Childbirth fear in Swedish fathers is associated with parental stress as well as poor physical and mental health

Objective

to compare self-rated health and perceived difficulties during pregnancy as well as antenatal attendance, birth experience and parental stress in fathers with and without childbirth related fear.

Design

a longitudinal regional survey. Data were collected by three questionnaires.

Setting

three hospitals in the middle-north part of Sweden.

Participants

1047 expectant fathers recruited in mid-pregnancy and followed up at two months and one year after birth.

Measurements

childbirth fear was assessed using the Fear of Birth Scale (FOBS). Self-rated physical and mental health and perceived difficulties were assessed in mid pregnancy. Two months after birth antenatal attendance, mode of birth and the birth experience were investigated. Parental stress was measured using the Swedish Parental Stress Questionnaire (SPSQ). Crude and adjusted odds ratios were calculated between expectant fathers who scored 50 and above (childbirth fear) and those that did not (no fear).

Findings

expectant fathers with childbirth related fear (13.6%) reported poorer physical (OR 1.8; 95% CI 1.2–2.8) and mental (OR 3.0; 1.8–5.1) health than their non-fearful counterparts. The fearful fathers were more likely to perceive difficulties in pregnancy (OR 2.1; 1.4–3.0), and the forthcoming birth (OR 4.3; 2.9–6.3) compared to fathers without childbirth fear. First-time fathers with fear attended fewer antenatal classes. Fathers with high fear reported higher mean scores in four of the five subscales of the SPSQ. Childbirth related fear was not associated with mode of birth or fathers' birth experience.

Key conclusions

expectant fathers with childbirth related fear had poorer health, viewed the pregnancy, birth and the forthcoming parenthood with more difficulties. They were less often present during antenatal classes and had higher parental stress.

Implications for practice

this study provides insight into the health of expectant fathers during pregnancy and highlights the importance of understanding how childbirth fear may affect expectant fathers in both the short and longer term.     

Psychometric aspects of the W-DEQ; a new questionnaire for the measurement of fear of childbirth

Up to now it has been difficult to study fear of childbirth because of a shortage of adequate psychological measurements. Therefore the Wijma Delivery Expectancy/ Experience Questionnaire (W-DEQ) was developed. This paper presents the theoretical background of the W-DEQ together with a documentation of the first psychometric studies. Examination of construct validity indicates that it seems to be possible to penetrate a psychological construct related to fear of childbirth by means of the W-DEQ, both before and after delivery, in nulliparous as well as in parous women. The questionnaire measures the construct more clearly in parous than in nulliparous women. Internal consistency reliability and split-half reliability of the W-DEQ of ≤ 0.87 are good for a new research instrument. More research is on its way to make the W-DEQ suitable even for measurements in applied settings     

Fine tuning fear of childbirth: the relationship between Childbirth Fear Questionnaire subscales and demographic and reproductive variables

Objective: The objective of the current study was to investigate the relationship between the newly developed Childbirth Fear Questionnaire (CFQ) and demographic and reproductive variables.

Background: The CFQ was developed in an effort to improve measurement and understanding of women’s childbirth fears. To our knowledge the CFQ is the only multidimensional measure of childbirth fears in which (a) multiple domains of childbirth fear are assessed and (b) individual subscales have been psychometrically developed.

Methods: Participants were 643 pregnant women residing in English-speaking countries, recruited via online forums. Participants completed a set of questionnaires, including the multidimensional CFQ, via an online survey. Given the differences in childbirth fear between nulliparous and multiparous women, findings are stratified by parity.

Results: Gestational age was largely unrelated to fear of childbirth. Age, income and education were negatively related to fear of childbirth. Assisted vaginal delivery and episiotomy in a previous pregnancy were positively associated with a fear of pain. Self-reported history of traumatic vaginal birth was associated with higher scores on all aspects of fear of childbirth. History of caesarean birth was not generally associated with increased childbirth fears, but women with a prior, self-reported traumatic caesarean birth reported more fear of future caesarean births.

Conclusions: Findings are consistent with previous reports of fear of childbirth. However, the CFQ provides increased specificity with respect to women’s childbirth fears. This information is relevant to both education and treatment planning for pregnant women and women wishing to reproduce.     

