Confirmatory Factor Analysis of the Perceived Stress Scale-4 in a Community Sample

A longitudinal examination of the psychometric properties of the English perceived stress scale- four (PSS-4) in mental health counsellors using item response theory

We examined the longitudinal psychometric properties of the Perceived Stress Scale - 4 items version (PSS-4) using item response theory with a sample of 361 mental health counsellors. Participants completed the PSS-4 at three timepoints at six-month intervals in a one-year period. There were 290 participants who (80.3%) identified as female, 51 (14.1%) identified as male, eight (2.2%) identified as gender variant/non-conforming, seven (1.9%) wrote in their own gender identity (e.g., genderqueer, gender expansive), three (0.8%) identified as Transgender male, and two (0.6%) did not respond to the item. The racial and ethnic backgrounds were as follows: White (87.3%), Multiracial (5.5%), Latino or Hispanic or Spanish (2.8%), Black or African American (1.4%), Asian (0.8%), Middle Eastern (0.8%), and five did not respond to the item (1.4%). We found unidimensionality evidence of the PSS-4 across all three timepoints and response categories were monotonically ordered. We also found that across all timepoints, the average person location was lower than the average item location, suggesting that the PSS-4 may not be well-targeted for this sample of mental health counsellors. We observed no significant interactions between timepoints, hours worked per week, and length of employment. Implications of the findings, including a discussion of the utility of the PSS-4 as a global measure of stress and with mental health counsellors.

Association between adverse childhood experiences and type 2 diabetes mellitus in later life: A case-control study

Adverse childhood experiences (ACEs) are potentially traumatic events that occur before 18 years of age. Studies emphasize the importance of childhood adversity as a risk factor for developing non-communicable diseases, including type-2 diabetes mellitus (T2DM) in adulthood. This case-control study involved 137 patients with T2DM and 134 non-diabetic adults of both genders (mean age 46.9 and 45.7 years, respectively). In addition to collecting socio-demographic, behavioral, and anthropological data, a 10-item ACE scale was utilized to gather information regarding childhood adversities, while perceived stress was assessed using the perceived stress scale-4. Fasting and 2-hour post glucose load blood sugar levels, HbA1c, and fasting lipid profiles were measured. Both univariable and multivariable binary logistic regression analyses were performed to investigate whether ACE is a potential risk factor for T2DM, with a significance level of 0.05. Around two-thirds of T2DM patients reported having ACE scores of 4 or higher, with the mean ACE score significantly higher in the case group than in the control group (3.96 vs. 3.34; p<0.0001). The logistic regression analysis found that T2DM was linked to female gender, hypertension, dyslipidemia, family history of DM, higher perceived stress, and a higher ACE score of 4 and above. After adjusting for confounding factors, individuals with an ACE score of 4 or higher had a significantly greater risk of developing T2DM (OR: 2.24; 95% CI 1.238-4.061). The study revealed a significant association between higher ACE scores and an increased risk of developing T2DM. As a recommendation, further investigation into the epigenetic mechanisms underlying this relationship is warranted.

Associations between weight bias internalization, weight status, and health among a diverse cohort of freshman college students

Mental health concerns are common among college students, especially students with higher body mass index (BMI). Weight bias internalization (WBI) is thought to contribute to these mental health disparities. However, little is known about how WBI differs among more diverse students, and to what extent WBI may explain associations between BMI and health in college populations. This study compared rates of WBI in Freshman college students (N = 1289) across gender, race/ethnicity, and sexual orientation, and assessed whether WBI mediated associations between BMI and mental health (depression, self-esteem, stress, loneliness) and behavioral health (disordered eating, physical activity, gym use). Black students and men demonstrated reduced WBI while bisexual women showed increased WBI. Further, WBI mediated the association of BMI with mental health and disordered eating, but not physical activity. These findings suggest that stigma may account for mental health disparities among higher-BMI students, and that minoritized groups are disproportionately impacted.

A three-arm randomised controlled trial of a telehealth intervention targeting improvement in addictive eating for Australian adults (the TRACE program)

