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1.  Factors associated with posttraumatic stress disorder and depression in war-survivors displaced in Croatia 
Croatian Medical Journal  2011;52(6):709-717.
To examine the role of perceived stressfulness of trauma exposure and economic, social, occupational, educational, and familial adaptation after trauma in posttraumatic stress disorder (PTSD) and depression in displaced war survivors.
A cross-sectional survey was conducted between March 2000 and July 2002 with a sample of 173 internally displaced persons or refugees and 167 matched controls in Croatia. Clinical measures included Structured Clinical Interview for DSM-IV and Clinician-Administered PTSD Scale.
Displaced war survivors reported the exposure to a mean ± standard deviation of 13.1 ± 8.3 war stressors, including combat, torture, serious injury, death of close persons, and loss of property. Compared to controls, they reported higher rates of marked to severe impact of war on family (16.2% vs 51.6%), social (7.2% vs 43.5%), economic (12.6% vs 55.4%), occupational (1.8% vs 15.9%), and educational (2.4% vs 8.8%) adaptation. In two logistic regression analyses, the strongest predictor of PTSD and depression was high level of perceived distress during trauma exposure. PTSD but not depression was associated with economic, social, occupational, educational, and familial adaptation after trauma.
Displaced survivors who experienced multiple war events perceived greater negative impact of war on their life domains compared to individuals who lived in a war setting but had no trauma exposure. The most important determinant of psychological outcomes was perceived stressfulness of war stressors. Although post-trauma adaptation in different life spheres had an impact, its effect was not robust and consistent across disorders. These findings suggest that it would be effective to use a trauma-focused approach in rehabilitation of war survivors.
PMCID: PMC3243315  PMID: 22180270
2.  Exploration of transitional life events in individuals with Friedreich ataxia: Implications for genetic counseling 
Human development is a process of change, adaptation and growth. Throughout this process, transitional events mark important points in time when one's life course is significantly altered. This study captures transitional life events brought about or altered by Friedreich ataxia, a progressive chronic illness leading to disability, and the impact of these events on an affected individual's life course.
Forty-two adults with Friedreich ataxia (18-65y) were interviewed regarding their perceptions of transitional life events. Data from the interviews were coded and analyzed thematically using an iterative process.
Identified transitions were either a direct outcome of Friedreich ataxia, or a developmental event altered by having the condition. Specifically, an awareness of symptoms, fear of falling and changes in mobility status were the most salient themes from the experience of living with Friedreich ataxia. Developmental events primarily influenced by the condition were one's relationships and life's work.
Friedreich ataxia increased the complexity and magnitude of transitional events for study participants. Transitional events commonly represented significant loss and presented challenges to self-esteem and identity. Findings from this study help alert professionals of potentially challenging times in patients' lives, which are influenced by chronic illness or disability. Implications for developmental counseling approaches are suggested for genetic counseling.
Human development can be described in terms of key transitional events, or significant times of change. Transitional events initiate shifts in the meaning or direction of life and require the individual to develop skills or utilize coping strategies to adapt to a novel situation [1,2]. A successful transition has been defined as the development of a sense of mastery over the changed event [3].
Transitions can be influenced by a variety of factors including one's stage of development, such as graduation from high school, historical events, including war, and idiosyncratic factors, such as health status [4,5]. Of particular interest in the present study are transitional life events, brought about or altered by progressive chronic illness and disability, and the impact of these events on the lives of affected individuals.
It has been recognized that the clinical characteristics of a chronic illness or disability may alter the course and timing of many developmentally-related transitional events [6]. For example, conditions associated with a shortened lifespan may cause an individual to pursue a career with a shorter course of training [6]. Specific medical manifestations may also promote a lifestyle incongruent with developmental needs [6,7]. For example, an adolescent with a disability may have difficulty achieving autonomy because of his/her physical dependence on others.
In addition to the aforementioned effects of chronic illness and disability on developmentally-related transitional events, a growing body of literature has described disease-related transitional events: those changes that are a direct result of chronic illness and disability. Diagnosis has received attention as being a key disease-related transitional event [8,9]. Studies have also noted other disease transitions related to illness trajectory [10], as the clinical features of the disease may require the individual to make specific adaptations. Disease-related events have also been described in terms of accompanying psychological processes, such as one's awareness of differences brought about by illness [11].
While disease-related events are seemingly significant, the patient's perception of the events is varied. Some events may be perceived as positive experiences for the individual. For example, a diagnosis may end years of uncertainty. Some individuals may perceive these transitional events as insignificant, as they have accommodated to the continual change brought about by a chronic disease [12,13].
The aforementioned impact of disability and chronic illness on transitional events may create psychological stress. Developed by Lazarus and Folkman, the Transitional Model of Stress and Coping describes the process of adaptation to a health condition [14]. This model purports that individuals first appraise a stressor and then utilize a variety of coping strategies in order to meet the stressor's demands [14]. Thus, in the context of chronic illness, the ability of the individual to cope successfully with the stress of a health threat contributes to the process of overall adaptation to the condition.
The process of adaptation can be more complex when the chronic illness or disability is progressive. Each transition brought about or altered by the disability may also represent additional loss, including the loss of future plans, freedom in social life and the ability to participate in hobbies [15]. These losses may be accompanied by grief, uncertainty, and a continual need for adaptation [16,17].
Friedreich ataxia (FRDA) is one example of a progressive disorder, leading to adolescent and adult onset disability. To better understand patients' perceptions of key transitional events and the factors perceived to facilitate progression through these events, individuals with FRDA were interviewed.