Postpartum experiences of first-time fathers in a Tanzanian suburb: A qualitative interview study

Objectives

to explore postpartum experiences of first-time fathers in a multicultural, low-income, suburban Tanzanian setting.

Design, setting and participants

individual qualitative interviews with ten first-time fathers, four to ten weeks post partum in Ilala suburb, Dar es Salaam, Tanzania.

Findings

these first-time fathers enjoyed fatherhood and revealed a sincere concern for the well-being of the mother and infant during the postpartum period. They described themselves as active in mother and infant care and household chores; however, they were limited by breadwinning responsibilities. The families were supported by relatives or laypersons. The mothers’ and infants’ nutrition had high priority but poverty was an obstacle. Timing of resumption of sex after childbirth was problematic as traditions prescribed abstinence while the woman is breast feeding. The risk of contracting HIV to the family was a concern. Reproductive and child health care often excluded fathers and gave unclear information.

Conclusion

these new fathers struggled to gain confidence and experience while engaging in family matters during post partum. Changing gender roles in the suburban Tanzanian society in general and their personal experiences of transition to fatherhood both facilitated and made the postpartum period problematic. The health sector does not respond with respect to fathers’ concerns for family health and needs for support.

Recommendations

these findings call for programmes on gender relations, which are supporting constructive masculinities and facilitate new fathers’ active participation and responsibilities in parenting, family health and their relations with their partners. Such programmes should not only target people in childbearing age but also their potential support persons. Health workers should welcome fathers and discuss strategies for good family health during post partum. Counselling couples together could facilitate their support for each other in optimising health post partum.     

Cross-cultural comparison of levels of childbirth-related fear in an Australian and Swedish sample

Background

research, conducted predominately in Scandinavian countries, suggests that a substantial number of women experience high levels of fear concerning childbirth which can impact on birth outcomes, the mother-infant relationship and the ongoing mental health of the mother. The prevalence of childbirth-related fear (CBRF) is not well known outside of the Nordic nations. This study aimed to examine the prevalence of CBRF in two rural populations (Sweden and Australia) and to pilot a short, easy-to-administer measurement tool.

Methods

a questionnaire assessing a range of childbirth-related issues was administered to women in the first trimester across two rural populations in Sweden (n=386) and Australia (n=123). CBRF was measured using the Fear of Birth Scale (FOBS) a two-item visual analogue scale.

Findings

close to 30% of women from the Australian and Swedish samples reported elevated levels of CBRF in the first trimester. A previous negative birth experience and less than positive attitudes to their current pregnancy and birth were predictive of high levels of fear. Swedish women with high levels of fear indicated a preference for caesarean section as the mode of birth in this pregnancy. A higher proportion (19%) of Australian women indicated that they would prefer an elective caesarean section, compared with only 8.8% of the Swedish sample; however, this was not related to high levels of fear. Preference for caesarean section was related to CBRF in the Swedish sample but not in the Australian sample.

Conclusion

the high proportion of women identified with CBRF suggests a need for monitoring of women during pregnancy, particularly those with a previous negative birth experience. The FOBS developed for this study could be used as a screening tool to identify women who require further investigation. Further cross-cultural research is needed to explore the role of fear in women’s preference for caesarean section.     

Fear of childbirth and emergency caesarean section in low-risk nulliparous women: a prospective cohort study

Abstract

Objective: To assess the association between fear of childbirth (FOC) and emergency caesarean section.

Design: A prospective cohort study of low-risk nulliparous women at term.

Setting: Nine obstetric departments in Denmark, May 2004–July 2005.

Population: A total of 2598 nulliparous women in spontaneous labor with a single fetus in cephalic presentation at term.

Methods: Self-reported FOC was assessed at 37 weeks of gestation by the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) version A and at admission to the labor ward by the Delivery Fear Scale (DFS). Mode of delivery was recorded by the attending staff. Logistic regression analyses were used to estimate unadjusted and adjusted odds ratios (OR).

Main outcome measures: Risk of emergency caesarean section in women who feared childbirth.

Results: FOC (W-DEQ sum score ≥85 and DFS sum score ≥70) was not associated with emergency caesarean section: adjusted OR?=?0.81 (95% CI: 0.48–1.36) and OR?=?0.97 (95% CI: 0.55–1.71), respectively.

Conclusion: In this prospective observational study, women with FOC did not have an increased risk of emergency caesarean section compared to women with no such fear.     