There is a substantial research base for addictive eating with development of interventions. The current 3-arm RCT aimed to investigate the efficacy of the TRACE (Targeted Research for Addictive and Compulsive Eating) program to decrease addictive eating symptoms and improve mental health. Participants (18-85 yrs) endorsing ≥3 addictive eating symptoms were randomly allocated to 1) active intervention, 2) passive intervention, or 3) control group. Primary outcome was change in addictive eating symptoms 3-months post-baseline measured by the Yale Food Addiction Scale. Depression, anxiety and stress were also assessed. A total of 175 individuals were randomised. Using Linear Mixed Models, from baseline to 3-months, there was significant improvement in symptom scores in all groups with mean decrease of 4.7 (95% CI: -5.8, -3.6; p < 0.001), 3.8 (95% CI: -5.2, -2.4; p < 0.001) and 1.5 (95% CI: -2.6, -0.4; p = 0.01) respectively. Compared with the control group, participants in the active intervention were five times more likely to achieve a clinically significant change in symptom scores. There was a significant reduction in depression scores in the active and passive intervention groups, but not control group [-2.9 (95% CI: -4.5, -1.3); -2.3 (95% CI: -4.3, -0.3); 0.5 (95% CI: -1.1, 2.1), respectively]; a significant reduction in stress scores within the active group, but not passive intervention or control groups [-1.3 (95% CI: -2.2, -0.5); -1.0 (95% CI: -2.1, 0.1); 0.4 (95% CI: -0.5, 1.2), respectively]; and the reduction in anxiety scores over time was similar for all groups. A dietitian-led telehealth intervention for addictive eating in adults was more effective than a passive or control condition in reducing addictive eating scores from baseline to 6 months. Trial registration: Australia New Zealand Clinical Trial Registry ACTRN12621001079831.

Examining mediators of the association between child maltreatment and sleep disturbance in college students

BACKGROUND

Childhood maltreatment has been associated with poorer mental and physical health across the lifespan, including disrupted sleep.

OBJECTIVE

The aim of this study was to assess four potential mediators of the association between child maltreatment and sleep in a sample of college students: daily rumination, perceptions of control over stressors, sleep hygiene, and distress.

PARTICIPANTS AND SETTING

University students (N = 234) completed self-report measures online.

METHODS

Childhood maltreatment was assessed at baseline and rumination, perceived control, sleep hygiene, and distress were assessed daily for 14 days and aggregated across days. Structural equation models were used to test hypotheses. The hypothesized model was compared to an alternate path reversal model.

RESULTS

Maltreatment was significantly associated with greater sleep disturbance (β = 0.17, p < .05). Of the mediators, only sleep hygiene partially mediated the association between maltreatment and sleep (β = 0.07, p < .01). The alternate path reversal model demonstrated that sleep disturbances mediated the relation between child maltreatment and sleep hygiene (β = 0.11, p < .001) and perceived control (β = 0.07, p < .05), and sleep disturbances partially mediated the relation between maltreatment and distress (β = 0.10, p < .01) and rumination (β = 0.09, p < .01).

CONCLUSIONS

Sleep hygiene may be implicated in the long-term health effects of child maltreatment. Further, sleep hygiene interventions may be useful for improving sleep among college students who have experienced maltreatment, and targeting students' sleep may have benefits for students' cognition and mood.

A brief measure of non-drug reinforcement: Association with treatment outcomes during initial substance use recovery

BACKGROUND

Translational research demonstrates that drug use is inversely associated with availability and engagement with meaningful non-drug reinforcers. Evaluation of non-drug reinforcement in treatment-receiving clinical populations is limited, likely owing to the time intensive nature of existing measures. This study explores the association of non-drug reinforcers with treatment outcomes using a novel, brief measure of past month non-drug reinforcement quantifying three elements: relative frequency, access, and enjoyability.

METHODS

Respondents enrolled in substance use treatment (residential, intensive outpatient, and medically managed withdrawal) in clinics across the United States (N = 5481) completed standardized assessments of non-drug reinforcement and treatment outcomes (i.e., return to use and life satisfaction) one-month after treatment discharge. Non-drug reinforcement measures (availability, engagement, enjoyability) were used as predictors of return to use and life satisfaction using generalized linear models.

RESULTS

Non-drug reinforcement indices were associated with return to use and life satisfaction in unadjusted models (e.g., 12.4 % versus 58.3 % return to use for those with the highest and lowest availability, respectively). Consistent results were observed in models adjusted for sociodemographic variables and risk factors (i.e., sleep disturbance, anhedonia, stress). Comparisons by drug class generally showed lower non-drug reinforcement among patients reporting heroin or methamphetamine as their primary drug.

CONCLUSIONS

Results highlight the importance of non-drug reinforcement during the first month following treatment. Rapid measurement of non-drug reinforcement in stepped care settings may illuminate critical deficits in early stages of behavior change, identify those at greatest risk for return to use, and provide targets for treatment to improve recovery trajectories.

