Clinical Practice & Epidemiology in Mental Health




ISSN: 1745-0179 ― Volume 14, 2018
RESEARCH ARTICLE

The Physical Body Experiences Questionnaire Simplified for Active Aging (PBE-QAG)



Giulia Cossu1, Emilio Loi1, Mauro Giovanni Carta1, Alessia Bramanti2, 3, *
1 Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
2 Istituto di Scienze Applicate e Sistemi Intelligenti, ISASI, Messina, Italy
3 IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy

Abstract

Background:

The physical activity has been indicated as an experience that can help achieve positive, self-oriented own body awareness. This awareness is an aspect that tends to get worse with age.

Objective:

Our study aims to verify the internal consistency of a questionnaire on physical awareness in a sample of Italian elders; a secondary objective is to measure if there is a relationship between physical awareness and perceived level of physical activity.

Methods:

Cross sectional study on a consecutive sample of elderly people was administered the “Physical Body Experiences Questionnaire simplified for active aging (PBE-QAG)”, inspired by the “Physical Body Experiences Questionnaire”, modified, simplified and adapted to be used in the elderly over 65. To elderly people the International Physical Activity Questionnaire. Cronbach’s alpha was also used to assess internal reliability of the total PBE-QAG. The factor structure was evaluated through Confirmatory Factor Analyses (CFAs).

Results:

The Cronbach’s alpha was 0.8 for the “body-mind relationship” scale, 0.81 for the “accepting your body” scale, 0.83 for the “awareness of physical skills” scale, and 0.65 for the “awareness of physical limits” scale. Cronbach’s alpha for the total PBE-QAG was 0.89. The CFA indicated a model with the 4 factors (CFI = 0.989, TLI = 0.984, RMSEA = 0.076).

People who conducted physical activity assiduously or regularly and over 10 minutes showed a better score to the PBE-QAG than those who declared a sporadic activity and for “less than 10 minute”, respectively.

Conclusion:

Our study revealed that the PBE-QAG shows an excellent total internal consistency. In the Italian sample of elderly people the questionnaire shows the model with the 4 factors described in literature.

Keywords: Active aging, Physical Awareness, Elderly, Physical Activity, Physical Body Experiences Questionnaire, International Physical Activity Questionnaire.


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 14
First Page: 70
Last Page: 77
Publisher Id: CPEMH-14-70
DOI: 10.2174/1745017901814010070

Article History:

Received Date: 29/01/2018
Revision Received Date: 27/02/2018
Acceptance Date: 08/03/2018
Electronic publication date: 26/03/2018
Collection year: 2018

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© 2018 Cossu et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Istituto di Scienze Applicate e Sistemi Intelligenti, ISASI, Via Torre Bianca, Istituto Marino, Mortelle, 98164 Messina, Italy; Tel: +39 09060128100; E-mail: alessia.bramanti@gmail.com




1. INTRODUCTION

By 2050, 22% worldwide and 35.9% of Italy population will be over 65 years. For many people, aging is characterized by the rise of chronic diseases. Thus, DALYs (Disability-Adjusted Life Years) will increase proportionally, with a dramatic burden on social and health costs [1Global FSR. The financial impact of longevity risk 2012.https://www.imf.org/external/pubs/ft/gfsr/2012/01/pdf/c4.pdf]. This alarm was highlighted by the European Union, which has indicated the research on active aging as a priority [2http://ec.europa.eu/programmes/horizon2020/en/h2020-section/health-demographic-change-and-wellbeing].

There is evidence of significant benefits from physical activity (PA) and exercise in the psychosocial, and chronic disease-related disability [3Sancassiani F, Machado S, Preti A. Physical activity, exercise and sport programs as effective therapeutic tools in psychosocial rehabilitation. Clin Pract Epidemiol Ment Health 2018; 14: 6-10.[http://dx.doi.org/10.2174/1745017901814010006] [PMID: 29515643] ].