Childbirth in exile: Asylum seeking women's experience of childbirth in Ireland

Objectives

the purpose of this study was to gain insight into women's experiences of childbirth in Ireland while in the process of seeking asylum. This paper will focus on one of the primary findings of the study, how lack of connection, communication and cultural understanding impacted the health and well-being of the women who participated.

Design

researchers adopted a structural approach to narrative analysis using Burke's (1969) dramatistic pentad to analyse 22 women's narrative accounts of their childbirth experiences. Ethical approval was granted, and the study was funded by the Irish Health Research Board.

Findings

Burke's (1969) dramatistic pentad revealed numerous accounts of Scene/Agent and Act/Agency imbalance in the women's experiences, highlighting lack of communication, connection and culturally competent care evident in their experiences and how this impacted the care they received.

Conclusion

inadequate, poorly organised maternity services complicated by lack of training in cultural understanding and sporadic access to interpreter services had a detrimental impact on care provision. Providers appeared to have little insight into the specific needs of this vulnerable group already traumatised by pre and post migratory stressors. The resulting lack of effective connection and communication exacerbated women's experiences of alienation, loneliness, and isolation and were universal in the women's accounts. Implications for practice need to focus in Burkean terms on ‘How’ (Agency) providers can meet the maternity care needs of asylum seeking women. Dedicated community based services, mandatory training in cultural competence, 24 hour access to interpreters, information leaflets in several languages are essential measures. Further research looking specifically at the antenatal care and childbirth education needs of ethnic minority women is needed. Also, there is an urgent need for further exploration of the barriers to communication and the utilisation of trained interpreters in the provision of effective care to non-English speaking ethnic minority women.     

Treatment of nulliparous women with severe fear of childbirth via the Internet: a feasibility study

Objective: The aim of the present study was to test the feasibility of Internet interventions among nulliparous women suffering from severe fear of childbirth (FOC) by means of an Internet-delivered therapist-supported self-help program based on cognitive behavioral therapy (ICBT).

Design: Prospective, longitudinal cohort study.

Setting: A feasibility study of an ICBT program for the treatment of severe FOC in pregnant women.

Sample: Twenty-eight Swedish-speaking nulliparous women with severe FOC recruited via a project home page from January 2012 to December 2013.Methods: The main components of the ICBT program for the treatment of severe FOC comprised psycho-education, breathing retraining, cognitive restructuring, imaginary exposure, in vivo exposure and relapse prevention. The study participants were anonymously self-recruited over the Internet, interviewed by telephone and then enrolled. All participants were offered 8 weeks of treatment via the Internet. Participants reported their homework weekly, submitted measurements of their fear and received feedback from a therapist via a secure online contact management system.

Main outcome measures: Level of FOC measured with the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ A) during screening at enrollment and weekly during the treatment (W-DEQ version A), and after the delivery (W-DEQ version B).

Results: A statistically significant (p?<?0.0005) decrease of FOC [W-DEQ sum score decreased pre to post-therapy, with a large effect size (Cohen’s d?=?0.95)].

Conclusions: The results of this feasibility study suggest that ICBT has potential in the treatment of severe FOC during pregnancy in motivated nulliparous women. The results need to be confirmed by randomized controlled studies.     

Childbirth as a forthcoming traumatic event: pretraumatic stress disorder during pregnancy and its psychological correlates

Background: Recent research has suggested that pretraumatic stress related to a forthcoming predictable traumatic event might exist and that such stress reactions would be a key, ‘but largely ignored’, aspect of the etiology of Posttraumatic Stress Disorder (PTSD). While it is now acknowledged that childbirth may lead to PTSD, less is known regarding pretraumatic reactions in pregnancy. This study aims to (a) explore the frequency of PTSD, Fear of Childbirth and tokophobia associated with the forthcoming delivery and (b) highlight associated features of pre-traumatic stress symptoms.

Methods: At 34 weeks’ gestation, a sample of 102 women completed questionnaires assessing anticipated labour pain, fear of childbirth, fear of pain, pretraumatic stress symptoms, perceived social support and depressive and anxiety symptoms.

Results: 8.8% of women met DSM-IV-TR criteria for PTSD related to the threatening forthcoming delivery. Fear of childbirth, anticipated labour pain, anxiety, and depressive symptoms were significant predictors of pretraumatic stress intensity.

