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1.  The role of resilience on psychological adjustment and physical health in patients with diabetes 
British journal of health psychology  2007;13(Pt 2):311-325.
This study used a longitudinal design to investigate the buffering role of resilience on worsening HbA1c and self-care behaviours in the face of rising diabetes-related distress.
A total of 111 patients with diabetes completed surveys and had their glycosylated hemoglobin (HbA1c) assessed at baseline and 1-year follow-up. Resilience was defined by a factor score of self-esteem, self-efficacy, self-mastery, and optimism. Diabetes-related distress and self-care behaviours were also assessed.
Baseline resilience, diabetes-related distress, and their interaction predicted physical health (HbA1c) at 1-year. Patients with low, moderate, and high resilience were identified. Those with low or moderate resilience levels showed a strong association between rising distress and worsening HbA1c across time (r=.57, .56, respectively). However, those with high resilience scores did not show the same associations (r=.08). Low resilience was also associated with fewer self-care behaviours when faced with increasing distress (r= −.55). These correlation coefficients remained significant after controlling for starting points.
In patients with diabetes, resilience resources predicted future HbA1c and buffered worsening HbA1c and self-care behaviours in the face of rising distress levels.
PMCID: PMC2899486  PMID: 17535497
2.  The CIET Aboriginal Youth Resilience Studies: 14 Years of Capacity Building and Methods Development in Canada 
Pimatisiwin  2008;6(2):65-88.
CIET started supporting Canadian Aboriginal community-based researchers of resilience in 1995. An evolving approach to Aboriginal resilience used a combination of standard instruments and questionnaires of local design. Over the years, CIET measured personal assets like sense of coherence, spirituality, knowledge, pride in one’s heritage, mastery or self-efficacy, self-esteem, low levels of distress, involvement in traditional ways and activities, church attendance. Other indicators reflected the social dimension of resilience: feeling supported; parental care and support; parental monitoring, attitudes, and example; peer support; and support from the wider community.
Pride in one’s heritage, self-esteem, low distress, and mastery were measurable personal assets of resilient Aboriginal youth in a variety of cultures and circumstances. Early efforts to link resilience with specific features of culture or spirituality did not meet with success — largely reflecting failure to ask the right questions. Parental care and support, parental monitoring, parental attitudes, and parental example clearly supported the resilient Aboriginal youth in most settings. But peers are an even stronger influence, critical in relation to different types of behaviour from smoking to drinking to substance abuse to violence, unsafe sex, and suicidal tendencies. More generally, having someone to confide in, to count on in times of crisis, someone to give advice and someone who makes one feel cared for are important factors in youth resilience and something that communities can help to provide even where the family is not the support it should be and where peers are more of a hindrance than a help.
CIET currently supports three resilience research projects involving Aboriginal youth in Canada: suicide prevention, reduction of HIV risk, and reduction of domestic violence. The latest resilience measurement tools include enculturation and revised approaches to Aboriginal spirituality.
PMCID: PMC2942846  PMID: 20862230 CAMSID: cams1051
3.  Coping Style and Quality of Life in Elderly Patients with Vision Disturbances 
Journal of Ophthalmology  2014;2014:584627.
Purpose. This study aims at evaluating coping style and quality of life in patients with glaucoma and cataract. Methods. The participants were patients (N = 237, 130F; mean age: M = 67,8; SD = 9,5) with low vision caused by cataract (N = 188) and glaucoma (N = 49) who answered the Quality of Life Questionnaire (QOLQ) by Schalock and Keith. The participants were divided by means of cluster analysis (k-means) according to coping styles measured by CISS (Endler and Parker) into three groups: (1) high mobilization for coping, (2) task-oriented coping, and (3) low mobilization for coping. Results. In all the group, a general quality of life was moderately lowered; however, in task-oriented group it was relatively high. Moreover, task-oriented group had significantly lower level of anxiety (STAI), hopelessness (HS), and loneliness (UCLA LS-R) and higher level of self-esteem (SES) in comparison to the patients from high mobilization and low mobilization for coping. Conclusions. In an old age, adaptive coping with vision disturbances does not necessarily mean flexibility in combining all coping styles, but rather task-oriented coping and an ability to use social support. Extreme mobilization for coping seems not adaptive similarly like low mobilization for coping because it violates balance between environmental requirements and personal resources.
PMCID: PMC4158297  PMID: 25215225
4.  Mechanisms of psychological resiliency in women after mastectomy 
Contemporary Oncology  2012;16(4):341-344.
Aim of the study
To investigate into the mechanisms of resiliency in women after mastectomy. We hypothesized that the mechanism of resiliency in women with breast cancer would involve facilitation of adaptive coping strategies and inhibition of maladaptive strategies. We tested a mediational model in which resiliency was related to satisfaction with life through coping strategies.
Material and methods
Thirty women after mastectomy aged 28–69 years (M = 53.23, SD = 9.00) completed the Ego Resiliency Scale, Mental Adjustment to Cancer Scale, and Satisfaction with Life Scale.
The bootstrapping technique revealed that there were significant indirect effects for positive reframing (95% CI: 0.01–0.36), hopelessness/helplessness (95% CI: 0.18–0.83) and anxious preoccupation (95% CI: 0.001–0.55) but not for fighting spirit. The models explained up to 33% of the variance in satisfaction with life.
