An Internet-Based Intervention to Increase the Ability of Lesbian, Gay, and Bisexual People to Cope With Adverse Events: Single-Group Feasibility Study.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people are at higher risk of mental health problems due to widespread hetero- and cisnormativity, including negative public attitudes toward the LGBTQ+ community. In addition to combating social exclusion at the societal level, strengthening the coping abilities of young LGBTQ+ people is an important goal. OBJECTIVE: In this transdiagnostic feasibility study, we tested a 6-week internet intervention program designed to increase the ability of nonclinical LGBTQ+ participants to cope with adverse events in their daily lives. The program was based on acceptance and commitment therapy principles. METHODS: The program consists of 6 web-based modules and low-intensity assistance for homework provided by a single care provider asynchronously. The design was a single-group assignment of 15 self-identified LGB community members who agreed to participate in an open trial with a single group (pre- and postintervention design). RESULTS: Before starting the program, participants found the intervention credible and expressed high satisfaction at the end of the intervention. Treatment adherence, operationalized by the percentage of completed homework assignments (32/36, 88%) was also high. When we compared participants' pre- and postintervention scores, we found a significant decrease in clinical symptoms of depression (Cohen d=0.44, 90% CI 0.09-0.80), social phobia (d=0.39, 90% CI 0.07-0.72), and posttraumatic stress disorder (d=0.30, 90% CI 0.04-0.55). There was also a significant improvement in the level of self-acceptance and behavioral effectiveness (d=0.64, 90% CI 0.28-0.99) and a significant decrease in the tendency to avoid negative internal experiences (d=0.38, 90% CI 0.09-0.66). The level of general anxiety disorder (P=.11; d=0.29, 90% CI -0.10 to 0.68) and alcohol consumption (P=.35; d=-0.06, 90% CI -0.31 to 0.19) were the only 2 outcomes for which the results were not statistically significant. CONCLUSIONS: The proposed web-based acceptance and commitment therapy program, designed to help LGBTQ+ participants better manage emotional difficulties and become more resilient, represents a promising therapeutic tool. The program could be further tested with more participants to ensure its efficacy and effectiveness. TRIAL REGISTRATION: ClinicalTrials.gov NCT05514964; https://clinicaltrials.gov/study/NCT05514964.

Testing the Effectiveness of an Intervention to Improve Romanian Teachers' LGBT+-Related Attitudes, Cognitions, Behaviors, and Affect: Protocol for a Randomized Controlled Trial.

BACKGROUND: Repeated stigmatization due to group membership constitutes a recurrent stressor with negative impact on physical and mental health (minority stress model). Among European countries, Romania ranks low on LGBT+ (lesbian, gay, bisexual, and transgender people. The "+" represents individuals whose identities do not fit typical binary notions of male and female [nonbinary]) inclusion, with 45% of Romanian LGBT+ respondents reporting discrimination in at least 1 area of life in the year preceding the survey. Importantly, while all LGBT+ people might experience minority stress, younger sexual minority individuals are more prone to the detrimental impacts of stigma on their mental and physical health. As such, interventions are necessary to improve the inclusion climate within schools, where young people spend most of their time. Until now, most interventions addressing this topic have been conducted on undergraduate students in Western countries, with no studies conducted in countries that have widespread anti-LGBT+ attitudes. OBJECTIVE: This paper describes the research protocol for a randomized controlled trial investigating whether LGBT+ stigma and bias among Romanian school teachers can be reduced using an internet-based intervention focusing on education and contact as primary training elements. METHODS: A sample of 175 school teachers will be randomly assigned to either the control or experimental group. The experimental group participants will receive the intervention first and then complete the outcome measures, whereas the control group will complete the outcome measures first and then receive the intervention. The 1-hour multimedia intervention is developed for internet-based delivery under controlled conditions. It includes 2 interactive exercises, 2 recorded presentations, animations, and testimonies from LGBT+ individuals. Data for attitudinal, behavioral, cognitive, and affective measures will be collected during the same session (before or after the intervention, depending on the condition). We also plan to conduct a brief mixed methods follow-up study at 6 to 8 months post participation to investigate potential long-term effects of training. However, due to attrition and lack of experimental control (all participants will have completed the intervention, regardless of the condition), these data will be analyzed and reported separately using a mixed methods approach. RESULTS: This paper details the protocol for the teacher intervention study. Data collection began in December 2022 and was completed by February 2023. Data analysis will be performed upon protocol acceptance. Follow-up measures will be completed in 2024. Results are expected to be submitted for publication following analysis in the spring of 2024. CONCLUSIONS: The findings of this study will establish the effectiveness of an internet-based intervention intended to lessen anti-LGBT stigma and sentiment in a nation where these views have long been prevalent. If successful, the intervention could end up serving as a resource for Romanian teachers and guidance counselors in high schools. TRIAL REGISTRATION: ISRCTN 84290049; https://doi.org/10.1186/ISRCTN84290049. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54254.