PA, including exercise and sport, is associated with better immune responses in old age: it impacts on metabolic disorders, including diabetes [4Codella R, Luzi L, Inverardi L, Ricordi C. The anti-inflammatory effects of exercise in the syndromic thread of diabetes and autoimmunity. Eur Rev Med Pharmacol Sci 2015; 19(19): 3709-22.[PMID: 26502862] ]. A systematic review has shown that physical exercise prevents falls in older people [5Rimland JM, Abraha I, Dell’Aquila G, et al. Effectiveness of non-pharmacological interventions to prevent falls in older people: A systematic overview. The SENATOR Project ONTOP Series. PLoS One 2016; 11(8): e0161579.[http://dx.doi.org/10.1371/journal.pone.0161579] [PMID: 27559744] ] and lowers cognitive and memory decline [6Kirk-Sanchez NJ, McGough EL. Physical exercise and cognitive performance in the elderly: current perspectives. Clin Interv Aging 2014; 9: 51-62.[PMID: 24379659] ]. We have conducted several studies on the use of physical exercise in the improvement of well-being, quality of life and depression symptoms, particularly in the elderly [7Mura G, Sancassiani F, Migliaccio GM, Collu G, Carta MG. The association between different kinds of exercise and quality of life in the long term. Results of a randomized controlled trial on the elderly. Clin Pract Epidemiol Ment Health 2014; 10: 36-41.[http://dx.doi.org/10.2174/1745017901410010036] [PMID: 24707314] -12Carta MG, Aguglia E, Bocchetta A, et al. The use of antidepressant drugs and the lifetime prevalence of major depressive disorders in Italy. Clin Pract Epidemiol Ment Health 2010; 6: 94.].

Among the dimensions that the physical activity expected to improve in the elderly there is the awareness of one’s body and a better acceptance of one’s own physicality, aspects that tend to get worse with age

Indeed, a recent study of Fredrickson and colleagues [13Fredrickson BL, Roberts TA, Noll SM, Quinn DM, Twenge JM. That swimsuit becomes you: Sex differences in self-objectification, restrained eating, and math performance. J Pers Soc Psychol 1998; 75(1): 269-84.[http://dx.doi.org/10.1037/0022-3514.75.1.269] [PMID: 9686464] ] has identified physical activity as an experience that can help achieve positive, self-oriented own body awareness. In this study, the authors introduced the concept of “embodiment” defined as the state in which a subject has cognition of his body as an essential and accepted part of his life; subsequently, this element has been seen as a potential protective factor against body image misperceptions and eating disorders According to Fredrickson and colleagues [13Fredrickson BL, Roberts TA, Noll SM, Quinn DM, Twenge JM. That swimsuit becomes you: Sex differences in self-objectification, restrained eating, and math performance. J Pers Soc Psychol 1998; 75(1): 269-84.[http://dx.doi.org/10.1037/0022-3514.75.1.269] [PMID: 9686464] ], the body awareness would consist of two components: “objectification of own body” and “subjective feelings of own body”. “Objectification of own body” occurs when a person takes cognition of how his/her body can be seen from the outside (“As I look at others?”), as opposed to the “subjective feeling of own body” in which a person is reflecting without outside comparison (“How do I feel with my body?”). Objectification theory [13Fredrickson BL, Roberts TA, Noll SM, Quinn DM, Twenge JM. That swimsuit becomes you: Sex differences in self-objectification, restrained eating, and math performance. J Pers Soc Psychol 1998; 75(1): 269-84.[http://dx.doi.org/10.1037/0022-3514.75.1.269] [PMID: 9686464] ] implies that there is a pressure dependent on culture adopting (endorsing) an observer perspective on own physical self. This self-objectification is required to lead to body shame and to use attention resources. The introspective awareness of own body (called non-objectivizing) is hypothesized to be more healthy because it sets people free being in harmony with the feelings of own body and allowing to appreciate the functionality of own physical self.

Our study aims to validate a questionnaire on physical awareness in a sample of Italian elders; a secondary objective of this study is to measure if there is a relationship between physical awareness and perceived level of physical activity.

We used a modified version of Physical Body Experiences (PBE) Questionnaire [14Menzel JE. The psychometric validation of the physical body experiences questionnaire 2010.], which consists of 36 items. The questionnaire of Menzel [14Menzel JE. The psychometric validation of the physical body experiences questionnaire 2010.] is not very suitable to be used in Italian elderly sample because it is too long and even the answers are not anchored to examples easily understood for an advanced Italian generation. It has never been validated in Italy or in the elderly population. The results of the study of Menzel [14Menzel JE. The psychometric validation of the physical body experiences questionnaire 2010.] indicate that the PBE Questionnaire consists of four different dimensions, which refer to those aspects that the author calls the “embodiment”: mind-body relationship, acceptance of his own body, awareness of physical skills and awareness of physical limits [14Menzel JE. The psychometric validation of the physical body experiences questionnaire 2010.].