Coping strategies fully explain the effect of resiliency on satisfaction with life in women after mastectomy. This finding provides additional evidence of the fundamental role of coping strategies in the mechanisms of resiliency. We obtained similar results in patients with type II diabetes and rheumatoid arthritis. The lack of significant associations of fighting spirit with resiliency suggests that this coping strategy may be beneficial for somatic health but its contribution to the mechanisms of psychological resiliency is complex.
PMCID: PMC3687422  PMID: 23788906
breast cancer; resiliency; positive emotions; coping strategies; satisfaction with life
5.  The relationship between resilience and personality traits in doctors: implications for enhancing well being 
PeerJ  2013;1:e216.
Objective. The health and well being of medical doctors is vital to their longevity and safe practice. The concept of resilience is recognised as a key component of well being and is an important factor in medical training to help doctors learn to cope with challenge, stress, and adversity. This study examined the relationship of resilience to personality traits and resilience in doctors in order to identify the key traits that promote or impair resilience.
Methods. A cross sectional cohort of 479 family practitioners in practice across Australia was studied. The Temperament and Character Inventory measured levels of the seven basic dimensions of personality and the Resilience Scale provided an overall measure of resilience. The associations between resilience and personality were examined by Pearson product-moment correlation coefficients, controlling for age and gender (α = 0.05 with an accompanying 95% confidence level) and multiple regression analyses.
Results. Strong to medium positive correlations were found between Resilience and Self-directedness (r = .614, p < .01), Persistence (r = .498, p < .01), and Cooperativeness (r = .363, p < .01) and negative with Harm Avoidance (r = .−555, p < .01). Individual differences in personality explained 39% of the variance in resilience [F(7, 460) = 38.40, p < .001]. The three traits which contributed significantly to this variance were Self-directedness (β = .33, p < .001), Persistence (β = .22, p < .001) and Harm Avoidance (β = .19, p < .001).
Conclusion. Resilience was associated with a personality trait pattern that is mature, responsible, optimistic, persevering, and cooperative. Findings support the inclusion of resilience as a component of optimal functioning and well being in doctors. Strategies for enhancing resilience should consider the key traits that drive or impair it.
PMCID: PMC3840414  PMID: 24282675
Temperament; Resilience; Character; Well being; Doctors
6.  Effects of gender, age, family support, and treatment on perceived stress and coping of patients with type 2 diabetes mellitus 
We previously found that the empowerment of patients with type 2 diabetes mellitus can be strongly affected by gender and age in addition to self-managed diet and exercise behaviors and treatment. This study was to examine the effects of gender, age, family support, and treatment on the perceived stress and coping of patients with type 2 diabetes mellitus living with family.
A survey was conducted of 140 adults with type 2 diabetes mellitus who were living with family. There was no significant difference in hemoglobin A1c (HbA1c) between male and female. Perceived stress and coping were measured with the Japanese version of the Appraisal of Diabetes Scale and the Lazarus Type Stress Coping Inventory. Stepwise regression analysis and path analysis were performed to identify factors that affect the perceived stress and coping of patients.
(1) Perceived stress and coping were strongly affected by gender. (2) Perceived stress and coping were affected by age for males, but perceived stress was not affected by age for females. However, females showed a greater “psychological impact of diabetes” than did males. Females aged between 50 and 69 years engaged in active problem solving, but awareness of diabetes was low. (3) Treatment regimens had an effect on HbA1c for both sexes, and diet therapy affected the awareness of diabetes of males and coping of females. (4) For females, “sense of self-control” was strongly associated with coping, and those who were living with non-spouse family members had a greater psychological impact of diabetes than those living with only their spouse. (5) For males, coping was strongly affected by living with their spouse.
The results suggest that perceived stress, coping, and diet regimen are deeply associated with gender and age and that a male with type 2 diabetes mellitus living with his spouse is strongly dependent on support from the spouse. It is important to take into account gender, age, and family environment to provide patients with an individualized approach to addressing perceived stress and to provide education program for coping that can maximize treatment and maintain better, continuous glycemic control.
PMCID: PMC4114439  PMID: 25075211
Appraisal of Diabetes Scale; Type 2 diabetes mellitus; Stress Coping Inventory; Gender; Spouse
7.  Chronic pain coping styles in patients with herniated lumbar discs and coexisting spondylotic changes treated surgically: Considering clinical pain characteristics, degenerative changes, disability, mood disturbances, and beliefs about pain control 
Pain catastrophizing, appraisals of pain control, styles of coping, and social support have been suggested to affect functioning in patients with low back pain. We investigated the relation of chronic pain coping strategies to psychological variables and clinical data, in patients treated surgically due to lumbar disc herniation and coexisting spondylotic changes.
The average age of study participants (n=90) was 43.47 years (SD 10.21). Patients completed the Polish versions of the Chronic Pain Coping Inventory-42 (PL-CPCI-42), Beck Depression Inventory (BDI-PL), Coping Strategies Questionnaire (CSQ-PL), Beliefs about Pain Control Questionnaire (BPCQ-PL), and Roland-Morris Disability Questionnaire (RMQ-PL).
