioning during IVF. 340

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MATERIALS AND METHODS Participants Participants were women who attended the Assisted Reproduction Unit (ARU) at the Department of Obstetrics and Gynaecology, the University of Hong Kong, for the first cycle of IVF from February 2001 to June 2003. The indications of conventional IVF included tubal, male factor infertility, endometriosis, unexplained, and mixed factors. Intracytoplasmic sperm injection (ICSI) was performed for couples with severe semen abnormalities (i.e., ⬍100,000 motile spermatozoa recovered after sperm preparation) and surgically retrieved spermatozoa from epididymis or testis in case of obstructive azoospermia. The waiting time for IVF treatment at the ARU was about 10 to 12 months. Monthly briefings were arranged at the ARU for patients who would receive their first treatment in 3 months’ time. During the briefing, a specialist nurse would provide medical information and advice on the treatment. At the end of each briefing, the patients were informed of the study. The first author approached those who had indicated their interest. In this study, we approached 494 infertile women, and 227 of them gave written consent to participate. They were randomized into the intervention group (n ⫽ 101), who would receive the EBMS intervention before their first IVF cycle, and the no-intervention control group (n ⫽ 126). The calculation of sample size was based on the reduction of anxiety levels. Assuming a moderate effect size of 0.5, at least 64 women for each group were required for a test at .05 two-tailed significance and a power of .80 (22). The randomization process was performed according to well-established guidelines (23). Drawing lots achieved randomization. Participants were notified of their group assignment individually. The attrition rates of the intervention and the control group were 31.68% and 8.73%, respectively. Reasons for dropout included spontaneous pregnancy, treatment postponement, and treatment termination (Fig. 1). As a result, 184 women (control: n ⫽ 115; intervention: n ⫽ 69) completed the entire study. The demographic characteristics are tabulated in Table 1. No significant difference was found between the intervention and the control group, except their religious affiliations. Intervention The Eastern Body-Mind-Spirit intervention. Each participant in the intervention group was first interviewed individually by the first author, who was the therapist throughout the intervention. She is one of the experienced practitioners of the EBMS group intervention at the Centre on Behavioral Health, the University of Hong Kong. The group intervention consisted of 4 weekly sessions that were held on Saturday or Sunday evenings. Each session lasted for 3 hours. A total of 14 groups completed the 4-week intervention within this 2-year study, with 7 to 10 members in each group. The intervention adopted the EBMS approach that was originally developed by Chan (20), which emphasizes a Vol. 85, No. 2, February 2006

FIGURE 1 Flow of participants through each stage of the study. 494 infertile women were approached Time One (T1):

227 infertile women were recruited and randomized

Educational talk

Randomization: n=227

Allocated to Group Intervention: n=101 Received allocated intervention: n=89 Refused allocated intervention: n=12 (Reason: Time constraint)

Allocated to Control Group: n=126

Around 2 months Attending Group Intervention: n=89 For 4 sessions: n=80 For 3 sessions: n=7 For 2 sessions: n=0 For 1 session: n=2 (Discontinued intervention due to spontaneous pregnancy)

Time Two (T2): The day starting daily injection

Around 1 month

Time Three (T3): Before embryo(s) transfer

Withdrawal: n=9 Reasons: Postponement of treatment due to medical reasons: n=5 Voluntary postponement of treatment: n=1 Treatment termination due to medical reasons: n=1 Spontaneous pregnancy: n=2

Withdrawal: n=7 Reasons: Postponement of treatment due to medical reasons: n=7 Treatment termination: n=1

Withdrawal: n=11 Reasons: Postponement of treatment due to medical reasons: n=5 Unknown reason: n=6

Withdrawal: n=4 Reasons: Postponement of treatment due to medical reasons: n=1 Unknown reason: n=3

Analyzed: n=69

Analyzed: n=115

Chan. Psychosocial intervention in IVF. Fertil Steril 2006.

holistic concept of health. Under the EBMS framework, physical (bodily functions), psychosocial (emotions and interpersonal relationships), and spiritual (meaning of life) well-being are believed to be interconnected and all play a major role in the face of stressful life events. To provide culturally relevant intervention for the women, concepts from Chinese philosophies and Traditional Chinese Medicine (TCM) were adopted into the course material. In Vitro Fertilization-Embryo Transfer (IVF-ET) treatment. Details of the protocol concerning ovarian stimulation regimen, gamete handling, ICSI, and assessment of oocyte/ embryo quality at the ARU, the University of Hong Kong, Fertility and Sterility姞

have been previously published (24, 25). In brief, participants were pretreated with Buserelin (Suprecur; Hoechst, Frankfurt, Germany) nasal spray (150 ␮g, 4 times a day) from the midluteal phase of the cycle preceding the treatment cycle and received human menopausal gonadotrophin (HMG, Pergonal; Serono, Geneva, Switzerland) for ovarian stimulation. Human chorionic gonadotrophin (HCG, Profasi; Serono, Geneva, Switzerland) was given intramuscularly (IM) when the leading follicle reached 18 mm in diameter and there were at least three follicles ⱖ16 mm in diameter. Serum oestradiol concentration was measured on the day of HCG administration. Oocyte retrieval was scheduled 36 341