Caring Climate and Support, Mental Health, and Academic Adjustment: Effects from a Cluster Randomized Controlled Trial in Upper Secondary Schools in Norway.

This cluster randomized controlled trial (RCT) examined the effect of a three year follow up of a multi-tier intervention aiming at improving the psychosocial environment in upper secondary schools in Norway. Two intervention conditions were tested: a universal single-tier intervention focused on improving the psychosocial school climate, the dream school program (DSP), and a multi-tier intervention combining the DSP with a targeted measure, the mental health support team (MHST). A total of 2203 students responded to the baseline survey. Of the 2203 pupils, 1884 responded to the first follow-up survey (year 1), 1287 pupils to the second (year 2), and 756 pupils to the third (year 3). The direct and indirect effects on school completion were analyzed using a multi-level linear mixed model. The results showed no significant effects of either the DSP or the DSP and MHST in combination on support, the school climate, mental health, or academic adjustment. We found no significant effect of the interventions on the proportion who had completed school or were in training (the three groups varied between 76.6% and 77.8%). Future similar studies should be attentive to the potential challenges of implementing RCTs in the school setting. Furthermore, the long-term effects of school interventions on the constructs included in this study could be difficult to capture due to the complexity of the phenomena. The implications of these findings are discussed.

Civic engagement and mental health trajectories in Norwegian youth.

Introduction: Applying variable-centered analytical approaches, several studies have found an association between civic engagement and youth mental health. In the present study, we used a person-centered approach to explore whether civic engagement was related to optimal trajectories of mental health compared to other trajectories. We also examined how sociodemographic factors, such as socioeconomic status (SES), gender and age were related to youth mental health trajectories. Methods: Our sample comprised 675 students (aged 16-22) who had participated in three waves of data collection (Mage = 18.85, SD = 0.55; 43% males) in the COMPLETE project, a cluster-randomized controlled trial that involved Norwegian upper secondary schools. Results: The results revealed three trajectories of mental health (reflecting a combination of mental distress and mental well-being): optimal, intermediate, and sub-optimal. Contrary to our expectations, higher levels of civic engagement were not related to the optimal trajectory of mental health vs. other trajectories. However, we found that students who reported higher levels of SES and males were more likely to follow the optimal trajectory compared to other trajectories. Discussion: While the findings on civic engagement could be due to our measurement's inability to capture the concept of "dugnad," a well-established civic activity in the Norwegian society, the findings regarding the influence of SES and gender suggest that there is still more work to be done concerning the assessment and advancement of factors that can address mental health inequalities across SES and gender.

Preventing Loneliness and Reducing Dropout: Results from the COMPLETE Intervention Study in Upper Secondary Schools in Norway.