In the PL-CPCI-42 results, resting, guarding and coping self-statements were frequently used as coping strategies (3.96 SD 1.97; 3.72 SD 1.72; 3.47 SD 2.02, respectively). In the CSQ-PL domains, catastrophizing and praying/hoping were frequently used as coping strategies (3.62 SD 1.19). The mean score obtained from the BDI-PL was 11.86 SD 7.23, and 12.70 SD 5.49 from the RMDQ-PL. BPCQ-PL results indicate that the highest score was in the subscale measuring beliefs that powerful others can control pain (4.36 SD 0.97). Exercise correlated significantly with beliefs about internal control of pain (rs=0.22). We identified associations between radiating pain and guarding (p=0.038) and between sports recreation and guarding (p=0.013) and task persistence (p=0.041).
Back pain characteristics, depressive mood, disability, and beliefs about personal control of pain are related to chronic LBP coping styles. Most of the variables related to advancement of degenerative changes were not associated with coping efforts.
PMCID: PMC3891316  PMID: 24370564
disc herniation; chronic pain coping styles; CPCI-42; beliefs about pain control
8.  Coping and resilience in adolescents with type 1 diabetes 
Adolescents with type 1 diabetes (T1D) must cope with the ongoing stress of treatment management, so it is important to identify the most adaptive coping strategies. Previous studies, however, have typically measured broad categories of coping (e.g. approach/avoidance) and few used instruments specifically designed for this population.
This article aimed to use a developmentally sensitive coping measure to explore how the use of specific coping strategies impacts resilience (i.e. quality of life, competence and metabolic control) in adolescents with T1D.
Thirty adolescents with T1D between the ages of 10 and 16 and their mothers completed questionnaires on adolescents’ coping strategy use, competence and quality of life. Clinical data (i.e. HbA1c) were obtained from adolescents’ medical records.
Greater use of primary control coping strategies (e.g. problem solving, emotional expression) was associated with higher competence scores, better quality of life and better metabolic control. Secondary control coping strategies (e.g. acceptance, distraction) were related to higher social competence, better quality of life and better metabolic control. Finally, the use of disengagement coping strategies (e.g. withdrawal or denial) was linked with lower competence and poorer metabolic control.
The results of this study support the use of developmentally sensitive coping measures by researchers and clinicians to determine the most effective coping strategies for adolescents with T1D.
PMCID: PMC3134245  PMID: 21143270
adolescent development; diabetes mellitus; resilience; type 1
9.  Posttraumatic growth, posttraumatic stress disorder and resilience of motor vehicle accident survivors 
Although some previous studies have suggested that posttraumatic growth (PTG) is comprised of several factors with different properties, few have examined both the association between PTG and posttraumatic stress disorder (PTSD) and between PTG and resilience, focusing on each of the factors of PTG. This study aimed to examine the hypothesis that some factors of PTG, such as personal strength, relate to resilience, whereas other factors, such as appreciation of life, relate to PTSD symptoms among Japanese motor vehicle accident (MVA) survivors.
This cross-sectional study was performed with 118 MVA survivors at 18 months post MVA. Data analyzed included self-reporting questionnaire scores on the Posttraumatic Growth Inventory (PTGI), the Impact of Event Scale- Revised (IES-R), and the Sense of Coherence (SOC) scale, which is one of the most widely used scales for measuring resilience. Correlations between scores on the PTGI and IES-R, the PTGI and SOC scale, and the IES-R and SOC scale were established by calculating Spearman's correlation coefficients.
PTGI was positively correlated with both SOC and PTSD symptoms, in spite of an inverse relationship between SOC and PTSD symptoms. Relating to others, new possibilities, and personal strength on the PTGI were correlated positively with SOC, and spiritual change and appreciation of life on the PTGI were positively correlated with PTSD symptoms.
Some factors of PTG were positively correlated with resilience, which can be regarded as an outcome of coping success, whereas other factors of PTG were positively correlated with PTSD symptoms, which can be regarded as signifying coping effort in the face of enduring distress. These findings contribute to our understanding of the psychological change experienced by MVA survivors, and to raising clinicians' awareness of the possibility that PTG represents both coping effort coexisting with distress and outcome of coping success.
PMCID: PMC2914073  PMID: 20573276
10.  Evaluating the effectiveness of personal resilience and enrichment programme (PREP) for HIV prevention among female sex workers: a randomised controlled trial 
BMC Public Health  2013;13:683.
Female sex workers (FSWs) are often considered as the vector, if not reservoir, of HIV and other sexually transmitted infections. Building upon the existing evidence on the role of psychological health in sexual health, the aim of this protocol is to describe a trial investigating the effectiveness of the Personal Resilience and Enrichment Programme (PREP), a resilience-promoting intervention that targets at psychological well-being i.e. self-esteem, self-efficacy and coping, to facilitate adaptation and ultimately safe sexual practices among FSWs, which could be an innovative strategy in controlling the spread of these infections.