The questionnaire used in this paper is an extremely simplified tool compared to the instrument that inspired it; moreover, it has been determined to be used in studies on elderly who use different outcome measures. The tool should, therefore, be as sustainable as possible.

2. MATERIALS AND METHODS

2.1. Study Design/Sample

The cross sectional study on a consecutive sample of elderly people was recruited at the University of the Third Age in the city of Cagliari, Italy.

2.2. Instruments

A) The “Physical Body Experiences Questionnaire simplified for active aging (PBE-QAG)”, has been inspired by the previously described instrument, PBE Questionnaire [14Menzel JE. The psychometric validation of the physical body experiences questionnaire 2010.], but modified, simplified and adapted for the elderly over 65, in Italian language. It is shorter than the instrument that inspired it. This is a 12 item tool (see appendix) whose responses are on a 5-point Lickert scale (from 1 = “Totally True” to 5 = “Totally False”). The questionnaire presents three questions for each of the hypothetical 4-dimensional factors of physical awareness (body relationship, acceptance of one’s body, awareness of physical skills, awareness of physical limits), already identified by the previously cited study [11Mura G, Carta MG. Physical activity in depressed elderly. A systematic review. Clin Pract Epidemiol Ment Health 2013; 9: 125-35.[http://dx.doi.org/10.2174/1745017901309010125] [PMID: 24009640] ] and acknowledged as useful for the research in the elderly.

B) The International Physical Activity Questionnaire (IPAQ) [15Craig CL, Marshall AL, Sjöström M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003; 35(8): 1381-95.[http://dx.doi.org/10.1249/01.MSS.0000078924.61453.FB] [PMID: 12900694] ] is a self-administered 9-item questionnaire that evaluates physical activity levels (as sedentary, light, moderate and vigorous) and energy expenditure over the past 7 days. The questionnaire was used to measure if the level of consciousness of the body, investigated by (PBE) Questionnaire also through the Confirmatory Factor Analyses (CFA), had a relationship with frequency, duration and intensity of physical activity reported by each elderly participant.

2.3. Statistical Analysis

The 12 items of the PBE-QAG were recorded and scored with those participants who received 1 mark for totally true and a 5 mark for indicating totally false. Responses from 2 to 4 indicated intermediate values.

Descriptive statistics were produced for the study participants, and included count and percentage. Observations with missing values have been excluded from the analyses. Cronbach’s alpha has been used to assess internal reliability of the PBE-QAG total and its sub-scales. The factor structure was evaluated by means of Confirmatory Factor Analyses (CFAs) performed using the estimator WLSMV that analyzes the polychoric correlation matrices, treating all the items as ordinal in the analyses. Goodness-of-fit indices were used to evaluate the models: Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI) ≥.95 and ≥ .90 indicated good and sufficient fit, respectively. Root Mean Square Error of Approximation (RMSEA) ≤ .05 or ≤ .08 indicated good and sufficient fit, respectively. Factors’ correlation has been estimated through Pearson’s r coefficient. Factor indicators with loadings lower than .30 have been excluded from the analysis. Finally, path diagrams have been used for a visual comparison of the factor loadings.

To measure if the level of physical activity was associated with the level of physical awareness, a multivariate regression analysis has been used. The physical awareness level, measured as score the QCFA, represented the dependent variable. The level of physical activity (as item scores on frequency, duration, and intensity of the IPAQ) has been used as a dependent variable. The analysis has been conducted correcting gender, age and level of education (years of study) as possible confounding variables. All analyses have been performed with R 3.3.2.

3. RESULT

3.1. Descriptive Information

The study included 106 participants: 43 (40.56%) were men. Twenty-eight participants (24.52%) had at least 5-year of education, 30 (28.3%) 8 years and 31 (29.24%) 13 years of education, 13 (12.26%) had a degree and 4 (3.77%) a post-degree. Mean age was 68.88 years (53-95). Seven (6.6%) subjects were unoccupied, 12 (11.32%) were occupied and 81 (76.4%) were retired. The 12-item QCFA-total score mean was 25.16±9.58.