This study examines the impact of interventions aimed at improving psychosocial health on students' perception of a caring school climate, their feelings of loneliness, and school completion in Norwegian upper secondary education. Two intervention conditions were tested: a universal single-tier intervention focused on improving the psychosocial school climate: the Dream School Program, and a multi-tier intervention combining the Dream School Program with a targeted measure, the Mental Health Support Team. The direct and indirect effects of these interventions on school completion were analyzed using structural equation models (SEM), with data from 1508 students (mean age at Time 1: 17.02 (SD = 0.92); 60.7% girls; 72.1% Norwegian-born). The results indicated that loneliness levels did not differ significantly between the intervention conditions. However, students in the multi-tier intervention group reported a significantly higher perception of a caring school climate compared to those in the single-tier intervention group. The multi-tier intervention group had a lower rate of school completion compared to the control group and the single-tier intervention group. The SEM analysis revealed that the multi-tier intervention reduced loneliness in the second year of upper secondary school by promoting a caring school climate in the first school year. In contrast, the single-tier intervention was associated with increased loneliness due to a decrease in the perception of a caring school climate. The implications of these findings are discussed.

Academic Stress, Academic Self-efficacy, and Psychological Distress: A Moderated Mediation of Within-person Effects.

Previous research has largely failed to separate the between- and within-person effects in the longitudinal associations between academic stress, academic self-efficacy, and psychological distress (symptoms of anxiety and depression). Filling this research gap, this study investigated if academic self-efficacy mediated the relationship between academic stress and psychological distress at the intraindividual level during 3 years of upper secondary school. Gender moderation was also examined in the hypothesised model. The present sample consisted of 1508 Norwegian adolescents (baseline M age = 16.42; 52.9% high perceived family wealth; 70.6% Norwegian-born). The random intercept cross-lagged panel model results indicated (1) positive and time-invariant direct effects from academic stress to psychological distress, (2) academic self-efficacy partially mediated these effects, and (3) psychological distress impacted later academic stress. Academic stress was more strongly related to academic self-efficacy and psychological distress at the interpersonal level for boys, while the intraindividual impact of academic stress on psychological distress was stronger for girls. The study findings might have implications for school-based implementation strategies and theoretical development.

Hello Darkness, My Old Friend: Moderating a Random Intercept Cross-lagged Panel Model of Loneliness and Symptoms of Anxiety and Depression.

The present study investigated the trait- and state-like associations between loneliness and symptoms of anxiety and depression during three years in middle to late adolescence. The moderating effect of gender and social self-efficacy was examined on the hypothesised model. The sample consisted of 1508 Norwegian upper secondary school students (61% female; mean age at T1 = 16.33; 52.9% high socioeconomic position; 70.6% Norwegian-born). We found 1) strong and positive trait- and state-like associations between loneliness and symptoms of anxiety and depression, 2) that anxiety and depressive symptoms consistently predicted later loneliness but not the other way around, 3) that gender moderated parts of the state-like associations between loneliness and symptoms of anxiety and depression, and 4) that social self-efficacy had no moderating effect on the longitudinal relationship between loneliness and anxiety and depressive symptoms. The present study might inform future research, theory development, and intervention strategies in middle to late adolescent samples.

The Within-Person Effect of Psychological Distress on Social Self-Efficacy: A Random Intercept Cross-Lagged Panel Model.

This study investigated the temporal relationship between social self-efficacy and psychological distress during 3 years in middle to late adolescence. The sample comprised 1508 participants (60.7% female; baseline mean age = 16.33, SD = .62; 52.9% high perceived family wealth; 70.6% born in Norway). We used a random intercept cross-lagged panel model to investigate the concurrent and subsequent associations between the two constructs. The results indicated (1) small to moderate and negative associations between the trait-like components and within-person fluctuations of social self-efficacy and psychological distress, (2) positive and significant carry-over stability effects on both constructs across time, and (3) that psychological distress predicted subsequent social self-efficacy more consistently across four time points, than social self-efficacy predicted later psychological distress.

Positive Youth Development and Mental Well-Being in Late Adolescence: The Role of Body Appreciation. Findings From a Prospective Study in Norway.