A total of 132 FSWs will be recruited and randomly assigned to either the intervention or usual care (control) groups in a multi-centred randomised controlled trial. Based on the resilience framework, this intervention is comprised of six weekly sessions focused on the awareness, expression and management of emotions, identifying roles and personal strengths, and effective problem-solving skills. Complex intervention assessment on both intervention process and effectiveness will be adopted when the primary outcome reduction of sexual risk behaviour and other psychological outcomes include their perceived stress, self-esteem, self-efficacy, coping overall resilience, and psychological distress will be measured at baseline, post-treatment and 3-month post-intervention and differences assessed by ANOVA. The relationship of resilience factors, psychological health and HIV preventive behaviours will be evaluated using structural equation modelling.
It is anticipated that this study will increase our understanding of the relationships between individual resilience attributes, positive adaptation, psychological health and sexual health practices. If successful, this programme will provide an innovative direction for HIV prevention by applying the personal resilience factors to promote both psychological well-being and safe sex for this high risk population.
Trial Registration
PMCID: PMC3733820  PMID: 23886280
Randomised controlled trial; Female sex workers; HIV prevention; Resilience; Protocol
11.  A cross-sectional study of stressors and coping mechanisms used by radiation therapists and oncology nurses: Resilience in Cancer Care Study 
Occupational stress and burnout are well-recognised experiences reported by cancer care workers. The aim was to describe the frequency and severity of potential stressors as well as the effectiveness of coping skills of radiation therapists (RTs) and oncology nurses (ONs), which make up the two largest occupational groups in cancer care.
A questionnaire was distributed to RTs and ONs in two large tertiary hospitals in Queensland. Descriptive data regarding severity of potential stressors at home and work as well as the perceived effectiveness of preferred coping styles for each stressor was compared for each professional group. Respondents were asked questions about their personal circumstances and to also complete five standardised questionnaires measuring resilience, mental well-being, depression, anxiety and burnout.
There were 71 respondents representing a response rate of 26%. The types of stressors differed between the two groups but both reported that heavy workload was the most severe workplace stressor. RTs reported higher stressor and coping strategy frequency than ONs. There were no identifiable differences between RTs and ONs in the types or effectiveness of coping strategies employed at home or work. Mental well-being for both groups was inversely correlated with depression, anxiety and burnout and positively correlated with resilience.
RTs experienced higher mean scores for stressors and coping than ONs. There were no significant between-group differences for anxiety, depression, burnout, mental well-being or resilience.
PMCID: PMC4282106  PMID: 25598975
Anxiety; cancer; coping; depression; Stress
12.  Personality and Dietary Intake – Findings in the Helsinki Birth Cohort Study 
PLoS ONE  2013;8(7):e68284.
Personality traits are associated with health outcomes including non-communicable diseases. This could be partly explained by lifestyle related factors including diet. The personality traits neuroticism, extraversion, openness, agreeableness, and conscientiousness are linked with resilience, meaning adaptability in challenging situations. Resilient people usually comply with favorable health behaviors.
Our objective was to explore the associations between food and nutrient intake, personality traits and resilience.
A validated semi-quantitative food frequency questionnaire was used to measure diet and the NEO-personality inventory to assess personality in 1681 subjects. Linear regression analysis was used to explore diet-personality associations and cluster analysis to define resilient and non-resilient personality profiles.
Adjusting for age, education and energy intake, and applying Bonferroni corrections, openness in men was associated with higher vegetable (14.9 g/d for 1 SD increase in the personality score, PBonf <0.01) and lower confectionery and chocolate (−2.8 g/d, PBonf <0.01) intakes. In women, neuroticism was associated with lower fish (−4.9 g/d, PBonf <0.001) and vegetable (−18.9 g/d, PBonf <0.01) and higher soft drink (19.9 g/d, PBonf <0.001) intakes. Extraversion, in women, associated with higher meat (5.9 g/d, PBonf <0.05) and vegetable (24.8 g/d, PBonf<0.001) intakes, openness with higher vegetable (23.4 g/d, PBonf <0.001) and fruit (29.5 g/d, PBonf <0.01) intakes. Agreeableness was associated with a lower soft drink (−16.2 g/d, PBonf <0.01) and conscientiousness with a higher fruit (32.9 g/d, PBonf<0.01) intake in women. Comparing resilient and non-resilient subjects, we found resilience in women to be associated with higher intakes of vegetables (52.0 g/d, P<0.001), fruits (58.3 g/d, P<0.01), fish (8.6 g/d, P<0.01) and dietary fiber (1.6 g/d, P<0.01).
Personality traits are associated with dietary intake and especially subjects with resilient personality profiles had healthier dietary intakes. These associations were stronger in women than in men.
PMCID: PMC3715473  PMID: 23874573
13.  The Coexistence of Coping Resources and Specific Coping Styles in Stress: Evidence from Full Information Item Bifactor Analysis 
PLoS ONE  2014;9(5):e96451.
Knowledge of coping styles is useful in clinical diagnosis and suggesting specific therapeutic interventions. However, the latent structures and relationships between different aspects of coping styles have not been fully clarified. A full information item bifactor model will be beneficial to future research.
One goal of this study is identification of the best fit statistical model of coping styles. A second goal is entails extended analyses of latent relationships among different coping styles. In general, such research should offer greater understanding of the mechanisms of coping styles and provide insights into coping with stress.