FRDA is a rare, progressive, neurodegenerative disorder affecting approximately one in 30,000 people in the United States [18]. It equally affects both men and women. Individuals with FRDA experience progressive muscle weakness and loss of coordination in the arms and legs. For most patients, ataxia leads to motor incapacitation and full-time use of a wheelchair, commonly by the late teens or early twenties. Other complications such as vision and hearing impairment, dysarthria, scoliosis, diabetes mellitus and hypertrophic cardiomyopathy may occur [19,20]. Cardiomyopathy and respiratory difficulties often lead to premature death at an average age of 37 years [21]. Currently, there are no treatments or cures for FRDA. Little is known about the specific psychological or psychosocial effects of the condition.
FRDA is an autosomal recessive condition. The typical molecular basis of Friedreich ataxia is the expansion of a GAA trinucleotide repeat in both copies of the FXN gene [22]. Age of onset usually occurs in late childhood or early adolescence. However, the availability of genetic testing has identified affected individuals with an adult form of the condition. This late-onset form is thought to represent approximately 10-15% of the total FRDA population [23].
Health care providers of individuals with progressive, neurodegenerative disorders can help facilitate their patients' progression through transitional events. Data suggest that improvements should be made in the care of these individuals. Shaw et al. [24] found that individualized care that helps to prepare patients for transition is beneficial. Beisecker et al. [25] found that patients desire not only physical care from their providers, but also emotional and psychosocial support.
Genetic counselors have an important opportunity to help patients with neuromuscular disorders progress through transitional events, as several of these conditions have a genetic etiology. Genetic counselors in pediatric and adult settings often develop long-term relationships with patients, due to follow-up care. This extended relationship is becoming increasingly common as genetic counselors move into various medical sub-specialties, such as neurology, ophthalmology, oncology and cardiology.
The role of the genetic counselor in addressing the psychosocial needs of patients has been advocated, but rarely framed in the context of developmental events [26]. Data suggest that patients may not expect a genetic counselor to address psychosocial needs [27]. In a survey of genetic counseling patients, Wertz [28] found a majority of respondents understood genetic conditions to have a moderate to serious effect on family life and finances, while almost half perceived there to be an effect on the spouse, quality of life, and the relationship between home and work. However, these topics were reportedly not discussed within genetic counseling sessions [27,28]. Overall, there is limited information about the experiences of transitional life events in FRDA, as well as a lack of recommendations for genetic counselors and other health care providers to assist patients through these events.
Our study investigated perceptions of patients with Friedreich ataxia to 1) identify key transitional events and specific needs associated with events; 2) describe perception of factors to facilitate progression through the identified events; and 3) explore the actual or potential role of the health care provider in facilitating adaptation to the identified events. Data were used to make suggestions for developmental genetic counseling approaches in the context of ongoing care of clients with hereditary, progressive, neurodegenerative conditions.
PMCID: PMC2987979  PMID: 20979606
3.  Can negative life events and coping style help explain socioeconomic differences in perceived stress among adolescents? A cross-sectional study based on the West Jutland cohort study 
BMC Public Health  2013;13:532.
Previous research suggests that perceived stress in adolescence is socially patterned, but that this relationship may depend on the measure of socioeconomic status (SES) used. This study examines if social gradients in perceived stress, negative life events, and coping exist amongst Danish adolescents, and, if life events and coping strategies can partly account for an association between SES and perceived stress. These relationships are studied separately for two different measures of SES.
Questionnaire data were collected from 3054 14–15 year old youths (83% response rate) during baseline measurement in the West Jutland birth cohort study. Parents were identified via the Central Office of Civil Registration in which the respondents are linked to their parents or guardians via their CPR-number, a personal identification number given to everyone in Denmark. The study employs data from two independent sources, adolescent self-report data (stress, life events and coping) and national registers (parental educational level, household income and confounder variables). Ordinary Least Squares regression estimated the effects of parental SES, negative life events and coping on perceived stress. Analyses were stratified by gender.
Girls reported more perceived stress than boys. SES accounted for a small but significant amount of the variance in perceived stress. Lower parental education and lower household income were associated with higher stress levels irrespective of gender, but the social gradient was strongest amongst girls when parents’ education was used to measure SES, and strongest for boys when income was used. Life events and coping were also found to be associated with SES and both mediated part of the SES-perceived stress relationship. In general, the social gradient in perceived stress was accounted for by the study variables to a higher degree among girls than among boys.
Lower parental education and household income are associated with higher levels of perceived stress amongst Danish adolescents. Furthermore, both life events and coping appear to mediate this relation. Gender differences in the ways SES and stress are related may exist.
PMCID: PMC3679909  PMID: 23724872
Social gradient; Perceived stress; Life events; Coping; Adolescence
4.  Self-perceived stress reactivity is an indicator of psychosocial impairment at the workplace 
BMC Public Health  2010;10:252.
Work related stress is associated with a range of debilitating health outcomes. However, no unanimously accepted assessment tool exists for the early identification of individuals suffering from chronic job stress. The psychological concept of self-perceived stress reactivity refers to the individual disposition of a person to answer stressors with immediate as well as long lasting stress reactions, and it could be a valid indicator of current as well as prospective adverse health outcomes. The aim of this study was to determine the extent to which perceived stress reactivity correlates with various parameters of psychosocial health, cardiovascular risk factors, and parameters of chronic stress and job stress in a sample of middle-aged industrial employees in a so-called "sandwich-position".
In this cross-sectional study, a total of 174 industrial employees were assessed for psychosocial and biological stress parameters. Differences between groups with high and low stress reactivity were analysed. Logistic regression models were applied to identify which parameters allow to predict perceived high versus low stress reactivity.