Although a vulnerable period, adolescence is a time of great potential for healthy development. Understanding factors that contribute to mental well-being in this period is of great importance to facilitate for healthy development. During the adolescence period the body goes through rapid and considerable changes, and the focus on body appearance and perfection is substantial at societal, media, and peer level. In this study, we investigated the association between dimensions characterizing positive youth development, and mental well-being among Norwegian adolescents 16-17 years 1 year later, and whether this association was mediated by degree of body appreciation. We further tested whether the indirect and direct paths between positive youth development dimensions and mental well-being were moderated by gender. We used data from the first and second follow-up of the control arm of the COMPLETE study, a cluster randomized controlled trial in upper secondary schools in Norway. Findings showed that positive youth development in grade 1, as measured by both a combined global PYD and the dimensions competence, and connection were significantly associated with mental well-being in grade 2 in models adjusted for mental well-being in grade 1, gender and perceived family affluence. Also, body appreciation in grade 1 significantly predicted mental well-being in grade 2 in models including each of global PYD, competence, connection, character, and caring dimensions. Contrary to our hypothesis, no mediating effects of body appreciation were observed, and no moderation of indirect effects by gender were observed.

Recovery at the Clubhouse: challenge, responsibility and growing into a role.

Purpose: To explore how people with mental illness experience recovery in the Clubhouse context, and which ingredients of the model they find active in promoting recovery.Methods: Hermeneutic-phenomenological design. Individual, semi-structured interviews with 18 Norwegian Clubhouse members. Systematic text condensation was used in analysis.Results: Three main themes emerged: "Balancing unlimited support with meeting challenges", with two sub-themes: "Unlimited membership: space for self-agency or hindering development?" and "Becoming a Clubhouse member: concerns and positive experiences". The second main theme was: "Learning how to build new skills and roles in the community". The third main theme was: "Getting better through and for work", with two sub-themes: "Work at the Clubhouse as a means to recovery" and "Preparing for a working life in society". Overall, participants experienced improved mental and social wellbeing and work readiness.Conclusions: Recovery in the Clubhouse context requires members' personal initiative, thus people having poor mental health might struggle with utilizing the Clubhouse. However, participants reported that lack of challenges within the community thwarted their recovery. Based on Salutogenesis, conscious application of challenge in Clubhouse activities might enhance members' recovery. Furthermore, participants' all-round involvement in their recovery journeys suggests the importance of shared decision-making in recovery-oriented services.

Salutogenesis as a theoretical framework for psychosocial rehabilitation: the case of the Clubhouse model.

Purpose: This study explored whether the holistic theory of salutogenesis may be a suitable theoretical framework for the Clubhouse model of psychosocial rehabilitation, a pioneer among psychosocial rehabilitation programmes.Methods: A systematic examination of elements of the Clubhouse model, as prescribed by the Clubhouse standards, was performed within the context of the theory of salutogenesis including its basic salutogenic orientation and the main concepts of sense of coherence and resistance resources.Results: We found that several standards and practices within the Clubhouse model can be understood as applications of salutogenesis. We have hypothesized that the Clubhouse model promotes peoples' sense of coherence and mental health. However, our investigation also showed that, to enhance the recovery of Clubhouse members, more explicitly incorporating some salutogenic principles, such as "appropriate challenges" and "active adaptation as the ideal in treatment", may benefit Clubhouse practice.Conclusions: The Clubhouse model of psychosocial rehabilitation is very consistent with the salutogenic orientation and main salutogenic concepts. The present study suggests that salutogenesis may be a suitable theoretical framework for the Clubhouse model and possibly in the psychosocial rehabilitation field in general.

"Finally, I belong somewhere I can be proud of" - Experiences of being a Clubhouse member in Norway.