Coping Styles Questionnaire (CSQ) and Generalized Self-Efficacy Scale (GSES) were administrated to officers suffering from military stress. Confirmatory Factor Analyses was performed to indentify the best fit model. A hierarchical item response model (bifactor model) was adopted to analyze the data. Additionally, correlations among coping styles and self-efficacy were compared using both original and bifactor models.
Results showed a bifactor model best fit the data. Item loadings on general and specific factors varied among different coping styles. All items loaded significantly on the general factor, and most items also had moderate to large loadings on specific factors. The correlation between coping styles and self-efficacy and the correlation among different coping styles changed significantly after extracting the general factor of coping stress using bifactor analysis. This was seen in changes from positive (r = 0.714, p<0.01) correlation to negative (r = −0.335, p<0.01) and also from negative (r = −0.296, p<0.01) to positive (r = 0.331, p<0.01).
Our results reveal that coping styles have a bifactor structure. They also provide direct evidence of coexisting coping resources and styles. This further clarifies that dimensions of coping styles should include coping resources and specific coping styles. This finding has implications for measurement of coping mechanisms, health maintenance, and stress reduction.
PMCID: PMC4006812  PMID: 24787952
14.  Computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training 
Working in a hospital during an extraordinary infectious disease outbreak can cause significant stress and contribute to healthcare workers choosing to reduce patient contact. Psychological training of healthcare workers prior to an influenza pandemic may reduce stress-related absenteeism, however, established training methods that change behavior and attitudes are too resource-intensive for widespread use. This study tests the feasibility and effectiveness of a less expensive alternative - an interactive, computer-assisted training course designed to build resilience to the stresses of working during a pandemic.
A "dose-finding" study compared pre-post changes in three different durations of training. We measured variables that are likely to mediate stress-responses in a pandemic before and after training: confidence in support and training, pandemic-related self-efficacy, coping style and interpersonal problems.
158 hospital workers took the course and were randomly assigned to the short (7 sessions, median cumulative duration 111 minutes), medium (12 sessions, 158 minutes) or long (17 sessions, 223 minutes) version. Using an intention-to-treat analysis, the course was associated with significant improvements in confidence in support and training, pandemic self-efficacy and interpersonal problems. Participants who under-utilized coping via problem-solving or seeking support or over-utilized escape-avoidance experienced improved coping. Comparison of doses showed improved interpersonal problems in the medium and long course but not in the short course. There was a trend towards higher drop-out rates with longer duration of training.
Computer-assisted resilience training in healthcare workers appears to be of significant benefit and merits further study under pandemic conditions. Comparing three "doses" of the course suggested that the medium course was optimal.
PMCID: PMC2851711  PMID: 20307302
15.  The Relationship between Health-Promoting Behaviors and Resilience in Patients with Chronic Kidney Disease 
The Scientific World Journal  2013;2013:124973.
This cross-sectional research study explored differences in health-promoting behavior and resilience among three groups of chronic kidney disease patients (high-risk, early chronic kidney disease; early CKD and pre-end stage renal disease; pre-ESRD) treated at the Nephrology outpatient clinic in northern Taiwan. A total of 150 CKD outpatients were interviewed using structured questionnaires including a CKD Health to Promote Lifestyle Scale, and resilience scale. We found that the pre-ESRD group had lower resilience than either high-risk or early CKD groups. Factors affecting pre-ESRD resilience were gender, occupational status, diabetes and health-promoting behaviors. Factors affecting resilience of the high-risk group included level of education and health-promoting behaviors while factors affecting resilience in the early CKD group involved whether they are employed and health promoting behaviors. A significant positive correlation was found between health promoting behavior and resilience in all study subjects. Multiple regression analysis found that factors which could effectively predict resilience in patients at high-risk for CKD were gender, whether the patient had a job, nutrition, self-actualization, and stress level, accounting for 69.7% of the variance. Therefore, nursing education should focus on health promotion advocacy throughout the life of not only patients but also their families.
PMCID: PMC3621294  PMID: 23589703
16.  How Does Anger Coping Style Affect Glycemic Control in Diabetes Patients? 
Although various forms of anger have been found to influence the psychological and physical health in many chronic illness populations, little is known about the effects of anger in diabetes patients.
Associations between anger coping style, diabetes-related psychological distress, and glycosylated hemoglobin (HbA1c) were examined in 100 diabetes patients.
Participants completed the Problem Areas in Diabetes and Coping Styles questionnaires, and had HbA1c assessments at study entry (Time 1=T1), six months (T2), and 12 months after T1 (T3).
Linear regression analyses revealed T1 anger coping associated with T3 HbA1c (β=.22, p<.05) but T1 HbA1c did not associate with T3 anger coping (β=.13, p=NS). After controlling for significant covariates (of gender, age, education, type and duration of diabetes), regression analyses revealed that T2 diabetes-related psychological distress partially mediated this association.
These results suggested that higher levels of anger coping may promote poorer HbA1c in diabetes patients by provoking greater diabetes-related distress. Areas of future research on this topic are discussed.
PMCID: PMC2900155  PMID: 18696309
anger coping; psychological distress; glycemic control; diabetes
17.  Resilience in infertile couples acts as a protective factor against infertility-specific distress and impaired quality of life 
Our hypothesis was that resilience (=psychosocial stress-resistance) reduces infertility-specific distress and maintains quality of life of infertile couples.