Conclusion: Our results extend prior findings on postpartum PTSD by showing that fear of labour pain is a specific construct, clearly independent from the experience of general pain. Our results suggest that childbirth may be experienced as threatening and traumatic and that this traumatic impact might develop way before the delivery. As a potential traumatic continuum from pre- to posttraumatic stress might exist, further longitudinal studies assessing pre-, peri- and posttraumatic reactions is needed to provide support for this hypothesis.     

Assessing the perception of the childbirth experience in Italian women: a contribution to the adaptation of the Childbirth Perception Questionnaire

Background

childbirth is a crucial experience in women's life as it has a substantial psychological, emotional and physical impact. A childbirth positive experience is important to the woman, infant's health and well-being, and mother–infant relationship. Furthermore, it is useful for the care providers to guarantee the best preparation, health service and support to childbearing women. The Childbirth Perception Questionnaire (CPQ) is a 27-item instrument designed to assess women's perception of their childbirth experience.

Objectives

to provide a first attempt to adapt the Childbirth Perception Questionnaire (CPQ) using a sample of Italian women. The psychometric properties of the scale and the quality of women's childbirth experience perception were assessed. Furthermore, the potential relation between the childbirth perception and the pain perception was explored.

Design

two separate studies were conducted. In Study 1, the factor structure and the reliability of the Italian translation of CPQ were assessed. Also a quantitative analysis of respondents' mean ratings was conducted. In Study 2 the relation between the CPQ and the Italian Pain Questionnaire (IPQ) was examined.

Setting

an inpatient gynaecologic–obstetric unit in a university medical centre in Italy.

Participants

195 women in Study 1 and 92 women in Study 2 completed the questionnaires.

Methods

in Study 1 the translated form of CPQ was administered in the 24–48 hours post partum. In Study 2, the participants completed the Italian version of the CPQ and the Italian Pain Questionnaire (IPQ) in the same postpartum time frame. Socio-demographic details and information about women's obstetric history were collected in both Study 1 and Study 2.

Findings

an exploratory factor analysis revealed a 24-item scale with a three-factor structure. The Italian version of the questionnaire was labelled Childbirth Experience Perception Scale (CEPS) and composed of three subscales: Labour and Delivery Perception, Control Perception and Change Perception. The questionnaire presented satisfactory internal consistency's indexes both in Study 1 (α coefficients range: .66–.83) and in Study 2 (α coefficients range: .70–.86). The analysis of women's mean scores on CEPS revealed a significant effect of age, social economic status, amniocentesis test, type of childbirth, childbirth preference, and disagreement between actual and preferred childbirth (p<.05). A significant correlation between the CEPS and IPQ scales was found (p<.05).

Conclusion

the current research evidenced that the Italian first adaptation of the CPQ, the Childbirth Experience Perception Scale, may be a valid and reliable measure of childbirth experience perception for use in different women's health clinical outcome and studies.     

No relationship between fear of childbirth and pregnancy-/delivery-outcome in a low-risk Dutch pregnancy cohort delivering at home or in hospital

Objective: To examine the relationship of fear of childbirth (FOC), general anxiety and depression during pregnancy and postpartum with birth complications. Methods: For this prospective cohort study 105 healthy women with low-risk pregnancies (until at least 30 weeks gestation) completed the Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) and the Hospital Anxiety and Depression Scale (HADS) at 30 weeks gestation and 6 weeks postpartum. These results were related with delivery characteristics. Results: FOC during pregnancy was not related to complications during labour and delivery. In a regression analysis, both multiparity and medical interventions were predictors for higher postpartum FOC. A positive correlation was found between FOC during pregnancy and FOC at six weeks postpartum, corrected for complications during childbirth (r = 0.45, p < 0.001). Conclusions: The birth giving process was not related to FOC during pregnancy, but the pre-partum level of FOC certainly is predictive of the level of postpartum FOC, suggesting that FOC as measured during gestation may influence the interpretation of the birth experience itself. We did find a positive relationship between both parity and medical interventions during childbirth and FOC postpartum.     