Purpose: The number of psychosocial Clubhouses is growing rapidly in Norway. However, more knowledge is needed about the subjective experience of Clubhouse members in terms of their recuperation processes and experiences in the Clubhouse context. Therefore, this qualitative study explored what it is like to be a Clubhouse member in Norway, and further discuss it in light of the theory of Salutogenesis on successful pathways to coping and well-being.Methods: Using a hermeneutic-phenomenological approach, the present study included in-depth, semi-structured individual interviews with 18 Clubhouse members from three accredited Norwegian Clubhouses. Analysis was conducted using systematic text condensation.Results: Three main themes emerged from the analysis: "Finally, I belong somewhere I can be proud of," "I feel more like an ordinary citizen, just different," and "I feel somewhat equal to others." Overall, the participants experienced improved mental and social well-being owing to their membership of a Clubhouse.Conclusions: Our findings correspond with previous international research. Owing to the positive effect participation in the Clubhouse seem to have on members' motivation, Salutogenesis might help explain helpful processes within the model. Moreover, the model might be a relevant example for policy and service development in mental health care and the labour market.

Young adult cancer patients' experiences of private social network support during cancer treatment.

AIMS AND OBJECTIVES: To explore young adult cancer patients' experiences of support from their private social network during cancer treatment. BACKGROUND: Cancer treatment in young adulthood (aged 18-35 years) can be distressing. Social support is crucial for health and well-being, especially for young people and in times of crisis. Research indicates that young cancer patients experience a lack of social network support, but little is known about the types of private social network support available during cancer treatment. DESIGN: Qualitative study with interpretive descriptive design. METHODS: Twenty young adult cancer patients with different cancer diagnoses were interviewed retrospectively using a semi-structured interview guideline. Data were analysed using systematic text condensation. The COREQ checklist for qualitative research was followed. RESULTS: "From independence to dependence" was identified as a bridging theme, which was elaborated by four sub-themes: (1) "My partner was my rock-or not"; (2) "My family stood by me-or not"; (3) "My friends supported me-or not"; and (4) "I lacked young adult cancer peers-or not." CONCLUSION: The patients' major sources of private social network support were their partners and close family members. Only a few friends supported them during cancer treatment, and most lacked peer support. The type of social network support they received varied, and not all support was perceived as helpful. Helpful network support was experienced as being unconditional and given with empathy and without prompting. Patients without sufficient support from a partner or family members seem to be especially vulnerable. RELEVANCE TO CLINICAL PRACTICE: Nurses play a crucial role in educating young adult cancer patients about the importance of social support and helping them to map their social network and being explicit when requesting support. Nurses should inform patients' networks about both helpful and unhelpful support and should facilitate interaction between patients.

"I Got My Diagnosis on a Yellow Post-it Note": Young Adult Cancer Patients' Experiences of the Process of Being Diagnosed With Cancer.

BACKGROUND: Cancer in young adults is rare but young adult cancer patients (YACPs) are at an increased risk of severe physical and psychosocial impairments during cancer treatment and survivorship. However, little is known about the onset of this process. OBJECTIVE: The aim of this study was to explore how young cancer survivors experience the process of being diagnosed with cancer. METHODS: A qualitative method founded on a phenomenological-hermeneutical approach was used and included in-depth interviews with 20 young adult survivors (aged 24-35 years) with different cancer diagnoses, analyzed by Systematic Text Condensation. RESULTS: The participants' experiences of the diagnosis process were elaborated according to 3 main themes: (1) "I felt something was wrong, but…," (2) "The traumatic uncertainty," and (3) "The day my world collapsed." CONCLUSION: The findings indicate that the YACPs experienced a diagnosis of cancer as a highly traumatic and long-lasting process, characterized by lack of information and uncertainty. The findings indicate that healthcare professionals do not acknowledge the vulnerable phase of life and transitional challenges of YACPs. IMPLICATIONS FOR CLINICAL PRACTICE: The findings highlight the need to raise awareness of cancer in young adulthood in the public and in the primary healthcare system, to shorten the diagnosis process, and to clarify responsibility for age-related information and psychosocial follow-up during the diagnosis process. Further research is highly warranted.

Indicators of positive youth development can be maladaptive: The example case of caring.