A Call to Validate the Stress Continuum Model

INTRODUCTION

Since the start of the Global War on Terrorism, exponential demands have been put on military personnel, their families, and the military health care system. In response to a Department of Defense Task Force on Mental Health, the U.S. military began developing and fielding programs to promote the psychological health of its personnel. As part of these initiatives, the Navy and Marine Corps developed the Stress Continuum model. The Stress Continuum is a stress classification system ("ready," "reacting," "injured," and "ill") that provides a common language for identifying, engaging, and intervening when stress reactions or stress injuries are present in military personnel. It is the foundation for resilience and prevention efforts across the Navy and Marine Corps. Although the Stress Continuum has strong face validity, is consistent with current theory, and has been agreed up by expert consensus, it has yet to be empirically validated. The goal of the current article is to begin to empirically validate the Stress Continuum using validated measures of psychological stress.

MATERIALS AND METHODS

We conducted a retrospective analysis of Stress Continuum data (n = 2,049) collected as part of a program evaluation of two Navy operational stress control programs. Receiver operating characteristic (ROC) curves and analyses were conducted to determine the classification quality of the Stress Continuum using a validated measure of stress (a brief version of the Perceived Stress Scale [PSS-4]).

RESULTS

For the first ROC curve, we used the "ill" category (vs. the other three categories) to identify the cut point on the PSS-4. PSS-4 cut point values of 9 and 10, respectively, maximized sensitivity and 1-specificity values. Using the chi-square test, we further found that a more accurate prediction for those in the "ill" category was using the cut point of 9 (79%) relative to 10 (71.8%). For the second and the third ROC curves, we used the "ill" and "injured" categories (vs. the other two categories) and "ill," "injured," and "reacting" categories (vs. the "ready" category), respectively. No optimal cut points on the PSS-4 were identified for these models, indicating that the PSS-4 could not reliably differentiate true-positive and false-positive rates.

CONCLUSIONS

We found that the "ill" category of the Stress Continuum was predictive of higher levels of stress on the validated measure of perceived stress. Thus, our findings strongly suggest that the individuals in the "ill" zone likely warrant some type of intervention by a trained professional.

FUTURE RESEARCH

The Navy has recently leveraged the Stress Continuum to create the Stress-o-Meter to support the fundamental principles of early recognition, peer intervention, and connection to services at the unit level. The Stress-o-Meter serves as a prevention tool that has the capability to collect information about stress levels throughout the entire unit at any time. Continued work on validating the Stress Continuum model and making it easily accessible to military units will ensure service members get the support they need and leaders are able to address the psychological health of their units.

A systematic review and meta-analytic confirmatory factor analysis of the perceived stress scale (PSS-10 and PSS-14)

Stress is defined as a person's interaction with their environment that is thought to threaten or affect an individual's potential, resources, and well-being. The most popular instrument to assess perceived stress is the Perceived Stress Scale (PSS). Therefore, making a systematic review of studies testing the internal structure of PSS and conducting a Meta-Analytic Confirmatory Factor Analysis (MACFA) on the database created with the information obtained from these studies are the aims of this research. A total of 76 samples from 57 unique studies were included in this database using various inclusion criteria (total N for PSS-14 = 28,632, for PSS-10 = 46,053). The correlated two-factor model for PSS was confirmed by MACFA performed on the pooled correlation matrix generated by the random effects meta-analysis. Findings of dimensionality analyses, factor loadings, omega values, and measurement invariance showed that the model that best explained the factor structure of PSS was the correlated two-factor model. The strict measurement invariance of the PSS was achieved across age and clinical status, and the internal consistency was high according to the omega values. Several recommendations moving forward are discussed.

Social Needs Screening and Intervention in Pediatric Primary Care: Impact on Families' Experience of Care

INTRODUCTION/OBJECTIVES

Social determinants of health (SDoH) screening and intervention in pediatric primary care depends upon caregiver disclosure of adverse household or social conditions and thus may be influenced by perceived bias or stigma. This paper examines to what extent parents' experience of their child's medical home is associated with their perceptions of a practice-based social needs intervention.

METHODS

We conducted a cohort study of data reported by 73 parents of children obtaining care in a medical home with an embedded SDoH navigation program. Using survey data collected in October 2021 and October 2022, we calculated descriptive statistics and non-parametric bivariate analyses of the association between engagement with the SDoH navigation program and parent-reported social needs, stress, and perception of care quality as measured by the Person-Centered Primary Care Measure (PCPCM).

RESULTS

Initial ratings of care quality were high (mean baseline PCPCM score = 3.63) and remained high on second interview (mean change in PCPCM score = -0.04, 95%CI -0.16, 0.09, P = .58) despite significant reductions in parents' ratings of access to care over time. Parents reported substantial stress, unmet social needs, and unmet healthcare needs, with 41 families (56%) ever using the practice-based SDoH program, including 16 (22%) who were new users in 2022. There was no association observed between PCPCM score and parent stress, unmet social needs, or use of SDoH services.