Questionnaire data of WHO Quality of Life assessment (WHOQOL; domains: ‘physical’, ‘psychological’, ‘social relationships’ and ‘environment’), Fertility Problem Inventory (FPI; scales: ‘social concern’, ‘sexual concern’, ‘relationship concern’, ‘rejection of childfree lifestyle’ and ‘need for parenthood’), Resilience Scale (RS), as well as sociographic and medical data were available for 199 infertile couples.
Age, medical diagnosis and ‘intensity of desire for a child’ had no influence on quality of life. High scores on ‘suffering from childlessness’ went along with less satisfaction on ‘physical’ and ‘psychological’ domains for the women only. For both partners, high scores on ‘suffering from childlessness’ went along with higher scores on all FPI scales. High resilience was associated with high scores on all WHOQOL domains for both partners, also with low scores on all FPI scales except for ‘need for parenthood’ for the women and with a low score only on ’relationship concern’ for the men.
For infertile couples, resilience can be considered as an unspecific protective factor against infertility-specific distress and impaired quality of life. When offering counselling to involuntarily childless couples, awareness should be raised for resilience as a couple’s resource and a “generic” factor of coping.
PMCID: PMC3224175  PMID: 21901362
Psychological factors; Infertility-specific distress; Resilience; Quality of life; Infertility; Protective factor
18.  Coping Styles, Well-Being and Self-Care Behaviors Among African Americans With Type 2 Diabetes 
The Diabetes educator  2008;34(3):501-510.
The purpose of this study was to describe how coping styles among African Americans with type 2 diabetes relate to diabetes appraisals, self-care behaviors, and health-related quality of life or well-being.
This cross-sectional analysis of baseline measures from 185 African Americans with type 2 diabetes enrolled in a church-based randomized controlled trial uses the theoretical framework of the transactional model of stress and coping to describe bivariate and multivariate associations among coping styles, psychosocial factors, self-care behaviors, and well-being, as measured by validated questionnaires.
Among participants who were on average 59 years of age with 9 years of diagnosed diabetes, passive and emotive styles of coping were used most frequently, with older and less educated participants using more often passive forms of coping. Emotive styles of coping were significantly associated with greater perceived stress, problem areas in diabetes, and negative appraisals of diabetes control. Both passive and active styles of coping were associated with better diabetes self-efficacy and competence in bivariate analysis. In multivariate analysis, significant proportions of the variance in dietary behaviors and mental well-being outcomes (general and diabetes specific) were explained, with coping styles among the independent predictors. A positive role for church involvement in the psychological adaptation to living with diabetes was also observed.
In this sample of older African Americans with diabetes, coping styles were important factors in diabetes appraisals, self-care behaviors, and psychological outcomes. These findings suggest potential benefits in emphasizing cognitive and behavioral strategies to promote healthy coping outcomes in persons living with diabetes.
PMCID: PMC2668814  PMID: 18535323
19.  “I know it when I see it.” The complexities of measuring resilience among parents of children with cancer 
Promoting parent resilience may provide an opportunity to improve family-level survivorship after pediatric cancer; however, measuring resilience is challenging.
The “Understanding Resilience in Parents of Children with Cancer” was a cross-sectional, mixed-methods study of bereaved and non-bereaved parents. Surveys included the Connor-Davidson Resilience scale, the Kessler-6 psychological distress scale, the Post-Traumatic Growth Inventory, and an open-ended question regarding the on-going impact of cancer. We conducted content analyses of open-ended responses and categorized our impressions as “resilient,” “not resilient,” or “unable to determine.” “Resilience” was determined based on evidence of psychological growth, lack of distress, and parent-reported meaning/purpose. We compared consensus-impressions with instrument scores to examine alignment. Analyses were stratified by bereavement status.
Eighty-four (88%) non-bereaved, and 21 (88%) bereaved parents provided written responses. Among non-bereaved, 53 (63%) were considered resilient, 15 (18%) were not. Among bereaved, 11 (52%) were deemed resilient, 5 (24%) were not. All others suggested a mixed or incomplete picture. Rater-determined “resilient” parents tended to have higher personal resources and lower psychological distress (p=<0.001–0.01). Non-bereaved “resilient” parents also had higher post-traumatic growth (p=0.02). Person-level analyses demonstrated that only 50–62% of parents had all 3 instrument scores aligned with our impressions of resilience.
Despite multiple theories, measuring resilience is challenging. Our clinical impressions of resilience were aligned in 100% of cases; however, instruments measuring potential markers of resilience were aligned in approximately half. Promoting resilience therefore requires understanding of multiple factors, including person-level perspectives, individual resources, processes of adaptation and emotional well-being.
PMCID: PMC4264630  PMID: 24756554
Cancer; Oncology; Pediatrics; Parents; Resilience; Psychosocial Outcomes
20.  Determinants of resilience to cigarette smoking among young Australians at risk: an exploratory study 
Numerous researchers studied risk factors associated with smoking uptake, however, few examined protective factors associated with smoking resilience. This study therefore aims to explore determinants of smoking resilience among young people from lower socioeconomic backgrounds who are at risk of smoking.