INTRODUCTION: Research on positive youth development typically takes a more-is-better approach in which higher scores on measures of positive youth development indicate better outcomes. We question the validity of this assumption and describe how an imbalance among the Five Cs of Positive Youth Development can lead to a situation where "more" is actually "less." We then provide an empirical illustration using cross-sectional data. METHODS: We examined conditional associations between indicators of thriving and the C of caring using survey data obtained from a sample of 2,386 students in Norway (mean age 16.60 years [SD = 1.98]; 44.8% girls). Multilevel models assessed whether associations between caring and the thriving indicators (here defined as greater mental well-being and lower anxiety and depressive symptoms) differed when versus when not controlling for overall positive youth development. RESULTS: When positive youth development was not included as a covariate, caring was positively associated with mental well being and anxiety but not significantly associated with depressive symptoms. After adding positive youth development to the model, caring became less strongly associated with mental well-being, more strongly associated with anxiety, and significantly (positively) associated with depressive symptoms. CONCLUSIONS: Our results indicate that, after controlling for a set level of positive youth development, caring does not predict adaptive outcomes in a monotonic more-is-better way. These findings illustrate an instance where developmental regulations benefit the context at the cost of the individual and therefore speak to a growing acknowledgement in the literature-young people may suffer if they "care too much."

Coping with changes and uncertainty: A qualitative study of young adult cancer patients' challenges and coping strategies during treatment.

Young adult cancer patients (YACPs), aged 18-35 years when diagnosed with cancer, are in a vulnerable transitioning period from adolescence to adulthood, where cancer adds a tremendous burden. However, YACPs' challenges and coping strategies are under-researched. The objective of this study was to explore what challenges YACP experience during their treatment, and what coping strategies they applied to them. We conducted a qualitative study with a phenomenological-hermeneutic design, including retrospective, semi-structured interviews of 16 YACPs who had undergone cancer treatment. Data were analysed using thematic analysis and interpreted applying the Cognitive Activation Theory of Stress (CATS). We found "coping with changes and uncertainty" as overarching topic for YACPs' challenges, particularly related to five themes, including (1) receiving the diagnosis, (2) encountering the healthcare system, (3) living with cancer, (4) dealing with the impact of the treatment and (5) reactions from the social network. YACPs' coping strategies applied to these challenges varied broadly and ranged from maladaptive strategies, such as neglecting the situation, to conducive emotional or instrumental approaches to manage their challenges. The findings call for age-specific needs assessments, information and support for YACPs, and their families in order to facilitate YACPs' coping during their treatment.

Psychometric properties of the five-item version of the Mindful Awareness Attention Scale (MAAS) in Norwegian adolescents.

OBJECTIVES: The aim of the present study was to examine the factor structure, model-based reliability, measurement invariance and concurrent validity of the five-item version of the Mindfulness Attention Awareness Scale (MAAS) in Norwegian adolescents. METHODS: An initial pilot study was carried out using a sample of 77 fifteen year olds. For the main analyses, a sample of 2140 Norwegian adolescents was used who participated in the cross-sectional Health Behaviour in School-Aged Children (HBSC) study. All participants were asked to complete a questionnaire. RESULTS: Confirmatory factor analyses found support for the one-factor structure of the five-item version of the MAAS. Acceptable model fit was found in both the pilot sample (χ2=6.48, df=5, p=0.26; root mean square error of approximation [RMSEA]=0.06; comparative fit index [CFI]=0.99; standardised root mean square residual [SRMR]=0.03) and the HBSC sample (χ2=27.1, df=4, p<0.001; RMSEA=0.05; CFI=0.99; SRMR=0.01). The model-based reliability of the scale was good (ω=0.84 and ω=0.81, respectively). Scalar measurement invariance was established for sex, age and material affluence. Finally, the five-item MAAS displayed concurrent validity through moderate negative associations with health complaints ( r=-0.44; p<0.001) and school stress ( b=-0.44, p<0.001), and a positive moderate correlation with life satisfaction ( r=0.26; p<0.001). CONCLUSIONS: The five-item version of the MAAS is an adequate measure of mindfulness in Norwegian adolescents. Due to the brief nature of the scale, it can easily be included in epidemiological and clinical studies with an interest for trait mindfulness. The five-item MAAS may therefore have great potential to facilitate more knowledge about the role of mindfulness in adolescent health.