In our sample various parameters of psychosocial stress like chronic stress and effort-reward imbalance were significantly increased in comparison to the normal population. Compared to employees with perceived low stress reactivity, those with perceived high stress reactivity showed poorer results in health-related complaints, depression, anxiety, sports behaviour, chronic stress, and effort-reward imbalance. The educational status of employees with perceived low stress reactivity is higher. Education, cardiovascular complaints, chronic stress, and effort-reward imbalance were moderate predictors for perceived stress reactivity. However, no relationship was found between stress reactivity and cardiovascular risk factors in our sample.
Job stress is a major burden in a relevant subgroup of industrial employees in a middle management position. Self-perceived stress reactivity seems to be an appropriate concept to identify employees who experience psychosocial stress and associated psychological problems at the workplace.
PMCID: PMC2881886  PMID: 20470413
5.  Does Gender Predict Medical Students’ Stress in Mansoura, Egypt? 
Medical education is perceived as being stressful with negative effects on students’ mental health. However, few studies have addressed the influence of gender on stress in medical students.
To compare male and female medical students in Egypt on sources of stress, perception of stress, anxiety, depression, physical symptomatology, and personality profile.
Data were collected through an anonymous self-administered questionnaire covering socio-demographic data, stressors, perceived stress scale, physical wellbeing factors, the Hospital Anxiety and Depression scale as well as neuroticism and extraversion subscales of the Eysenck Personality Questionnaire.
Stressors were reported by 94.5% of the total sample with equal gender proportions. Univariate analysis indicated that female students scored higher than males on depression and neuroticism scales while male and female medical students were similar on level of perceived stress, number of stressors, clinical anxiety, physical well-being factors and the extraversion scale. Multivariate logistic regression revealed that the independent predictors of a high stress level were the presence of more than five stressors, clinical anxiety and depression, and increased scores on the global sickness index and on the extraversion and neuroticism sub-scales.
Despite there being no significant difference in perceived stress according to gender, females were less likely to cite relationship problems with teachers and substance abuse as sources of stress. Moreover, females scored significantly higher than males on depression and neuroticism scales.
PMCID: PMC2779606  PMID: 20168973
gender; medical student; stress; depression; anxiety.
6.  Perceived Stress, Sources and Severity of Stress among medical undergraduates in a Pakistani Medical School 
Recently there is a growing concern about stress during undergraduate medical training. However, studies about the same are lacking from Pakistani medical schools. The objectives of our study were to assess perceived stress, sources of stress and their severity and to assess the determinants of stressed cases.
A cross-sectional, questionnaire-based survey was carried out among undergraduate medical students of CMH Lahore Medical College, Pakistan during January to March 2009. Perceived stress was assessed using the perceived stress scale. A 33-item questionnaire was used to assess sources of stress and their severity.
The overall response rate was 80.5% (161 out of 200 students). The overall mean perceived stress was 30.84 (SD = 7.01) and was significantly higher among female students. By logistic regression analysis, stressed cases were associated with occurrence of psychosocial (OR 5.01, 95% CI 2.44-10.29) and academic related stressors (OR 3.17 95% CI 1.52-6.68). The most common sources of stress were related to academic and psychosocial concerns. 'High parental expectations', 'frequency of examinations', 'vastness of academic curriculum', 'sleeping difficulties', 'worrying about the future', 'loneliness', 'becoming a doctor', 'performance in periodic examinations' were the most frequently and severely occurring sources of stress. There was a negative but insignificant correlation between perceived stress and academic performance (r = -0.099, p > 0.05).
A higher level of perceived stress was reported by the students. The main stressors were related to academic and psychosocial domains. Further studies are required to test the association between stressed cases and gender, academic stressors and psychosocial stressors.
PMCID: PMC2820489  PMID: 20078853
7.  Life events, perceived stress and depressive symptoms in a physical activity intervention with young adult women 
Examine interactive effects of life events, perceived stress and depressive symptoms during a randomized controlled aerobics intervention among women (aged 18–30) in the urban U.S. Midwest, 2006–2009.
Participants [n=372 at baseline and n=303 at follow up] completed perceived stress, depressive symptoms and life events scales at baseline and 5–6 month follow-up. Life events were correlated with perceived stress and depressive symptoms scales using Pearson correlation. Multivariate linear regression tested the relationship between the 20 most common life events with perceived stress and depressive symptoms. Regression models explored relationships between life events, perceived stress and depressive symptoms and the intervention effect.
Higher levels of perceived stress and depressive symptoms correlated with more life events. At baseline, for every additional life event, depressive symptoms were higher; follow-up showed marginal significance with depressive symptoms, but a strong positive association with perceived stress. In the stratified model, for every life event at follow up, the perceived stress scale increased by 0.68 in the exercise group, but not in the controls. For every life event at follow-up, depressive symptoms were higher in controls, but not in the exercise group.
Perceived stress and depressive symptoms co-occurred with life events at baseline and follow-up for participants. At follow up, perceived stress increased significantly among exercisers; depressive symptoms were significantly higher among controls. Findings suggest that new participation in structured physical activity entails a change in daily life that may buffer against depressive symptoms in relation to life events but not perceived stress.
PMCID: PMC3505451  PMID: 23189088
life events; adult women; exercise intervention; perceived stress; depressive symptoms
8.  Stress, Coping Strategies and Related Factors in a Sample of Iranian Adolescents 
Since the stress and coping are the most reported problems by adolescents, this study aims to apprise the stressors, coping strategies and influential factors among male adolescents.
The effect of stressors, coping strategies and some demographics variables were studied in 402 male adolescents in Tehran, Iran. A self-administered questionnaire was used to collect the data. A multiple regression was performed to assess factors related to perceived stress.
The mean age of adolescents was 15.44 (SD=0.68) years. The mean value of perceived stress for the whole sample was 17.99 (SD=6.02). Cognitive/emotional coping was the most frequent coping style. The findings revealed that there was a significant correlation between perceived and accumulative stress. In multiple regression analysis, the accumulative stress, social resources, parent`s education and grade point average were found to be significant predictors of perceived stress.