Emotional freedom techniques and breathing awareness to reduce childbirth fear: A randomized controlled study

BackgroundEmotional freedom techniques (EFT) and breathing awareness (BA) are applicable during labour. The present study aimed to determine the effectiveness of EFT and BA in the reduction of childbirth fear.Materials and methodsThis randomized controlled study included 120 pregnant women, of whom the EFT, BA and control groups. The women in the EFT and BA groups were offered their intervention in the latent, active and transition phases of labour.ResultsThere was no significant difference in the sociodemographic and obstetric factors between the groups (p > 0.05). The Subjective Units of Distress Scale in active and transition phases were significantly lower in the EFT group. The difference in the scores for the Wijma Delivery Expectancy/Experience Questionnaire (version B) between the groups was significant (p < 0.001).ConclusionBoth EFT and BA were observed to be beneficial in clinical practice; the EFT was found to be more effective and permanent.     

Stress in fathers in the perinatal period: A systematic review

Backgrounddespite the evidence that fatherhood has a long-term positive and protective effect on men's health, there is also evidence that fatherhood in the perinatal period can be complex and demanding. Due to the potential increase in stressors in the perinatal period, there is reason to hypothesise that it is a time of increased stress for fathers. However, it is not clear how significant a problem stress is for fathers during this stage of life. This is in part, due to the fact that the available research has not been systematically reviewed.Purposethe purpose of this systematic review was to critically appraise the empirical evidence that examined stress in fathers in the perinatal period.Designsystematic review.Methodsa systematic review protocol was developed and registered with PROSPERO (Reference number: CRD42016035821). The review was guided by the PRISMA reporting process. Electronic databases Medline, CINAHL, the Cochrane Library, PsycARTICLES, PsycINFO, Psychology and Behavioural Sciences Collections were searched to identify studies that met the inclusion criteria. Studies that researched fathers in the perinatal period were included if stress was the principal focus of the research, if stress was in the title and/or aim of the study or if stress was an outcome or dependent variable. Data were extracted and presented in narrative form including tables and figures.Findingseighteen studies met the inclusion criteria. The findings indicate that fathers experience stress in the perinatal period, particularly at the time of birth. Stress levels were found to increase from the antenatal period to the time of birth, with a decrease in stress levels from the time of birth to the later postnatal period. There are a number of factors that contribute to stress in fathers in the perinatal period and these included negative feelings about the pregnancy, role restrictions related to becoming a father, fear of childbirth and feelings of incompetence related to infant care. The review found that stress has a negative impact on fathers, with higher stress levels contributing to mental health issues such as anxiety, depression, psychological distress and fatigue.Key conclusionduring the perinatal period fathers experience stress and face unique stressors that can impact negatively on their health and social relationships.     

Dads as breastfeeding advocates: results from a randomized controlled trial of an educational intervention

OBJECTIVE: Recognizing that an expectant father may influence a mother's decision to breast- or formula-feed, we tested the effectiveness of a simple, educational intervention that was designed to encourage fathers to advocate for breastfeeding and to assist his partner if she chooses to breastfeed. STUDY DESIGN: We conducted a randomized controlled trial in which expectant fathers (n = 59) were assigned randomly to attend either a 2-hour intervention class on infant care and breastfeeding promotion (intervention) or a class on infant care only (control group). The classes, which were led by a peer-educator, were interactive and informal and utilized different media to create an accessible environment for participants. Couples were recruited during the second trimester from a university obstetrics practice. RESULTS: Overall, breastfeeding was initiated by 74% of women whose partners attended the intervention class, as compared with 41% of women whose partners attended the control class (P = .02). CONCLUSION: Expectant fathers can be influential advocates for breastfeeding, playing a critical role in encouraging a woman to breastfeed her newborn infant.     

Experiential factors associated with childbirth-related fear in Swedish women and men: a population based study

The aim of this study was to investigate and compare experiential factors associated with childbirth-related fear in women and in men. A questionnaire was completed by 410 women and 329 men who prior to the study had had a healthy baby at Ume? university hospital, Sweden. The level of fear was estimated, and twenty-nine statements designed to measure experiences and perceptions connected to childbirth and childbirth-related fear, were subjected to exploratory factor analysis. Factor scores were calculated and differences among women and men with intense and mild/moderate fear were estimated. Intense fear was reported by 23% of the women and 13% of the men. The factor analysis identified four factors explaining 52% of the variance in woman and 50% in men. The factors were named 'exposedness and inferiority', 'communicative difficulties', 'norms of harmony' and 'insecurity and danger'. The relative order of the factors varied in relation to gender, and in the women, 'exposedness and inferiority' had the greatest explanatory power, while this was true for 'communicative difficulties' in the men. Most factors were reported to a significantly higher extent by respondents with intense fear. The results are discussed from a gender perspective.     