Working toward a good life as a cancer survivor: a longitudinal study on positive health outcomes of a rehabilitation program for young adult cancer survivors.

BACKGROUND: Research on cancer rehabilitation targeting young adult cancer survivors (YACS) is limited, and little is known about the positive health outcomes of rehabilitation programs tailored specifically for this vulnerable group. OBJECTIVE: The aim of this study was to investigate whether a complex rehabilitation program improved the health-related quality of life (HRQOL) and physical capacities of YACS. METHODS: A longitudinal prospective study using Norwegian norm-based comparisons was conducted. Twenty YACS (24-35 years old) with different cancer diagnoses participated in a complex rehabilitation program lasting for 6 months, focusing on goal setting, exercise, psychoeducation, individual follow-up, and peer support. RESULTS: Health-related quality of life was measured by EORTC QOL C-30 and the scores showed significant increases in overall HRQOL (P < .005-.001) and all functional dimensions (P < .001-.05) and a decrease in fatigue (P < .000-.05) and effect sizes between 0.72 and 1.30. Significant changes occurred within physical fitness (P < .005), lung capacity (P < .05), and left-hand strength (P < .001), but not right-hand strength and body mass index, with effect sizes between -0.04 and 0.48. The values of HRQOL were stable after a 1-year follow-up. CONCLUSIONS: A complex cancer rehabilitation program especially tailored for YACS seems to build positive health outcomes such as HRQOL and physical capacity in a long-term perspective. The content and structure of the program were feasible with high compliance. The results underline the importance of targeting rehabilitation interventions to YACS in need after cancer treatment, acknowledging rehabilitation as a process that requires adequate time and follow-up. IMPLICATIONS FOR PRACTICE: Healthcare providers should be aware of YACS' symptom burden and monitor HRQOL and physical parameters to ascertain holistic cancer survivorship care.

'Passed and cleared' - Former tobacco smokers' experience in quitting smoking.

The literature contains many reports on cigarette smokers and smoking cessation, but there are fewer qualitative studies on smokers' and ex-smokers' experiences with smoking cessation and health care professionals. The aim of the present study was to give voice to ex-smokers' own experiences with smoking cessation through the health care system. The study collected data from focus group interviews with 28 informants divided into four groups. Results from this study do not point to one particular reason for successful smoking cessation, but instead to the combination of pressures from several factors. The informants seem to have reached a point where external pressure made them receptive to: the fear of diseases, legislation, taking advice from health care personnel, views of children and grandchildren and providing a new identity as ex-smoker. Factors that helped to quit were: recent efforts to make it difficult to smoke in Norway, encouragement to seek help to change their tobacco habits, smoking cessation programmes that are integrated into health care practice, health professionals who demonstrate sensitivity and genuine interest during their meetings with smokers. Health professionals in specialized health care must be made aware of their role as the first important step in their patients' road to quitting smoking.

'It is the situation that makes it difficult': experiences of nursing students faced with a high-stakes drug calculation test.

Test anxiety affects the learning, performance and well-being of students, and it increases as the stakes get higher. Norwegian nursing students must pass a drug calculation test with a flawless performance if they are to qualify as nurses. The aim of the current study was to investigate the test anxiety experiences of students faced with such a high-stakes test. We used a mixed methods approach where the data were collected using a survey questionnaire and a focus group interview. In total, 203 freshman nursing students completed the questionnaire, six of whom also participated in the focus group interview. The survey results showed that 44.3% of the students reported high mathematics test anxiety in the months before the drug calculation test. More than 12% of the high-anxiety students reported a low mathematics self-concept. High and medium self-concept students also experienced high test anxiety. Our analysis of the focus group interview data confirmed that the high stakes of the test increased the test anxiety dramatically.