The findings suggest that increased level of perceived stress is associated with accumulative stress, social resources and parent`s education that are modifiable factors. Stress management education might be a solution to overcome increased perceived stress.
PMCID: PMC3372014  PMID: 22737538
Perceived stress; Adolescents; Coping; Iran
9.  Cortisol in hair measured in young adults - a biomarker of major life stressors? 
Stress as a cause of illness has been firmly established. In public health and stress research a retrospective biomarker of extended stress would be an indispensible aid. The objective of this pilot study was to investigate whether concentrations of cortisol in hair correlate with perceived stress, experiences of serious life events, and perceived health in young adults.
Hair samples were cut from the posterior vertex area of (n = 99) university students who also answered a questionnaire covering experiences of serious life events, perceived Stress Scale and perceived health during the last three months. Cortisol was measured using a competitive radioimmunoassay in methanol extracts of hair samples frozen in liquid nitrogen and mechanically pulverised.
Mean cortisol levels were significantly related to serious life events (p = 0.045), weakly negatively correlated to perceived stress (p = 0.025, r = -0.061) but nor affected by sex, coloured/permed hair, intake of pharmaceuticals or self-reported health. In a multiple regression model, only the indicator of serious life events had an independent (p = 0.041) explanation of increased levels of cortisol in hair. Out of four outliers with extremely high cortisol levels two could be contacted, both reported serious psychological problems.
These findings suggest that measurement of cortisol in hair could serve as a retrospective biomarker of increased cortisol production reflecting exposure to major life stressors and possibly extended psychological illness with important implications for research, clinical practice and public health. Experience of serious life events seems to be more important in raising cortisol levels in hair than perceived stress.
PMCID: PMC3217842  PMID: 22026917
Biomarker; Coping; Cortisol; Hair; Serious life events; Stress
10.  What contributes to perceived stress in later life? A recursive partitioning approach 
Psychology and aging  2011;26(4):830-843.
One possible explanation for the individual differences in outcomes of stress is the diversity of inputs that produce perceptions of being stressed. The current study examines how combinations of contextual features (e.g., social isolation, neighborhood quality, health problems, age discrimination, financial concerns, and recent life events) of later life contribute to overall feelings of stress. Recursive partitioning techniques (regression trees and random forests) were used to examine unique interrelations between predictors of perceived stress in a sample of 282 community-dwelling adults. Trees provided possible examples of equifinality (i.e., subsets of people with similar levels of perceived stress but different predictors) as well as for the identification both of contextual combinations that separated participants with very high and very low perceived stress. Random forest analyses aggregated across many trees based on permuted versions of the data and predictors; loneliness, financial strain, neighborhood strain, ageism, and to some extent life events emerged as important predictors. Interviews with a subsample of participants provided both thick description of the complex relationships identified in the trees, as well as additional risks not appearing in the survey results. Together, the analyses highlight what may be missed when stress is used as a simple unidimensional construct and can guide differential intervention efforts.
PMCID: PMC3177031  PMID: 21604885
Perceived Stress; Loneliness; Regression Trees; Random Forests; Aging
11.  Fatigue and Sleep Disturbance Related to Perceived Stress in Chinese HIV-Positive Individuals: A Mixed Methods Study 
Few studies of HIV+ individuals in China have examined the associations between HIV-related stress with sleep disturbance and fatigue, which are common complaints among people living with HIV/AIDS (PLWHA). We carried out this study to examine the relationships among perceived stress, sleep disturbance, and fatigue in PLWHA in China.
A mixed methods study design was used during data collection in Shanghai, China, from December 2009 to March 2010. Qualitative in-depth interviews were conducted with 19 HIV+ females. Additionally, cross-sectional audio computer-assisted self-interviews (ACASI) were conducted to collect quantitative data from a convenience sample of 107 HIV+ patients (84% were male) including the following scales: 1) Perceived Stress Scale for PLWHA, 2) General Sleep Disturbance Scale, and 3) Fatigue Scale.
The major themes that emerged from the in-depth interviews were around life stress with HIV, sleep disturbance, and fatigue. Participants presented varying amounts of stress around worrying about whether to disclose their diagnosis and whether they might transmit the disease to their family. In addition, in the cross-sectional data, 40% of the participants reported clinically significant sleep disturbances (GSDS > 3) with an average of 3 nights of disturbed sleep in the past week (M=2.87, SD=1.21) and moderate fatigue severity (M=5.24, SD=2.27). In mediation analyses, the data suggests that the relationship between perceived stress and fatigue was largely (53%) mediated through sleep disturbance.
Chinese PLWHA described how stress had caused them to become sleepless and fatigued. The quantitative data also demonstrated significant levels of sleep disturbance and fatigue, where were due to perceived stress with HIV disease. A systematic self-management intervention to decrease perceived stress should be designed and implemented in mental health resource-limited settings such as China in order to reduce sleep disturbance and fatigue.
PMCID: PMC3840538  PMID: 24288655
China; PLWHA; Perceived stress; Sleep disturbance; Fatigue; Cronbach alpha coefficient
12.  A Stress-Coping Model of Mental Illness Stigma: II. Emotional Stress Responses, Coping Behavior and Outcome 
Schizophrenia research  2009;110(1-3):65-71.