Overall, 92 out of 92 vocational education students accepted invitation to participate in this exploratory study. The Adelaide Technical and Further Education (TAFE) Arts campus was chosen for the study given the focus on studying resilience in young people of lower socioeconomic status i.e. resilient despite the odds. A self-report questionnaire comprising a measure of resilience: sense of coherence, sense of humour, coping styles, depression, anxiety and stress, and family, peers and community support, was distributed among participants aged 15 to 29. Additional factors researched are parental approval and disapproval, course type, and reasons for not smoking. Using the Statistical Package for the Social Sciences (SPSS, version 13.0), analyses were undertaken using frequencies, means, standard deviations, independent sample t-tests, correlations, analysis of variance, logistic regression, and chi-square test.
Twenty five (27%) out of 92 students smoked. Young people with peer support tended to smoke (p < .05). A relationship between daily smoking and depression, anxiety and stress was also found (p < .05). When both mothers and fathers disapproved of their children smoking, it had a greater influence on females not smoking, compared with males. The majority of students chose 'health and fitness' as a reason for not smoking. Students in the Dance course tended to not smoke.
The current study showed that most students chose 'health and fitness' as the reason for not smoking. Single anti-smoking messages cannot be generalised to all young people, but should recognise that people within different contexts, groups and subcultures will have different reasons for choosing whether or not to smoke. Future studies should use larger samples with a mixed methods design (quantitative and qualitative).
PMCID: PMC2914043  PMID: 20609260
21.  A Review on the Psychobiology of Dementia Caregiving: A Focus on Resilience Factors 
Current psychiatry reports  2011;13(3):219-224.
The recent aging trend in the United States has resulted in an exponential growth in the number of informal dementia caregivers. Caring for a family member with dementia has been associated with negative health outcomes likely associated with physiologic changes resulting from stress. Yet caregiving is not always associated with health morbidity. In this review, we highlight resilience factors that appear to have a beneficial relationship with health outcomes. We highlight eleven studies that examined the relationship of one of three broad resilience domains (personal mastery, self-efficacy, and coping style) to caregiver health outcomes. Our main findings were that higher levels of personal mastery and self-efficacy, and increased use of positive coping strategies appear to have a protective effect on various health outcomes in dementia caregivers. Continued research is warranted to help guide prospective directions for caregiver interventions focusing on increasing caregiver resilience and the corresponding impact on caregiver health.
PMCID: PMC3182821  PMID: 21312008
Biomarkers; caregivers; resilience; health; coping; stress; morbidity
22.  Self-rated health, life-style, and psychoendocrine measures of stress in healthy adult women 
Upsala Journal of Medical Sciences  2010;115(4):266-274.
Self-rated health (SRH) is a robust predictor of subsequent health outcome, independent of objective health measures and life-style-related health risk factors. However, the determinants of SRH are as yet largely unknown. In accordance with the prevailing stress theory, we hypothesized that SRH is associated with personal coping resources, psychological strain, life-style variables, and endocrine variables.
A total of 106 healthy women, 22–59 years of age, were followed for up to 3 years with annual blood sampling (cortisol, prolactin, testosterone) and written questionnaires in which information on SRH, psychological strain, coping resources, socio-economic and life-style variables was sought.
In bivariate, screening logistic regression analyses, intended to find candidate variables for a final analysis model, all coping resource variables (sense of coherence, mastery, and self-esteem) were significantly related to SRH, and so were two psychological strain variables (vital exhaustion, and sleep disturbances), one life-style variable (fitness), but none of the endocrine variables. In the final multivariate analysis model, including all candidate variables, only vital exhaustion (P < 0.0001), fitness (P = 0.0002), and sense of coherence (P = 0.0006) were independently associated with SRH, together explaining 74% of the SRH variance.
Some elements of the hypothesis, i.e. the effects of coping resources, psychological strain, and life-style variables on SRH, were supported by the results, while others, i.e. effects of endocrine measures on SRH, were not, indicating a possible gender difference.
PMCID: PMC2971485  PMID: 20977316
Cortisol; prolactin; self-rated health; sense of coherence; testosterone; vital exhaustion
23.  DRD4-exonIII-VNTR Moderates the Effect of Childhood Adversities on Emotional Resilience in Young-Adults 
PLoS ONE  2011;6(5):e20177.
Most individuals successfully maintain psychological well-being even when exposed to trauma or adversity. Emotional resilience or the ability to thrive in the face of adversity is determined by complex interactions between genetic makeup, previous exposure to stress, personality, coping style, availability of social support, etc. Recent studies have demonstrated that childhood trauma diminishes resilience in adults and affects mental health. The Dopamine receptor D4 (DRD4) exon III variable number tandem repeat (VNTR) polymorphism was reported to moderate the impact of adverse childhood environment on behaviour, mood and other health-related outcomes. In this study we investigated whether DRD4-exIII-VNTR genotype moderates the effect of childhood adversities (CA) on resilience. In a representative population sample (n = 1148) aged 30–34 years, we observed an interactive effect of DRD4 genotype and CA (β = 0.132; p = 0.003) on resilience despite no main effect of the genotype when effects of age, gender and education were controlled for. The 7-repeat allele appears to protect against the adverse effect of CA since the decline in resilience associated with increased adversity was evident only in individuals without the 7-repeat allele. Resilience was also significantly associated with approach-/avoidance-related personality measures (behavioural inhibition/activation system; BIS/BAS) measures and an interactive effect of DRD4-exIII-VNTR genotype and CA on BAS was observed. Hence it is possible that approach-related personality traits could be mediating the effect of the DRD4 gene and childhood environment interaction on resilience such that when stressors are present, the 7-repeat allele influences the development of personality in a way that provides protection against adverse outcomes.