CONCLUSIONS

Parents' perceptions of care delivered in their child's medical home appears to be stable on repeat measurement, and independent of family context or interactions with social needs navigation services offered in the practice.

Psychometric validation of the Perceived Stress Scale (PSS-10) among family caregivers of people with schizophrenia in China

BACKGROUND

The 10-item Perceived Stress Scale (PSS-10) is a widely used measure of perceived stress that has been validated in various populations, yet with inconsistent results on its factor structure. The present study examines the reliability and validity of the PSS-10 in a population not previously examined: Chinese family caregivers of persons with schizophrenia, with a focus on factor analysis.

METHODS

A sample of 449 family caregivers of persons with schizophrenia was recruited for psychometric testing of the scale. The factor structure of PSS-10 was tested by randomly dividing the sample into two groups for both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). The scale was further tested for internal consistency, test-retest reliability, convergent validity, discriminant validity and concurrent validity.

RESULTS

EFA extracted two factors: perceived helplessness with six negative phrasing items and perceived efficacy with four positive phrasing items. CFA confirmed the structure of two factors with satisfactory model fit indices. Convergent validity was supported by high standard regression weight (0.78-0.92), average variance extracted (AVE=0.79-0.81) and composite reliability (0.88-0.94), while discriminant validity was confirmed by higher AVE estimates than the squared interconstruct correlations. The PSS-10 showed good internal consistency and test-retest reliability, with Cronbach's alpha of 0.79 and intraclass correlation coefficient of 0.91, respectively. Concurrent validity was demonstrated by its significant positive correlations with stigma, depression and anxiety, as well as significant negative correlations with social support, family functioning and positive caregiving experiences.

CONCLUSION

The two-factor PSS-10 has good psychometric characteristics assessing the perceived stress of family caregivers of people with schizophrenia. The findings indicate that the PSS-10 can be used to measure perceived stress in future research and practice among caregivers of people with schizophrenia, and potentially, other caregiving samples.

Wellness in Nursing Education to Promote Resilience and Reduce Burnout: Protocol for a Holistic Multidimensional Wellness Intervention and Longitudinal Research Study Design in Nursing Education

BACKGROUND

The United States faces a nursing shortage driven by a burnout epidemic among nurses and nursing students. Nursing students are an integral population to fuel the nursing workforce at high risk of burnout and increased rates of perceived stress.

OBJECTIVE

The aim of this paper is to describe WellNurse, a holistic, interdisciplinary, multidimensional longitudinal research study that examines evidence-based interventions intended to reduce burnout and increase resilience among graduate and undergraduate nursing students.

METHODS

Graduate and undergraduate nursing students matriculated at a large public university in the northeastern United States are eligible to enroll in this ongoing, longitudinal cohort study beginning in March 2021. Participants complete a battery of health measurements twice each semester during the fourth week and the week before final examinations. The measures include the Perceived Stress Scale, the Satisfaction with Life Scale, the Oldenburg Burnout Inventory, the Brief Resilience Scale, and the Pittsburgh Sleep Quality Index. Participants are eligible to enroll in a variety of interventions, including mindfulness-based stress reduction, mindful eating, fitness training, and massage therapy. Those who enroll in specific, targeted interventions complete additional measures designed to target the aim of the intervention. All participants receive a free Fitbit device. Additional environmental changes are being implemented to further promote a culture that supports academic well-being, including recruiting a diverse student population through evidence-based holistic admissions, inclusive teaching design, targeted resilience and stress reduction workshops, and cultural shifts within classrooms and curricula. The study design protocol is registered at Open Science Framework (DOI 10.17605/OSF.IO/NCBPE).

RESULTS

The project was funded on January 1, 2022. Data collection started in March 2022. A total of 267 participants have been recruited. Results will be published after each semester starting in December 2023. WellNurse evaluation follows the Rapid Cycle Quality Improvement framework to continuously monitor ongoing project processes, activity outcomes, and progress toward reducing burnout and increasing resilience. Rapid Cycle Quality Improvement promotes the ability to alter WellNurse interventions, examine multiple interventions, and test their effectiveness among the nursing education population to identify the most effective interventions.

CONCLUSIONS

Academic nursing organizations must address student burnout risk and increase resilience to produce a future workforce that provides high-quality patient care to a diverse population. Findings from WellNurse will support evidence-based implementations for public baccalaureate and master's nursing programs in the United States.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49020.

The mental health impact of the ongoing Russian-Ukrainian war 6 months after the Russian invasion of Ukraine

Objective

This study aimed to investigate the impact of the ongoing war in Ukraine on the mental health of Ukrainians, focusing on war-induced trauma, disturbances in self-organization, post-traumatic stress disorder, complex post-traumatic stress disorder, anxiety, stress, and depression.