TABLE 1 Characteristics of participants. Intervention group (n ⴝ 69)

Control group (n ⴝ 115)

P value

36.0 ⫾ 3.28 6.76 ⫾ 2.90

35.0 ⫾ 3.49 6.99 ⫾ 2.85

.132 .594 .174

15 8 44 2

19 6 88 2

17 21 12 13 6

42 30 25 6 8

6 43 13 7

19 66 25 4

51 18

85 30

25 23 7 5 9

33 51 17 8 6

Mean age (y) (⫾ SD) Mean years of marriage (⫾ SD) Occupation Housewife Part-time Full-time Unemployed Religion No religion Chinese folk religion Christian Buddhist Other Education Junior high school or below Senior high school College/university Other Type of infertility Primary Secondary Cause of infertility Tubal Male factor Endometriosis Unexplained Mixed

.035

.139

1.000

.197

Chan. Psychosocial intervention in IVF. Fertil Steril 2006.

hours after the HCG injection. A maximum of three normally cleaving embryos were replaced into the uterine cavity 48 hours after the retrieval. Excess good quality embryos were frozen for subsequent transfer. Participants were referred for antenatal care if they had ongoing pregnancies beyond 10 –12 weeks of gestation. Clinical pregnancies are defined by the presence of one or more gestation sacs, or the histological confirmation of gestational product in miscarriages. Psychological assessment. Psychometric measurements were taken at three time points of the study: during recruitment in the educational talk (T1), on the first day of ovarian stimulation (T2), and on the day of ET (T3). Instruments used in this study include: Chinese State-Trait Anxiety Inventory (C-STAI). The C-STAI was used to measure the patient’s anxiety level (26). The original STAI developed by Spielberger and his colleagues is a 4-point Likert scale containing 40 items, with 20 state-anxiety items (as a transitory emotional state) and 20 trait-anxiety items (as the general proneness to anxiety) (27). 342

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State-anxiety items measure the temporal and situational feelings of fear or worry (1 ⫽ not at all, 4 ⫽ very much so), whereas trait-anxiety items measure the tendency of an individual to be anxious (1 ⫽ almost never, 4 ⫽ almost always). Higher scores indicate greater anxiety, ranging from 20 to 80 for each of the scales. Among Chinese female adolescents, the C-STAI reported test-retest reliability of 0.96 with an alpha coefficient of 0.82 (28). High internal consistency of the C-STAI (state-anxiety: r ⫽ 0.90, traitanxiety: r ⫽ 0.81) among Chinese secondary-school students has also been reported (29). Content, convergent, discriminate, construct, and criterion-related validity of the C-STAT have been reported (27, 30). Childbearing Importance Index. Two self-constructed prompts (“Childbearing is . . . to me.” and “Childbearing is . . . to the marriage.”) were given to participants to indicate their answers on a Likert-type scale ranging from “1” (very unimportant) to “10” (very important). About 60% of the participants (control: n ⫽ 80; intervention: n ⫽ 31) completed this measure. Vol. 85, No. 2, February 2006

TABLE 2 Psychometric measurements across time. Time point

State anxiety Intervention Control Trait anxiety Intervention Control Childbearing importance (self) (1–10) Intervention Control Childbearing importance (marriage) (1–10) Intervention Control

T1

T2

T3

F1,2a

F1,2,3b

47.12 44.62

43.53 45.10

42.69 43.70

8.513c

4.663d

43.83 42.46

44.96 41.28

44.13 41.78

1.431

1.300

7.83 7.75

7.29 7.61

7.13 7.44

4.810d

0.912

6.96 6.95

6.29 6.75

6.50 6.27

1.126

1.043

a

F value for repeated-measure ANOVA using data at T1 and T2. F value for repeated-measure ANOVA using data at T1 T2, and T3. c P⬍.05. d P⬍.01. b

Chan. Psychosocial intervention in IVF. Fertil Steril 2006.

RESULTS On the day of ovarian stimulation (T2), repeated-measure ANOVA showed that participants who received the intervention reported a lower Childbearing Importance Index (Self) score than they did before the intervention, F ⫽ 4.810, P⬍.05. At the same time, there was a significant drop of State Anxiety score in the intervention group, F ⫽ 8.513, P⬍.01. No significant changes were observed in their Trait Anxiety and Childbearing Importance Index (Marriage) scores.