Stigma can be a major stressor for people with schizophrenia and other mental illnesses, leading to emotional stress reactions and cognitive coping responses. Stigma is appraised as a stressor if perceived stigma-related harm exceeds an individual’s perceived coping resources. It is unclear, however, how people with mental illness react to stigma stress and how that affects outcomes such as self-esteem, hopelessness and social performance. The cognitive appraisal of stigma stress as well as emotional stress reactions (social anxiety, shame) and cognitive coping responses were assessed by self-report among 85 people with schizophrenia, schizoaffective or affective disorders. In addition to self-directed outcomes (self-esteem, hopelessness), social interaction with majority outgroup members was assessed by a standardized role-play test and a seating distance measure. High stigma stress was associated with increased social anxiety and shame, but not with cognitive coping responses. Social anxiety and shame predicted lower self-esteem and more hopelessness, but not social performance or seating distance. Hopelessness was associated with the coping mechanisms of devaluing work/education and of blaming discrimination for failures. The coping mechanism of ingroup comparisons predicted poorer social performance and increased seating distance. The cognitive appraisal of stigma-related stress, emotional stress reactions and coping responses may add to our understanding of how stigma affects people with mental illness. Trade-offs between different stress reactions can explain why stress reactions predicted largely negative outcomes. Emotional stress reactions and dysfunctional coping could be useful targets for interventions aiming to reduce the negative impact of stigma on people with mental illness.
PMCID: PMC2720565  PMID: 19237266
stigma; stress; coping; anxiety; shame; self-esteem; hopelessness; social performance
13.  Psychosocial Factors in Risk of Cervical Intraepithelial Lesions 
Journal of Women's Health  2009;18(4):513-518.
This study examines the relationship among psychosocial factors, behavioral risks for abnormal cervical cytology, and abnormal cervical cytology.
A self-administered questionnaire was used to measure perceived stress, discrimination, lifetime stressful events, optimism, social support, and psychological state. Women with normal Pap smears attending a primary care clinic and women attending a colposcopy clinic because of an abnormal Pap smear were eligible. The scores between the two groups were compared.
A total of 265 women participated in the study. There were no significant relationships between psychosocial factors and cervical cytology status. In a regression model, age (B = −0.057, p = 0.001) was predictive of having abnormal cervical cytology. Smoking was correlated with an increased family Apgar score (p = 0.021), Perceived Stress Scale (PSS) score (p = 0.049), and Revised Life Stressor Checklist score (p < 0.001). A higher mean number of lifetime male partners was related to increased family Apgar score (p = 0.012), Revised Life Stressor Checklist score (p < 0.001), and major event discrimination (p < 0.001). Earlier age at coitarche was associated with increased family Apgar score (p < 0.001).
These results do not support that psychosocial factors play a role in the risk of developing abnormal cervical cytology. Behavioral risks for developing abnormal cervical cytology are associated with life stressors, family function, and perceived discrimination.
PMCID: PMC2857606  PMID: 19361319
14.  Anxiety symptoms among Chinese nurses and the associated factors: a cross sectional study 
BMC Psychiatry  2012;12:141.
Nurses are an indispensable component of the work force in the health care system. However, many of them are known to work in a stressful environment which may affect their mental well-being; the situation could be worse in rapidly transforming societies such as China. The purpose of this study was to investigate anxiety symptoms and the associated factors in Chinese nurses working in public city hospitals.
A cross-sectional survey was performed for Chinese nurses in public city hospitals of Liaoning Province, northeast China. Seven hospitals in different areas of the province were randomly selected for the study. The Zung Self-Rating Anxiety Scale was used to measure anxiety symptoms. Effort-reward imbalance questionnaire and Job Content Questionnaire were used to assess the work stressors. Univariate analysis and stepwise multivariate logistic regression analysis were used to identify the factors associated with anxiety symptoms.
All registered nurses in the seven city hospitals, totaling 1807 registered nurses were surveyed. Of the returned questionnaires, 1437 were valid (79.5%) for analysis. Utilizing the total raw score ≥ 40 as the cut-off point, the prevalence of anxiety symptoms in these nurses was 43.4%. Demographic factors (education, chronic disease and life event), lifestyle factors (regular meals and physical exercise), work conditions (hospital grade, job rank, monthly salary, nurse-patient relationships, job satisfaction and intention of leaving), job content (social support and decision latitude), effort-reward imbalance and overcommitment were all significantly related to the anxiety symptoms. Multivariate logistic regression analysis showed main factors associated with anxiety symptoms were lower job rank (OR 2.501), overcommitment (OR 2.018), chronic diseases (OR 1.541), worse nurse-patient relationship (OR 1.434), higher social support (OR 0.573), lower hospital grade (OR 0.629), taking regular meals (OR 0.719) and higher level of job satisfaction (OR 0.722).
A large proportion of Chinese nurses working in public city hospitals had anxiety symptoms, which warrants immediate investigation and intervention from the hospital administrators. Meanwhile, results of the study suggest that proper counseling, promotion of healthy lifestyle behavior and improvements to the social environment in the work place may be helpful toward reducing or preventing the anxiety symptoms.
PMCID: PMC3492072  PMID: 22978466
15.  Appraisals of stressors and common mental disorder from early to mid-adulthood in the 1946 British birth cohort 
Journal of Affective Disorders  2009;119(1-3):66-75.
We examined the extent to which perceived life change following experiences of stressful life events, differentiated by type of stressor, influenced mental health during adulthood.
The analytic sample of 2073 cohort members was drawn from the MRC National Survey of Health and Development, a sample followed since their birth in March 1946. Logistic regression was used to assess the relationship between stressors reported at 36 and 43 years and common mental disorder at 36, 43, and 53 years. Common mental disorder was measured using the Present State Exam at 36 years, the Psychiatric Symptom Frequency at 43 years, and the 28-item General Health Questionnaire at 53 years.
Data spanning across nearly 20 years suggest that stressors perceived to have contributed to a notable life change increased the likelihood of scoring above the cut off score for common mental disorder in comparison to stressors experienced without subsequent life change. Models were adjusted for gender, educational attainment, social class, relationship status, and past episodes of common mental disorder. This relationship appears to be most evident for proximal family and economic stressors and distal interpersonal relationship stressors experienced by close friends and relatives.