Methods

Data was collected from 703 participants 6 months after the full-scale invasion using a structured questionnaire that included sections on socio-demographic information, trauma-related issues, and mental health.

Results

The study found that levels of depression and anxiety were relatively low, while stress and resilience were relatively high among Ukrainians affected by the war. However, those who were directly exposed to military actions, physical violence, or severe human suffering had higher levels of anxiety, depression, stress, and trauma-related symptoms. The war experience varied by gender, age, and living conditions. Participants who stayed in Ukraine had significantly lower anxiety, depression, stress, and trauma-related symptoms compared to those who moved abroad. Anxiety, depression, stress, low resilience, and subjective satisfaction with living conditions were predictors of trauma-related symptoms, including PTSD and CPTSD.

Conclusion

These findings suggest that the mental health of Ukrainians affected by the war was impacted differently depending on their level of exposure to violence and their living conditions. Additionally, the study identified several predictors of trauma-related symptoms, including PTSD and CPTSD, such as anxiety, depression, stress, low resilience, and subjective satisfaction with living conditions. Future research should further explore the relationships between trauma type, sociodemographic factors, resilience, stress, anxiety, depression, and PTSD and CPTSD to better understand the mediation mechanisms underlying these relationships and to develop effective interventions to support the well-being of Ukrainians during this difficult time.

The Perceived Stress Scale 2&2: a two-factorial German short version of the Perceived Stress Scale

Background

Stress is among the leading causes for diseases. The assessment of subjectively perceived stress is essential for resilience research. While the Perceived Stress Scale (PSS) is a widely used questionnaire, a German short version of the scale is not yet available. In the current study, we developed such a short version using a machine learning approach for item reduction to facilitate the simultaneous optimization of multiple psychometric criteria.

Method

We recruited 1,437 participants from an online panel, who completed the German long version of the PSS along with measures of mental health and resilience. An ant-colony-optimization algorithm was used to select items, taking reliability, and construct validity into account. Findings on validity were visualized by psychological network models.

Results

We replicated a bifactor structure for the long version of the PSS and derived a two-factor German short version of the PSS with four items, the PSS-2&2. Its factors helplessness and self-efficacy showed differential associations with mental health indicators and resilience-related factors, with helplessness being mainly linked to mental distress.

Conclusion

The valid and economic short version of the PSS lends itself to be used in future resilience research. Our findings highlight the importance of the two-factor structure of the PSS short versions and challenge the validity of commonly used one-factor models. In cases where the general stress factor is of interest, researchers should use the longer versions of the PSS that allow for the interpretation of total scores, while the PSS-2&2 allows of an economic assessment of the PSS factors helplessness and self-efficacy.

Examining the efficacy of a telehealth intervention targeting addictive eating in Australian adults (the TRACE Programme): a randomised controlled trial protocol

INTRODUCTION

Approximately 15%-20% of the adult population self-report symptoms of addictive eating. There are currently limited options for management. Motivational interviewing-based interventions, containing personalised coping skills training, have been found to be effective for behaviour change in addictive disorders (eg, alcohol). This project builds upon foundations of an addictive eating feasibility study previously conducted and co-design process involving consumers. The primary aim of this study is to examine the efficacy of a telehealth intervention targeting addictive eating symptoms in Australian adults compared with passive intervention and control groups.

METHODS AND ANALYSIS

This three-arm randomised controlled trial will recruit participants 18-85 years, endorsing ≥3 symptoms on the Yale Food Addiction Scale (YFAS) 2.0, with body mass index >18.5 kg/m2. Addictive eating symptoms are assessed at baseline (pre-intervention), 3 months (post-intervention) and 6 months. Other outcomes include dietary intake and quality, depression, anxiety, stress, quality of life, physical activity and sleep hygiene. Using a multicomponent clinician-led approach, the active intervention consists of five telehealth sessions (15-45 min each) delivered by a dietitian over 3 months. The intervention uses personalised feedback, skill-building exercises, reflective activities and goal setting. Participants are provided with a workbook and website access. The passive intervention group receives the intervention via a self-guided approach with access to the workbook and website (no telehealth). The control group receives personalised written dietary feedback at baseline and participants advised to follow their usual dietary pattern for 6 months. The control group will be offered the passive intervention after 6 months. The primary endpoint is YFAS symptom scores at 3 months. A cost-consequence analysis will determine intervention costs alongside mean change outcomes.

ETHICS AND DISSEMINATION

Human Research Ethics Committee of University of Newcastle, Australia provided approval (H-2021-0100). Findings will be disseminated via publication in peer-reviewed journals, conference presentations, community presentations and student theses.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry (ACTRN12621001079831).