PMCID: PMC3103527  PMID: 21637770
24.  "This does my head in". Ethnographic study of self-management by people with diabetes 
Self-management is rarely studied 'in the wild'. We sought to produce a richer understanding of how people live with diabetes and why self-management is challenging for some.
Ethnographic study supplemented with background documents on social context. We studied a socio-economically and ethnically diverse UK population. We sampled 30 people with diabetes (15 type 1, 15 type 2) by snowballing from patient groups, community contacts and NHS clinics. Participants (aged 5-88, from a range of ethnic and socio-economic groups) were shadowed at home and in the community for 2-4 periods of several hours (total 88 visits, 230 hours); interviewed (sometimes with a family member or carer) about their self-management efforts and support needs; and taken out for a meal. Detailed field notes were made and annotated. Data analysis was informed by structuration theory, which assumes that individuals' actions and choices depend on their dispositions and capabilities, which in turn are shaped and constrained (though not entirely determined) by wider social structures.
Self-management comprised both practical and cognitive tasks (e.g. self-monitoring, menu planning, medication adjustment) and socio-emotional ones (e.g. coping with illness, managing relatives' input, negotiating access to services or resources). Self-management was hard work, and was enabled or constrained by economic, material and socio-cultural conditions within the family, workplace and community. Some people managed their diabetes skilfully and flexibly, drawing on personal capabilities, family and social networks and the healthcare system. For others, capacity to self-manage (including overcoming economic and socio-cultural constraints) was limited by co-morbidity, cognitive ability, psychological factors (e.g. under-confidence, denial) and social capital. The consequences of self-management efforts strongly influenced people's capacity and motivation to continue them.
Self-management of diabetes is physically, intellectually, emotionally and socially demanding. Non-engagement with self-management may make sense in the context of low personal resources (e.g. health literacy, resilience) and overwhelming personal, family and social circumstances. Success of self-management as a policy solution will be affected by interacting influences at three levels: [a] at micro level by individuals' dispositions and capabilities; [b] at meso level by roles, relationships and material conditions within the family and in the workplace, school and healthcare organisation; and [c] at macro level by prevailing economic conditions, cultural norms and expectations, and the underpinning logic of the healthcare system. We propose that the research agenda on living with diabetes be extended and the political economy of self-management systematically studied.
PMCID: PMC3349490  PMID: 22458767
Diabetes; Self-management; Structuration theory; Ethnography
25.  Health coping strategies of the people vulnerable to climate change in a resource-poor rural setting in Bangladesh 
BMC Public Health  2013;13:565.
Among the many challenges faced by the people of Bangladesh, the effects of climate change are discernibly threatening, impacting on human settlement, agricultural production, economic development, and human health. Bangladesh is a low-income country with limited resources; its vulnerability to climate change has influenced individuals to seek out health coping strategies. The objectives of the study were to explore the different strategies/measures people employ to cope with climate sensitive diseases and sickness.
A cross-sectional study was conducted among 450 households from Rajshahi and Khulna districts of Bangladesh selected through multi-stage sampling techniques, using a semi-structured questionnaire supplemented by 12 focus group discussions and 15 key informant interviews.
Respondents applied 22 types of primary health coping strategies to prevent climate related diseases and sickness. To cope with health problems, 80.8% used personal treatment experiences and 99.3% sought any treatments available at village level. The percentage of respondents that visited unqualified health providers to cope with climate induced health problems was quite high, namely 92.7% visited village doctors, 75.9% drug stores, and 67.3% self-medicated. Ninety per cent of the respondents took treatment from unqualified providers as their first choice. Public health facilities were the first choice of treatment for only 11.0% of respondents. On average, every household spent Bangladesh Currency Taka 9,323 per year for the treatment of climate sensitive diseases and sickness. Only 46% of health expenditure was managed from their savings. The rest, 54% expenditure, was supported by using 24 different sources, such as social capital and the selling of family assets. The rate of out-of-pocket payment was almost 100%.
People are concerned about climate induced diseases and sickness and sought preventive as well as curative measures to cope with health problems. The most common and widely used climate health coping strategies among the respondents included self-medicating and seeking the health service of unqualified private health care providers. Per family spending to cope with such health problems is expensive and completely based on out of pocket payment. There is no fund pooling, community funding or health insurance program in rural areas to support the health coping of the people. Policies are needed to reduce out-of-pocket payment, to improve the quality of the unqualified providers and to extend public health services at rural areas and support climate related health coping. Collection of such knowledge on climate related health coping strategies can allow researchers to study any specific issue on health coping, and policy makers to initiate effective climate related health coping strategies for climate vulnerable people.
PMCID: PMC3687681  PMID: 23759111
Health coping strategies; Choice of care; Unqualified providers; Health expenditure; Health insurance; Climate sensitive diseases; Resource poor setting in Bangladesh

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