All study information is based on self-reports and details about the nature of the life change or cognitive attribution style were not available.
Appraisals of changes following stressful life events may be more important than the occurrence of stressors alone in assessing the impact of stressful life events on adult mental health.
PMCID: PMC3504661  PMID: 19394087
Depression; Anxiety; Stressful life events; Birth cohort
16.  Stress Level and Smoking Status in Central Iran: Isfahan Healthy Heart Program 
ARYA Atherosclerosis  2011;6(4):144-148.
Individuals are faced with numerous stressful life events which can negatively influence mental health. Many individuals use smoking as a means of confronting stress. Given the relatively high prevalence of smoking in central Iran, the present study was conducted to compare stress levels in smokers, non-smokers and those who had quit smoking.
This study was conducted as part of Isfahan Cardiovascular Research Program on 9752 individuals in the cities of Isfahan, Arak, and Najafabad in 2008. Sampling was performed using multi-stage cluster randomization method. Data on age, sex, demographic characteristics, and smoking status was collected through interviews. Stress level detected by General Health questionnaire.Logistic regression and chi- squere test was used for data analyzing.
In the present study, 30% of non-smokers, 32.1% ex- smoker and 36.9% of smokers had GHQ of 4 and higher (P=0.01). In regression analysis, the final model which was controlled for age, sex, socioeconomic statues (including place of residence, marital status and education level) showed that the odds ratio of stress in smokers and ex- smoker was significantly higher than in non-smokers (OR=1.66 and OR=1.12, respectively).
Since in conducted studies, mental problems and stresses have had an important role in people's smoking, it seems suitable to use the results of this study to present intervention for correct methods of coping with stress towards reducing the prevalence of smoking in the community.
PMCID: PMC3347833  PMID: 22577433
Cigarette; Stress; Community-based Program.
17.  Combinations of Stressors in Midlife: Examining Role and Domain Stressors Using Regression Trees and Random Forests 
Global perceptions of stress (GPS) have major implications for mental and physical health, and stress in midlife may influence adaptation in later life. Thus, it is important to determine the unique and interactive effects of diverse influences of role stress (at work or in personal relationships), loneliness, life events, time pressure, caregiving, finances, discrimination, and neighborhood circumstances on these GPS.
Exploratory regression trees and random forests were used to examine complex interactions among myriad events and chronic stressors in middle-aged participants’ (N = 410; mean age = 52.12) GPS.
Different role and domain stressors were influential at high and low levels of loneliness. Varied combinations of these stressors resulting in similar levels of perceived stress are also outlined as examples of equifinality. Loneliness emerged as an important predictor across trees.
Exploring multiple stressors simultaneously provides insights into the diversity of stressor combinations across individuals—even those with similar levels of global perceived stress—and answers theoretical mandates to better understand the influence of stress by sampling from many domain and role stressors. Further, the unique influences of each predictor relative to the others inform theory and applied work. Finally, examples of equifinality and multifinality call for targeted interventions.
PMCID: PMC3693607  PMID: 23341437
Loneliness; Random forests; Regression trees; Stress.
18.  Perceived stress, life events & coping among higher secondary students of Hyderabad, India: A pilot study 
Background & objectives:
Psychosocial stressors leading to allostatic load need to be explored further as these have great scope for early intervention. Stress studies done in India are mostly based on sources of stress and objective measures of stress. Therefore, the objective of the present study was to assess stress appraisal among students (16-17 yr) and to identify institution-specific differences (Private vs. Government) in stress appraisal and coping.
The study was carried out among 16-17 yr old apparently normal students. Eighty students were recruited from six schools ensuring equal representation from gender/category of schools (Government/ Private). Validated and culturally adaptable behavioural scales for perceived stress (PSS), stressful life events (LES) and coping were administered. Psychological morbidity was assessed using GHQ-12. Data on 75 students were available for statistical analysis.
The students of both Government and Private schools showed similar stress perception, though the former tend to have a higher mean score. The scores were significantly higher on avoidance coping (P<0.05). The stepwise regression model showed coping as the independent predictor of perceived stress (R2= 10%).
Interpretation & conclusions:
Students from Government schools had significantly higher scores on avoidance coping and therefore, suitable for a systematic study on chronic stress for early intervention.
PMCID: PMC3171919  PMID: 21808136
Coping; life events; perceived stress
19.  Cumulative Stress and Cortisol Disruption among Black and Hispanic Pregnant Women in an Urban Cohort 
While adult hypothalamic-pituitary-adrenocortical (HPA) axis functioning is thought to be altered by traumatic experiences, little data exist on the effects of cumulative stress on HPA functioning among pregnant women or among specific racial and ethnic groups. Individuals may be increasingly vulnerable to physiological alterations when experiencing cumulative effects of multiple stressors. These effects may be particularly relevant in urban poor communities where exposure to multiple stressors is more prevalent. The goal of this study was to explore the effects of multiple social stressors on HPA axis functioning in a sample of urban Black (n = 68) and Hispanic (n = 132) pregnant women enrolled in the Asthma Coalition on Community, Environment, and Social Stress (ACCESS). Pregnant women were administered the Revised Conflict Tactics Scale (R-CTS) survey to assess interpersonal violence, the Experiences of Discrimination (EOD) survey, the Crisis in Family Systems-Revised (CRISYS-R) negative life events survey, and the My Exposure to Violence (ETV) survey, which ascertains exposure to community violence. A cumulative stress measure was derived from these instruments. Salivary cortisol samples were collected five times per day over three days to assess area under the curve (AUC), morning change, and basal awakening response in order to characterize diurnal salivary cortisol patterns. Repeated measures mixed models, stratified by race/ethnicity, were performed adjusting for education level, age, smoking status, body mass index and weeks pregnant at time of cortisol sampling. The majority of Hispanic participants (57%) had low cumulative stress exposure, while the majority of Black participants had intermediate (35%) or high (41%) cumulative stress exposure. Results showed that among Black but not Hispanic women, cumulative stress was associated with lower morning cortisol levels, including a flatter waking to bedtime rhythm. These analyses suggest that the combined effects of cumulative stressful experiences are associated with disrupted HPA functioning among pregnant women. While the etiology of racial/ethnic differences in stress-induced HPA alterations is not clear, this warrants further research.