Effect of neuro-linguistic programming on COVID-19 fear in kidney transplant patients: A randomized controlled study

This study was conducted experimentally to evaluate the effect of neuro-linguistic programming (NLP) on fear of COVID-19 in kidney transplant patients. The study was carried out between June 2021 and October 2021. The Personal Information Form and COVID-19 Fear Scale (FCV–19S) were used to collect data. The obtained data obtained were evaluated using the SPSS 25 software. NLP was found to reduce the fear of COVID-19 in kidney transplant patients. Clinical nurses can use NLP techniques to support patients with fear in similar patient groups. Patients can be provided with access to training programs where they can learn NLP techniques.Clinicaltrials.govNCT05115435.     

Childbirth traditions and cultural perceptions of safety in Nepal: Critical spaces to ensure the survival of mothers and newborns in remote mountain villages

Objective

to uncover local beliefs regarding pregnancy and birth in remote mountainous villages of Nepal in order to understand the factors which impact on women's experiences of pregnancy and childbirth and the related interplay of tradition, spiritual beliefs, risk and safety which impact on those experiences.

Design

this study used a qualitative methodological approach with in-depth interviews framework within social constructionist and feminist critical theories.

Setting

the setting comprised two remote Nepalese mountain villages where women have high rates of illiteracy, poverty, disadvantage, maternal and newborn mortality, and low life expectancy. Interviews were conducted between February and June, 2010.

Participants

twenty five pregnant/postnatal women, five husbands, five mothers-in-law, one father-in-law, five service providers and five community stakeholders from the local communities were involved.

Findings

Nepalese women, their families and most of their community strongly value their childbirth traditions and associated spiritual beliefs and they profoundly shape women's views of safety and risk during pregnancy and childbirth, influencing how birth and new motherhood fit into daily life. These intense culturally-based views of childbirth safety and risk conflict starkly with the medical view of childbirth safety and risk.

Key conclusions and implications for practice

if maternity services are to improve maternal and neonatal survival rates in Nepal, maternity care providers must genuinely partner with local women inclusive of their cultural beliefs, and provide locally based primary maternity care. Women will then be more likely to attend maternity care services, and benefit from feeling culturally safe and culturally respected within their spiritual traditions of birth supported by the reduction of risk provided by informed and reverent medicalised care.     

Test-retest reliability of the Kuopio instrument for fathers (KIF): a questionnaire to assess fathers' feelings, experiences and preparation for their wife/partner's delivery

Objective

to assess the test–retest reliability of the Greek version of the Kuopio Instrument for Fathers (KIF) questionnaire that explores fathers’ feelings, experiences and preparation for their wife/partner's delivery.

Design

the KIF questionnaire was translated into Greek, back translated and adapted to the Greek population. After a pilot test, it was administered to a sample of fathers. Originally, 149 fathers completed the KIF questionnaire, and they were asked to complete it once again 1–2 weeks later.

Findings

out of a sample of 149 fathers, 72 (48.3%) returned the retest questionnaire. Sixty-five of these fathers had completed all the items, and thus only these cases were included in the data analysis. The mean age of the sample was 35.42±7.55 years. For 34 (52.3%) fathers, this was their first child. The mean total test score of fathers for the 35-item scale that assessed the feelings related to their wife/partner's delivery was 99.09±11.88 and the mean total retest score was 102.30±9.99. The correlation coefficient between the two scores was 0.975 (p<0.001). The mean total test and retest scores for the 19-item scale that evaluated the experiences related to their wife/partner's delivery were 50.78±17.57 and 49.59±18.21, respectively. The correlation coefficient was 0.947 (p<0.001). The intraclass correlation coefficients for the items of both scales ranged from 0.73 to 0.99, exceeding 0.85 in most cases.

Conclusion

the test–retest properties of the KIF questionnaire in the Greek population proved to be very satisfactory. Future validation and longitudinal studies are necessary to refine the instrument.