Integrated care for older multimorbid heart failure patients: protocol for the ESCAPE randomized trial and cohort study

ESCAPE

Evaluation of a patient-centred biopsychosocial blended collaborative care pathway for the treatment of multimorbid elderly patients.

THERAPEUTIC AREA

Healthcare interventions for the management of older patients with multiple morbidities.

AIMS

Multi-morbidity treatment is an increasing challenge for healthcare systems in ageing societies. This comprehensive cohort study with embedded randomized controlled trial tests an integrated biopsychosocial care model for multimorbid elderly patients.

HYPOTHESIS

A holistic, patient-centred pro-active 9-month intervention based on the blended collaborative care (BCC) approach and enhanced by information and communication technologies can improve health-related quality of life (HRQoL) and disease outcomes as compared with usual care at 9 months.

METHODS

Across six European countries, ESCAPE is recruiting patients with heart failure, mental distress/disorder plus ≥2 medical co-morbidities into an observational cohort study. Within the cohort study, 300 patients will be included in a randomized controlled assessor-blinded two-arm parallel group interventional clinical trial (RCT). In the intervention, trained care managers (CMs) regularly support patients and informal carers in managing their multiple health problems. Supervised by a clinical specialist team, CMs remotely support patients in implementing the treatment plan-customized to the patients' individual needs and preferences-into their daily lives and liaise with patients' healthcare providers. An eHealth platform with an integrated patient registry guides the intervention and helps to empower patients and informal carers. HRQoL measured with the EQ-5D-5L as primary endpoint, and secondary outcomes, that is, medical and patient-reported outcomes, healthcare costs, cost-effectiveness, and informal carer burden, will be assessed at 9 and ≥18 months.

CONCLUSIONS

If proven effective, the ESCAPE BCC intervention can be implemented in routine care for older patients with multiple morbidities across the participating countries and beyond.

COVID-19 government measures and their impact on mental health: a cross-sectional study of older primary care patients in Germany

Background

With the outbreak of COVID-19, government measures including social distancing and restrictions of social contacts were imposed to slow the spread of the virus. Since older adults are at increased risk of severe disease, they were particularly affected by these restrictions. These may negatively affect mental health by loneliness and social isolation, which constitute risk factors for depressiveness. We aimed to analyse the impact of perceived restriction due to government measures on depressive symptoms and investigated stress as mediator in an at-risk-population in Germany.

Methods

Data were collected in April 2020 from the population of the AgeWell.de-study, including individuals with a Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) score ≥9, using the depression subscale of the Brief Symptom Inventory (BSI-18) and the Perceived Stress Scale (PSS-4). Feeling restricted due to COVID-19 government measures was surveyed with a standardized questionnaire. Stepwise multivariate regressions using zero-inflated negative binomial models were applied to analyse depressive symptoms, followed by a general structural equation model to assess stress as mediator. Analysis were controlled for sociodemographic factors as well as social support.

Results

We analysed data from 810 older adults (mean age = 69.9, SD = 5). Feeling restricted due to COVID-19 government measures was linked to increased depressiveness (b = 0.19; p < 0.001). The association was no longer significant when adding stress and covariates (b = 0.04; p = 0.43), while stress was linked to increased depressive symptoms (b = 0.22; p < 0.001). A final model confirms the assumption that the feeling of restriction is mediated by stress (total effect: b = 0.26; p < 0.001).

Conclusion

We found evidence that feeling restricted due to COVID-19 government measures is associated with higher levels of depressive symptoms in older adults at increased risk for dementia. The association is mediated by perceived stress. Furthermore, social support was significantly associated with less depressive symptoms. Thus, it is of high relevance to consider possible adverse effects of government measures related to COVID-19 on mental health of older people.

Meaning in challenging times: Sense of meaning supports wellbeing despite pandemic stresses