PMCID: PMC3057193  PMID: 21423846
20.  Mental health status among Burmese adolescent students living in boarding houses in Thailand: a cross-sectional study 
BMC Public Health  2013;13:337.
In Tak province of Thailand, a number of adolescent students who migrated from Burma have resided in the boarding houses of migrant schools. This study investigated mental health status and its relationship with perceived social support among such students.
This cross-sectional study surveyed 428 students, aged 12–18 years, who lived in boarding houses. The Hopkins Symptom Checklist (HSCL)-37 A, Stressful Life Events (SLE) and Reactions of Adolescents to Traumatic Stress (RATS) questionnaires were used to assess participants’ mental health status and experience of traumatic events. The Medical Outcome Study (MOS) Social Support Survey Scale was used to measure their perceived level of social support. Descriptive analysis was conducted to examine the distribution of sociodemographic characteristics, trauma experiences, and mental health status. Further, multivariate linear regression analysis was used to examine the association between such characteristics and participants’ mental health status.
In total, 771 students were invited to participate in the study and 428 students chose to take part. Of these students, 304 completed the questionnaire. A large proportion (62.8%) indicated that both of their parents lived in Myanmar, while only 11.8% answered that both of their parents lived in Thailand. The mean total number of traumatic events experienced was 5.7 (standard deviation [SD] 2.9), mean total score on the HSCL-37A was 63.1 (SD 11.4), and mean total score on the RATS was 41.4 (SD 9.9). Multivariate linear regression analysis revealed that higher number of traumatic events was associated with more mental health problems.
Many students residing in boarding houses suffered from poor mental health in Thailand’s Tak province. The number of traumatic experiences reported was higher than expected. Furthermore, these traumatic experiences were associated with poorer mental health status. Rather than making a generalized assumption on the mental health status of migrants or refugees, more detailed observation is necessary to elucidate the unique nature and vulnerabilities of this mobile population.
PMCID: PMC3636114  PMID: 23587014
21.  Stressful Life Events and the Metabolic Syndrome 
Diabetes Care  2009;33(2):378-384.
Stress may play a role in the pathogenesis of the metabolic syndrome. However, the scant evidence available is not population-based, restricting the external validity of the findings. Our aim was to test associations between stressful life events, their accumulation, and the metabolic syndrome in a large population-based cohort. We also tested associations between stress and the individual components related to the metabolic syndrome.
This was a population-based, random sample of 3,407 women and men aged 18–78 years residing in Western Finland. Metabolic syndrome was defined according to the National Cholesterol Education Program Adult Treatment Panel III and International Diabetes Federation criteria. The severity of 15 stressful life events pertaining to finance, work, social relationships, health, and housing was self-rated.
In comparison with subjects not reporting any extremely stressful life events, those reporting work- or finance-related events had an increased odds for having the metabolic syndrome. The risk was further increased according to accumulation of stressful finance-related events and to having at least three stressful life events in any of the life domains assessed. Accumulation of stressful life events was associated with insulin resistance, obesity, and triglycerides. The associations were not confounded by sex, age, lifestyle, or family history of diabetes.
Life events perceived as stressful, particularly those related to finance and work, may be a signal for poor metabolic health.
PMCID: PMC2809287  PMID: 19880581
22.  Maternal Coping Style and Perceived Adequacy of Income Predict CRH Levels at 14–20 Weeks of Gestation 
Biological research for nursing  2010;12(2):125-136.
This exploratory study examines the role of psychosocial–behavioral variables as predictors of elevated corticotropin-releasing hormone (CRH) at 14–20 weeks of gestation.
One hundred and twenty women were enrolled into the study. Blood samples were collected at 14–20 weeks of pregnancy and assayed for CRH. Participants completed questionnaires that included the Perceived Stress Scale, the Center for Epidemiologic Studies (CES) Depression Scale, the Pregnancy-Specific Anxiety (PAS) Scale, the Norbeck Social Support Questionnaire, the Life Orientation Test, the Brief COPE scale, and questions regarding violence/abuse, and work, sleep, and nutritional patterns.
Pregnant women with high CRH levels (15 pcg/ml and above) perceived their income to be inadequate, slept more hours at night, stood more hours during the day, and used the coping styles of disengagement or religion but not humor. Logistic regression identified three predictors for high CRH (accounting for 42.2% of the variance): perceived inadequacy of income and the use of “religion” and “disengagement” to cope with stress.
These results are the first known to identify coping style and perceived income inadequacy as predictors of high CRH. Women with perceived inadequacy of income had almost three times the odds for high CRH. Women who used religion or disengagement to cope with stress had 14 times and 7 times the odds for high CRH levels, respectively. Higher CRH levels are associated with preterm birth (PTB). Thus, it may be important to include maternal coping style and perceptions of income inadequacy in future investigations of CRH levels and PTB.
PMCID: PMC3775608  PMID: 20798157
corticotropin-releasing hormone; maternal stress; preterm birth; pregnancy; coping; income; biobehavioral
23.  A Stress-Coping Model of Mental Illness Stigma: I. Predictors of Cognitive Stress Appraisal 
Schizophrenia research  2009;110(1-3):59-64.