3.2. Internal Reliability of the PBE-QAG

The Cronbach’s alpha was 0.8 for the “body-mind relationship” scale, 0.81 for the “accepting your body” scale, 0.83 for the “awareness of physical skills” scale, and 0.65 for the “awareness of physical limits” scale. Cronbach’s alpha for the total PBE-QAG was 0.89.

3.3. Factor Structure

Factor structure has been evaluated to check the QCFA ability to measure the hypothesized four factor-dimensions of the questionnaire. We conducted a CFA, fitting a model with the 4 factors described in literature [13Fredrickson BL, Roberts TA, Noll SM, Quinn DM, Twenge JM. That swimsuit becomes you: Sex differences in self-objectification, restrained eating, and math performance. J Pers Soc Psychol 1998; 75(1): 269-84.[http://dx.doi.org/10.1037/0022-3514.75.1.269] [PMID: 9686464] ]. Overall, this model showed a good fit (CFI = 0.989, TLI = 0.984, RMSEA = 0.076). Fig. (1) reports the estimates of the loadings for the 4-factor model. All the items were associated with quite high loadings, even though it is worth noticing that the item 11 of the questionnaire on factor 4 was not high as the others (0.36).

Fig. (1)
Stime of model of the 4 factors of QCFA.


Table 1 shows the strength of the association between physical awareness (QCFA score) and frequency of physical activity (IPAQ frequency of activity score); the measurement was correct for possible confounding factors. People who conducted physical activity assiduously (3/4 times a week) or regularly (1/2 times a week) showed a better score on the physical awareness questionnaire than those who declared a sporadic activity.

Table 1
Results of the multivariate regression analysis with physical awareness level (measured as score the QCFA) as the dependent variable and frequency of physical activity (IPAQ frequency of activity score) as the independent variable (controlling for sex, age and education).


Table 2 shows the strength of the association between physical awareness (QCFA score) and duration of physical activity (IPAQ duration of activity score); the measurement was correct for possible confounding factors. People who conducted physical activity over 10 minutes (sum of “up to 20 minutes”, “up to 30 minutes”, “40 minutes or more”) showed a better score to the physical awareness questionnaire than those who declared “less than 10 minutes” of activity.

Table 2
Results of the multivariate regression analysis with physical awareness level (measured as score the QCFA) as the dependent variable and activity duration as the independent variable (controlling for sex, age and education).


The perception of a different intensity of physical activity (IPAQ intensity score) did not seem to be associated with the level of physical awareness (QCFA score) (Table 3).

Table 3
Results of the multivariate regression analysis with physical awareness level (measured as score the QCFA) as the dependent variable and activity type as the independent variable (controlling for sex, age and education).


4. DISCUSSION

The main result of our study is that the physical activities are associated with a better bodily awareness in elderly; this association, in turn, may be related to mental health benefits and to quality of life.

Our work revealed that the PBE-QAG shows an excellent total internal consistency measured through the Cronbach α coefficient. Indeed, the consistency is questionable when the coefficient is greater than 0.60; acceptable if is greater than 0.70; good when it exceeds 0.80; excellent when it exceeds 0.80 [16Cortina J. What is coefficient alpha? An examination of theory and applications. J Appl Psychol 1993; 78: 98-104.[http://dx.doi.org/10.1037/0021-9010.78.1.98] ]. The internal consistency is also acceptable for the single sub-scales, even though the “Physical Limit Awareness” sub-scale has had a questionable performance at the limits of sufficiency. Factorial analysis confirmed the 4-factor structure (mind-body relationship; body acceptance; physical skills awareness; physical limitation awareness), which had been highlighted by a similar 36-item tool (PBE) [14Menzel JE. The psychometric validation of the physical body experiences questionnaire 2010.], aimed to measure the same construct. In our study, we verified the scale validity to measure the construct in a specific sample of elderly people. Compared to the instrument previously validated in literature [14Menzel JE. The psychometric validation of the physical body experiences questionnaire 2010.], PBE-QAG has the advantage of brevity, which makes it applicable also in studies in which multiple outcome needs to be taken into consideration and several instruments are required in relation to the different outcome measures which must be measured.