The COVID-19 pandemic created stress and trauma for many individuals. Traumatic experiences often trigger reflection on meaning in life, with subsequent growth or despair. This study evaluates the role of meaning in life in buffering stressors in the early stages of the COVID-19 pandemic. The purpose of this study was to determine the extent to which the negative effects of COVID-19 stressors (self-perceived stress, emotional state, and cognitive adaptation to stress in the pandemic) are influenced by meaning in life in the context of the early stages of the pandemic. Further, this study described differences in meaning in life observed across demographic groups. Web-based surveys were completed by 831 Slovenian participants in April of 2020. Demographic data; perceptions of stressors related to lacking necessities, movement restrictions, and concerns at home; meaning in life; perceived overall health status; anxiety; emotional state; and perceived stress were measured. A moderately strong sense of meaning in life (M = 5.0, SD = 0.74, range 1-7) was reported by participants, and meaning in life was associated with enhanced wellbeing (B = 0.06-.28, p < .01). Both direct and indirect relationships were observed between stressors and wellbeing outcomes. The indirect effects of meaning in life were especially prominent in the relationship between stressors related to lacking necessities and concerns at home and outcomes of anxiety, perceived stress, and negative emotions, contributing 13-27% of the total observed effects. Increased meaning in life was observed across older age groups (F(5, 825) = 4.8, p < .001) and for those in partnered relationships (t(829) = -3.397, p <.001). A strong sense of meaning in life was associated with improved well-being, even for individuals who experienced pandemic-related stressors. Public health initiatives and media may help improve resilience to pandemic trauma by emphasizing the collective meaning in challenging situations.

Who benefits most from a prenatal HEPA filter air cleaner intervention on childhood cognitive development? The UGAAR randomized controlled trial

BACKGROUND

Air pollution exposure during pregnancy affects children's brain function. Maternal stress and nutrition, socioeconomic status, and the child's sex may modify this relationship.

OBJECTIVE

To identify characteristics of children with the largest increases in full-scale IQ (FSIQ) after their mothers used HEPA filter air cleaners during pregnancy.

METHODS

In this randomized controlled trial we randomly assigned women to receive 1-2 air cleaners or no air cleaners during pregnancy. We analyzed maternal hair samples for cortisol and dehydroepiandrosterone (DHEA). When the children were 48 months old, we measured FSIQ with the Wechsler Preschool and Primary Scale of Intelligence. We evaluated ten potential modifiers of the intervention-FSIQ relationship using interaction terms in separate regression models. To account for correlations between modifiers, we also used a single regression model containing main effects and intervention x modifier terms for all potential modifiers.

RESULTS

Among 242 mother-child dyads with complete data, the intervention was associated with a 2.3-point increase (95% CI: -1.5, 6.0 points) in mean FSIQ. The intervention improved mean FSIQ among children of mothers in the bottom (5.4 points; 95% CI: -0.8, 11.5) and top (6.1 points; 95% CI: 0.5, 11.8) cortisol tertiles, but not among those whose mothers were in the middle tertile. The largest between-group difference in the intervention's effect was a 7.5-point (95% CI: -0.7, 15.7) larger increase in mean FSIQ among children whose mothers did not take vitamins than among children whose mothers did take vitamins (interaction p-value = 0.07). We also observed larger benefits among children whose mothers did not complete university, and those with lower hair DHEA concentrations, hair cortisol concentrations outside the middle tertile, or more perceived stress.

CONCLUSION

The benefits of reducing air pollution during pregnancy on brain development may be greatest for children whose mothers who do not take vitamins, experience more stress, or have less education.

Metacognition in Community-Dwelling Older Black and African American Adults During the COVID-19 Pandemic

BACKGROUND

Cognitive assessment of older adults typically includes symptom reports and objective evaluations. However, there is often poor agreement between these measures. Cultural norms, stress, and anxiety may also influence cognitive self-appraisal and performance. Little research describes how other factors affect the self-report/objective test discrepancies noted in the literature.

OBJECTIVE

This study investigated whether the disparity between subjective cognitive concerns and objective cognitive performance is related to measures of anxiety and stress in older Black and African American adults.

METHODS

Telephone screenings were administered to 206 older adults (ages 64-94) during the first year of the pandemic. Demographic data, objective memory (Telephone Interview for Cognitive Status [TICS-m]), an adaptation of the subjective memory measure, the Cognitive Change Questionnaire, emphasizing executive functioning in everyday life [CCQ-e]), Generalized Anxiety Disorder-7 (GAD-7), and Perceived Stress Scale-4 (PSS4) were measured. Metacognition Discrepancy Index (MDI) was calculated from the standardized residual after regressing TICS-m on CCQ-e scores to quantify the discrepancy between cognitive self-appraisal and objective cognitive functioning.

RESULTS

Neither GAD-7 nor PSS-4 moderated the relationship between TICS-m and CCQ-e, and TICS-m scores weakly predicted subjective CCQ-e scores (F(1, 197)=4.37, p = 0.038, R2 = 0.022). The MDI correlated with stress and anxiety (rs = 0.294, 0.396, ps < 0.001).

CONCLUSION

Discrepancies exist between objectively measured and self-evaluated cognition. Elevations in stress and anxiety are associated with greater overestimation of cognitive difficulties relative to objective performance. Pandemic-related stressors may have worsened anxiety and diminished self-appraisal of cognitive abilities for some individuals, while others may remain reluctant to acknowledge impairments. Social and emotional factors are meaningful considerations in assessing cognitive difficulties.