On the day of embryo transfer (T3), repeated-measure ANOVA showed that participants in the intervention group had a significant drop of State Anxiety score compared to the control group. However, no significant changes were observed in the Trait Anxiety and Childbearing Importance Index scores (both Self and Marriage). Table 2 summarizes the psychometric data taken at the three time points. The clinical profile of the participants can be found in Table 3. Chi-square analysis suggested a marginally higher

TABLE 3 Clinical profile of participants.

Infertility duration (y) BMI (Kg/m2) Basal FSH level (IU/L) hMG dosage (ampoules) hMG duration (days) Serum oestradiol2 (pmol/L) No. of follicles ⱖ16 mm2 No. of follicles aspirated No. of eggs obtained

Intervention group (n ⴝ 69) (range)

Control group (n ⴝ 115) (range)

5.0 (2.0–11.0) 21.2 (15.4–30.2) 6.4 (3.3–11.8) 26 (16–66) 12.0 (8.0–22.0) 9728 (308–32437) 6.0 (1.0–17.0) 12.0 (1.0–38.0) 8.0 (1.0–26.0)

5.0 (1.0–15.0) 21.2 (14.8–33.5) 6.2 (2.4–18.7) 26 (16–72) 13.0 (8.0–21.0) 7077 (665–38400) 5.0 (0–20) 10.0 (1.0–43.0) 6.0 (1.0–36.0)

Note: Data are median (range). BMI ⫽ body mass index; FSH ⫽ follicle-stimulating hormone; hMG ⫽ human menopausal gonadotropin. Chan. Psychosocial intervention in IVF. Fertil Steril 2006.

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TABLE 4 Clinical outcome of IVF treatment. Intervention group (n ⴝ 65)

Control group (n ⴝ 108)

8 (2.3) 52 (80.0) 5 (7.7) 18 (27.7) 18/127 (14.2) 3/18 (16.7)

16 (14.8) 83 (76.9) 9 (8.3) 16 (14.8) 17/159 (10.7) 4/16 (25.0)

No. of embryos replaced (n) (%) One Two Three Pregnancy rate Implantation rate Multiple pregnancy rate Pregnancy outcome Ongoing pregnancy First-trimester miscarriage Ectopic Molar a

P value .880

.062 .477 a a

13 3 1 1

13 3 0 0

Sample size too small for chi-square analysis.

Chan. Psychosocial intervention in IVF. Fertil Steril 2006.

pregnancy rate in the intervention group than in the control group, although the trend was nonsignificant (P⫽.065). The intervention group and the control group did not differ significantly in the number of replaced embryos, implantation rate, multiple pregnancy rate, and pregnancy outcome (Table 4). DISCUSSION The objective of the current study was to evaluate the effectiveness of the EBMS intervention group model for Chinese women undergoing IVF. The four-session intervention groups were run before ovarian stimulation. The EBMS approach was developed based on TCM and Chinese philosophies of life and health. This was the first psychosocial intervention sensitive to Eastern culture and specifically designed for a Chinese population. The model recognized the importance of the mind, body and spiritual systems and maintaining harmony between oneself and the environment. It therefore adopts a holistic, dynamic, and systemic perspective in understanding human functioning. Under the EBMS framework, physical (bodily function), psychosocial (emotions and interpersonal relationship), and spiritual (meaning of life) well-being are believed to be interconnected and all play a major role in one’s holistic health in response to stressful life events. Therefore, unlike contemporary counseling approaches focusing on symptom-reduction, EBMS is a strength-focused approach enhancing holistic health and building up personal competence and resilience to reduce the effect of anxiety and other psychological distresses. Our results were similar to those of the previous study on brief stress management support groups developed by McNaughton-Cassill and her colleagues (13), which concluded that the social support derived from the group and the help with the stress of IVF were highly valued by group 344

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participants. They also supported the conclusion drawn by Boivin in a review of psychosocial intervention in infertility that women would benefit more in education and skills training such as relaxation exercises (19). In the present study, women who participated in the intervention experienced significant improvement on their psychosocial wellbeing throughout the course of IVF by alleviating the situational anxiety (State Anxiety), which is the anxiety experienced when actually in a specific situation, such as IVF treatment. The State Anxiety score of the intervention group decreased significantly at T2 and T3, demonstrating the effectiveness of the intervention in helping participants cope with the higher levels of anxiety that would be experienced on the first day of ovarian stimulation and on the day of embryo transfer. Research indicates that people have a natural preferred tendency to have certainty about upcoming aversive events, where certainty is elaborated as predictability and controllability (31). Lack of prediction and control are considered as the root cause of the development and maintenance of anxiety (32, 33). Higher degrees of unpredictability and uncontrollability may serve to promote higher feelings of anxiety (34). To assuage one’s internal sense of anxiety and fear, people attempt to control the situation and make sufficient preparation for the upcoming events. The primary goal of the intervention is to improve the holistic well-being of the participants by teaching them a variety of health-enhancing exercises such as breathing exercise, body scan, meditation, guided imagery, massage, acupressure, and yoga. Participants performed a self-help role and gained a sense of control through self-practicing. Mental rehearsal and making detailed daily arrangements for the treatment procedure were discussed and planned during the intervention. Anticipatory psychosocial responses were rehearsed to help them prepare Vol. 85, No. 2, February 2006