Stigma can be a major stressor for individuals with schizophrenia and other mental illnesses. It is unclear, however, why some stigmatized individuals appraise stigma as more stressful, while others feel they can cope with the potential harm posed by public prejudice. We tested the hypothesis that the level of perceived public stigma and personal factors such as rejection sensitivity, perceived legitimacy of discrimination and ingroup perceptions (group value; group identification; entitativity, or the perception of the ingroup of people with mental illness as a coherent unit) predict the cognitive appraisal of stigma as a stressor. Stigma stress appraisal refers to perceived stigma-related harm exceeding perceived coping resources. Stress appraisal, stress predictors and social cue recognition were assessed in 85 people with schizophrenia, schizoaffective or affective disorders. Stress appraisal did not differ between diagnostic subgroups, but was positively correlated with rejection sensitivity. Higher levels of perceived societal stigma and holding the group of people with mental illness in low regard (low group value) independently predicted high stigma stress appraisal. These predictors remained significant after controlling for social cognitive deficits, depressive symptoms and diagnosis. Our findings support the model that public and personal factors predict stigma stress appraisal among people with mental illness, independent of diagnosis and clinical symptoms. Interventions that aim to reduce the impact of stigma on people with mental illness could focus on variables such as rejection sensitivity, a personal vulnerability factor, low group value and the cognitive appraisal of stigma as a stressor.
PMCID: PMC2720567  PMID: 19269140
stigma; stress; cognitive appraisal; rejection sensitivity; perceived legitimacy of discrimination; ingroup perception; group value
24.  Health-related quality of life and influencing factors among rural left-behind wives in Liuyang, China 
BMC Women's Health  2014;14:67.
In China, the number of left-behind wives in rural areas has reached 47 million. Left-behind wives might have more psychological stress and lower life quality. This study was to examine the health-related quality of life and influencing social and cognitive factors in a sample of left-behind wives in rural areas of China.
The demographic data questionnaire, the Short Form 36 Health Survey Scale, Center for Epidemiological Studies Depression Scale, Perceived Social Support Scale, Simplified Coping Style Questionnaire, and Perceived Stress Scale were completed by a sample of 1,893 left-behind wives and 969 non-left-behind wives.
Left-behind wives had lower scores on physical component summary (PCS), mental component summary (MCS) , and all the eight subscales of the SF-36 than non-left-behind wives (P < 0.05), especially on the role limitations due to emotional problems (RE) and on MCS. Compared to non-left-behind wives, left-behind wives scored higher in depression, stress, and passive coping styles, and scored significantly lower in social support and active coping styles. Logistic regression analysis showed that the status of being left behind, age, education years, monthly income, employment, physical health status, active coping styles, and depression were influencing factors on the PCS of rural women, whereas the status of being left behind, monthly income, physical health status, sense of marriage security, stress, social support, passive coping styles, and depression were influencing factors on the MCS of rural women.
Left-behind wives scored lower on health-related quality of life than non-left-behind wives. Low health-related quality of life was associated with left behind status, older age, less education, low monthly income, unemployment, bad physical health status, passive coping styles, low social support, high level of stress, and high depression.
PMCID: PMC4024212  PMID: 24886024
Left-behind wives; Rural area; Health-related quality of life; Cross-sectional study
25.  Measuring Disparities across the Distribution of Mental Health Care Expenditures 
Previous mental health care disparities studies predominantly compare mean mental health care use across racial/ethnic groups, leaving policymakers with little information on disparities among those with a higher level of expenditures.
Aims of the Study
To identify racial/ethnic disparities among individuals at varying quantiles of mental health care expenditures. To assess whether disparities in the upper quantiles of expenditure differ by insurance status, income and education.
Data were analyzed from a nationally representative sample of white, black and Latino adults 18 years and older (n=83,878). Our dependent variable was total mental health care expenditure. We measured disparities in any mental health care expenditures, disparities in mental health care expenditure at the 95th, 97.5th, and 99th expenditure quantiles of the full population using quantile regression, and at the 50th, 75th, and 95th quantiles for positive users. In the full population, we tested interaction coefficients between race/ethnicity and income, insurance, and education levels to determine whether racial/ethnic disparities in the upper quantiles differed by income, insurance and education.
Significant Black-white and Latino-white disparities were identified in any mental health care expenditures. In the full population, moving up the quantiles of mental health care expenditures, Black-White and Latino-White disparities were reduced but remained statistically significant. No statistically significant disparities were found in analyses of positive users only. The magnitude of black-white disparities was smaller among those enrolled in public insurance programs compared to the privately insured and uninsured in the 97.5th and 99th quantiles. Disparities persist in the upper quantiles among those in higher income categories and after excluding psychiatric inpatient and emergency department (ED) visits.
Disparities exist in any mental health care and among those that use the most mental health care resources, but much of disparities seem to be driven by lack of access. The data do not allow us to disentangle whether disparities were related to white respondent’s overuse or underuse as compared to minority groups. The cross-sectional data allow us to make only associational claims about the role of insurance, income, and education in disparities. With these limitations in mind, we identified a persistence of disparities in overall expenditures even among those in the highest income categories, after controlling for mental health status and observable sociodemographic characteristics.
Implications for Health Care Provision and Use
Interventions are needed to equalize resource allocation to racial/ethnic minority patients regardless of their income, with emphasis on outreach interventions to address the disparities in access that are responsible for the no/low expenditures for even Latinos at higher levels of illness severity.
Implications for Health Policies
Increased policy efforts are needed to reduce the gap in health insurance for Latinos and improve outreach programs to enroll those in need into mental health care services.
Implications for Further Research
Future studies that conclusively disentangle overuse and appropriate use in these populations are warranted.
PMCID: PMC3662479  PMID: 23676411

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