Especially, in studies on active aging, the awareness of own body is a measure that is interesting to take in consideration to quantify other dimensions of general well-being such as quality of life, satisfaction on social support or perception of social well-being. It may be also important to understand whether an impairment of this dimension may be related to the presence of psychopathological distress or disabling illnesses [17Mantovani G, Astara G, Lampis B, et al. Evaluation by multidimensional instruments of health-related quality of life of elderly cancer patients undergoing three different “psychosocial” treatment approaches. A randomized clinical trial. Support Care Cancer 1996; 4(2): 129-40.[http://dx.doi.org/10.1007/BF01845762] [PMID: 8673350] , 18Mantovani G, Astara G, Lampis B, et al. Impact of psychosocial interventions on quality of life of elderly cancer patients. Psychooncology 1996; 5: 127-35.[http://dx.doi.org/10.1002/(SICI)1099-1611(199606)5:2<127::AID-PON220>3.0.CO;2-L] ]. In cohort studies, it is important to understand whether these dimensions can affect each other; in fact, physical awareness can be an editable construct [19Carta MG, Angermeyer MC, Sancassiani F, et al. A follow-up on patients with severe mental disorders in Sardinia after two changes in regional policies: Poor resources still correlate with poor outcomes. BMC Psychiatry 2013; 13: 333.[http://dx.doi.org/10.1186/1471-244X-13-333] [PMID: 24313930] ].

The study confirms the conviction often reported in the literature (but rarely demonstrated) that a sufficiently sustained physical activity, as duration and frequency, is associated with better bodily awareness, although the study does not seem to confirm that a more intense physical activity increases the awareness. However, the data are preliminary. The hypothesis reveals a better physical awareness as a factor of well-being, which needs to be verified in longitudinal studies that may clarify the possible causal connection between physical activity and body consciousness. In relation to the demonstrated association, we can postulate that a greater physical activity produces better awareness and not vice versa.

To demonstrate the possibility to measure physical awareness and to confirm the dimensions of such construct in the elderly, as described in previous studies in non-elderly adults [14Menzel JE. The psychometric validation of the physical body experiences questionnaire 2010.], this study can be considered as the first step to conduct other studies of this type on active aging.

The study has been carried out in a limited sample, whose recruitment methods (from a “University of the Third Age”) may have caused a bias of choice in relation to high schooling. However, it is important to note that in Italy the people are admitted to such “University of the Third Age” regardless of their previous educational level. In addition, the correction of the factor education in the analysis did not make any significant difference in the results.

The PBE-QAG, validate by larger studies, may be useful first in clinical trials and then in clinical practice, to evaluate how bodily awareness of elderly with chronic disease and its correlation with physical activity may impact on the quality of life and psychological well-being.

CONCLUSION

Our study revealed that the PBE-QAG shows an excellent total internal consistency in elderly people. In addition, a sufficiently sustained physical activity was associated with better bodily awareness.

APPENDIX

People can experience themselves during their daily physical activity in many different ways. We ask you to read the sentences below and indicate to what extent each statement is true for you. We ask you to evaluate it in the most honest and accurate way possible based on your personal experience of the last month.

Referring to my experience of the last 30 days.


ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The ethics committee of the “Azienda Mista Ospedaliero Universitaria di Cagliari” has approved the study presented in this paper. Data were anonymized and each subject has been identified by a code.

HUMAN AND ANIMAL RIGHTS

No Animals were used. All the reported experiments involving humans were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2008.