for treatment. Group participants acquired comprehensive knowledge about IVF, which increased the predictability of the treatment process for them. The effectiveness of such multi-modal intervention is promising in helping group participants alleviate anxiety. Infertile women usually had a feeling of loss of control in their reproductive role and life, and thus placed a high expectation on the success of IVF. However, due to individual variations in the number and quality of retrieved eggs and success rates of 20%–25%, IVF is not a procedure over which it is possible to exercise such control. Letting go is one of the main themes in the spiritual domain. Women in the intervention group were encouraged to let go of primary control (i.e., intention to change the environment) to regain secondary control (i.e, accommodation to the external reality). Spiritual health is another crucial intervention component in EBMS. Spirituality is currently conceptualized in terms of the meaning and purpose of life, children, and family, which corresponds to recent studies on spirituality (35, 36). Spirituality is rapidly evolving in the provision of health care services. Spiritual health was highly emphasized in EBMS, which involved a process of meaning reconstruction. The mind-body group intervention model has long been developed in Western countries (37), adding a spiritual dimension to the intervention may enhance its effect. Further study on the impact of spiritual health towards infertility is highly recommended. Aside from a lowered anxiety level, the intervention group showed a lower score on the “self” aspect of Childbearing Importance Index (Self) score following intervention. As mentioned, the meaning of life and children were reviewed and discussed in the intervention. The women were encouraged to reprioritize and reconstruct new meaning in their lives and try not to focus on IVF results or childlessness but on personal fulfillment during the process. This was a form of cognitive reappraisal on the importance of childbearing in their lives. Nevertheless, although no significant change was observed in the marital aspect of the Childbearing Importance Index, Chinese women are usually people-oriented and are expected to conform to the gender-stereotyped role of xiang fu jiao zi (i.e., supporting their husband and rearing sons). Although their perception regarding the importance of childbearing for themselves could be transformed after the intervention, they strongly held the belief that childbearing was still important to marriage. Demographic data, ovarian response, and the number of embryos replaced were comparable between the intervention and control groups. The intervention group had a higher pregnancy rate trend, although the difference did not reach statistical significance. Because of the small number of pregnancies, subgroup analysis was not performed to find out whether unexplained infertility was associated with a higher pregnancy rate following group intervention. Based on the pregnancy rates of the present study, a larger sample size (172 women in each group) would be required to confirm Fertility and Sterility姞

any statistical significance. Group intervention should be offered to women waiting for IVF treatment because of the reduction in anxiety level during IVF treatment and a possible improvement in pregnancy rate. In the present study, only women were recruited into the intervention because their husbands were usually busy in their work and might not complete the whole intervention program. Group intervention for couples may be a better approach as husbands play a crucial role both in reproduction and IVF treatment. Husbands are the most important person offering immediate tangible and emotional support to their wives; they may also experience anxiety throughout the IVF treatment (1). It is also essential to involve husband and offer support or stress management to them. One major limitation of the present study is the high attrition rate. A disproportionate number of dropouts were from the intervention group at T2 and T3. Among 101 participants allocated to group intervention, 12 refused to participate at the outset due to time constraints; 9 participants withdrew from the study at T2; 5 postponed treatment due to medical reasons; and 2 became pregnant spontaneously. One of the nine participants who withdrew from the intervention group at T2 did so voluntarily because she found a new direction in life, and, as a result, childbearing was no longer a priority issue for her. This was also in line with the intervention goal of EBMS where participants’ meaning of life and children were reviewed and revised. An additional 11 participants withdrew from the study at T3, 5 postponed treatment due to medical reasons, and 6 withdrew due to unknown reasons (Fig. 1). In conclusion, the EBMS group intervention model appears to be effective in the reduction of anxiety for Chinese women before IVF treatment; whole person well-being is achieved by maintaining a state of harmonious balance between the internal and integrated whole of the person in the aspects of body, mind, and spirit. Further long-term evaluation of the psychosocial status of these women will be necessary to assess the long-term and maintenance effects of the intervention. Acknowledgments: This project was funded by a grant from Committee on Research and Conference Grants (Grant No.: EC1526-00), the University of Hong Kong. We express our appreciation to Wai-mui Yung, M.S.W., for helping in the early phase of data collection, and Chui-Pik Ho, R.N., and Wai-man Cheung, R.N., for their assistance in providing informational support during group intervention.

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Vol. 85, No. 2, February 2006