CONSENT FOR PUBLICATION

Participants gave their written informed consent.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Global FSR. The financial impact of longevity risk 2012.https://www.imf.org/external/pubs/ft/gfsr/2012/01/pdf/c4.pdf
[2] http://ec.europa.eu/programmes/horizon2020/en/h2020-section/health-demographic-change-and-wellbeing
[3] Sancassiani F, Machado S, Preti A. Physical activity, exercise and sport programs as effective therapeutic tools in psychosocial rehabilitation. Clin Pract Epidemiol Ment Health 2018; 14: 6-10.[http://dx.doi.org/10.2174/1745017901814010006] [PMID: 29515643]
[4] Codella R, Luzi L, Inverardi L, Ricordi C. The anti-inflammatory effects of exercise in the syndromic thread of diabetes and autoimmunity. Eur Rev Med Pharmacol Sci 2015; 19(19): 3709-22.[PMID: 26502862]
[5] Rimland JM, Abraha I, Dell’Aquila G, et al. Effectiveness of non-pharmacological interventions to prevent falls in older people: A systematic overview. The SENATOR Project ONTOP Series. PLoS One 2016; 11(8): e0161579.[http://dx.doi.org/10.1371/journal.pone.0161579] [PMID: 27559744]
[6] Kirk-Sanchez NJ, McGough EL. Physical exercise and cognitive performance in the elderly: current perspectives. Clin Interv Aging 2014; 9: 51-62.[PMID: 24379659]
[7] Mura G, Sancassiani F, Migliaccio GM, Collu G, Carta MG. The association between different kinds of exercise and quality of life in the long term. Results of a randomized controlled trial on the elderly. Clin Pract Epidemiol Ment Health 2014; 10: 36-41.[http://dx.doi.org/10.2174/1745017901410010036] [PMID: 24707314]
[8] Mura G, Sancassiani F, Machado S, et al. Efficacy of exercise on depression: A systematic review. Int J Psychosoc Rehabil 2014; 18: 23-36.
[9] Carta MG, Hardoy MC, Pilu A, et al. Improving physical quality of life with group physical activity in the adjunctive treatment of major depressive disorder. Clin Pract Epidemiol Ment Health 2008; 4: 1.[http://dx.doi.org/10.1186/1745-0179-4-1] [PMID: 18221549]
[10] Mura G, Cossu G, Migliaccio GM, et al. Quality of life, cortisol blood levels and exercise in older adults: Results of a randomized controlled trial. Clin Pract Epidemiol Ment Health 2014; 10: 67-72.[http://dx.doi.org/10.2174/1745017901410010067] [PMID: 25006344]
[11] Mura G, Carta MG. Physical activity in depressed elderly. A systematic review. Clin Pract Epidemiol Ment Health 2013; 9: 125-35.[http://dx.doi.org/10.2174/1745017901309010125] [PMID: 24009640]
[12] Carta MG, Aguglia E, Bocchetta A, et al. The use of antidepressant drugs and the lifetime prevalence of major depressive disorders in Italy. Clin Pract Epidemiol Ment Health 2010; 6: 94.
[13] Fredrickson BL, Roberts TA, Noll SM, Quinn DM, Twenge JM. That swimsuit becomes you: Sex differences in self-objectification, restrained eating, and math performance. J Pers Soc Psychol 1998; 75(1): 269-84.[http://dx.doi.org/10.1037/0022-3514.75.1.269] [PMID: 9686464]
[14] Menzel JE. The psychometric validation of the physical body experiences questionnaire 2010.
[15] Craig CL, Marshall AL, Sjöström M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003; 35(8): 1381-95.[http://dx.doi.org/10.1249/01.MSS.0000078924.61453.FB] [PMID: 12900694]
[16] Cortina J. What is coefficient alpha? An examination of theory and applications. J Appl Psychol 1993; 78: 98-104.[http://dx.doi.org/10.1037/0021-9010.78.1.98]
[17] Mantovani G, Astara G, Lampis B, et al. Evaluation by multidimensional instruments of health-related quality of life of elderly cancer patients undergoing three different “psychosocial” treatment approaches. A randomized clinical trial. Support Care Cancer 1996; 4(2): 129-40.[http://dx.doi.org/10.1007/BF01845762] [PMID: 8673350]
[18] Mantovani G, Astara G, Lampis B, et al. Impact of psychosocial interventions on quality of life of elderly cancer patients. Psychooncology 1996; 5: 127-35.[http://dx.doi.org/10.1002/(SICI)1099-1611(199606)5:2<127::AID-PON220>3.0.CO;2-L]
[19] Carta MG, Angermeyer MC, Sancassiani F, et al. A follow-up on patients with severe mental disorders in Sardinia after two changes in regional policies: Poor resources still correlate with poor outcomes. BMC Psychiatry 2013; 13: 333.[http://dx.doi.org/10.1186/1471-244X-13-333] [PMID: 24313930]

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"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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