Correlates of psychological distress among adults with obesity during the COVID-19 pandemic

OBJECTIVE

The present study evaluated changes in stress and loneliness among participants with obesity engaged in weight loss self-management in the United States (US) during COVID-19, and identified factors that may increase risk or protect against psychosocial distress during this time.

DESIGN

Participants who were enrolled in a weight self-management program prior to the COVID-19 pandemic (N = 55, 91% female, 36% Caucasian, mean age = 49.8 years) completed an online survey about social, economic and health behaviour changes during COVID-19 and their relationship to changes in perceived stress and loneliness.

MAIN OUTCOME MEASURES

Perceived Stress (PSS-4), Loneliness (PROMIS loneliness and social isolation questionnaire).

RESULTS

Compared to pre-COVID assessments, stress and loneliness increased 40% two months into the COVID-19 pandemic-related shutdown. Higher body mass index (BMI) and social distancing were associated with increases in both loneliness and stress. Alcohol intake was associated with increased stress, and working from home was associated with increased loneliness.

CONCLUSION

Individuals with obesity endorsed increased stress and loneliness during COVID-19, which may be exacerbated among those with a higher BMI and greater adherence to social distancing guidelines. Ongoing attention to psychosocial well-being among individuals with obesity will remain imperative both during the ongoing pandemic and beyond.

Public attitudes towards neurotechnology: Findings from two experiments concerning Brain Stimulation Devices (BSDs) and Brain-Computer Interfaces (BCIs)

This study contributes to the emerging literature on public perceptions of neurotechnological devices (NTDs) in their medical and non-medical applications, depending on their invasiveness, framing effects, and interindividual differences related to personal needs and values. We conducted two web-based between-subject experiments (2×2×2) using a representative, nation-wide sample of the adult population in Germany. Using vignettes describing how two NTDs, brain stimulation devices (BSDs; NExperiment 1 = 1,090) and brain-computer interfaces (BCIs; NExperiment 2 = 1,089), function, we randomly varied the purpose (treatment vs. enhancement) and invasiveness (noninvasive vs. invasive) of the NTD, and assessed framing effects (variable order of assessing moral acceptability first vs. willingness to use first). We found a moderate moral acceptance and willingness to use BSDs and BCIs. Respondents preferred treatment over enhancement purposes and noninvasive over invasive devices. We also found a framing effect and explored the role of personal characteristics as indicators of personal needs and values (e.g., stress, religiosity, and gender). Our results suggest that the future demand for BSDs or BCIs may depend on the purpose, invasiveness, and personal needs and values. These insights can inform technology developers about the public's needs and concerns, and enrich legal and ethical debates.

Potential paths to suicidal ideation and suicide attempts among high-risk women

Although men are more likely to die by suicide, women experience a greater and more rapidly increasing rate of suicidal ideation (SI) and are 3 times more likely to attempt suicide than men. Despite this increased risk, little is known about factors that contribute to SI or suicide attempts (SA) among women. We examined factors associated with SI and SA among women and identified mood-related symptoms that differentiate women who reported attempting suicide from those who did not. Women at elevated risk for depression from across the U.S. (N = 3372; age 18 to 90) completed a survey regarding depression, anxiety, sociodemographic and reproductive status, behavioral/mental health history, and exposure to adversity. Structural equation modeling and logistic regression were used to analyze the data. Variables with the most significant relationships to SI were severity of depression (OR = 5.2, p = 0.000) and perceived stress (OR = 1.18, p = 0.000) while frequency of suicidal thoughts (OR = 3.3, p = 0.000), family history of a depression diagnosis (OR = 1.6, p = 0.000) and exposure to violence (OR = 1.9, p = 0.000) had the strongest association with SA. Childhood abuse/trauma was associated with SA (OR = 1.13, p = 0.000) but not SI. 'Feeling bad about themselves, a failure, or having let themselves or their family down' was the symptom that most clearly differentiated women who attempted suicide from women who reported suicidal ideation but no SA. The salience of childhood abuse and domestic/community violence to women's risk for a suicide attempt reinforces previous findings that these adversities may differentiate suicide risk for women versus men. Continued research is essential to understand varied paths that may lead to suicidal behavior among women, some which appear unrelated to the frequency or intensity of their suicidal thoughts.

The Protective Role of Resilience in the Development of Social Media Addiction in Tertiary Students and Psychometric Properties of the Slovenian Bergen Social Media Addiction Scale (BSMAS)

With the onset of the COVID-19 pandemic, social media became one of the most utilized sources of information relating to the disease. With the increased reliance on social media, the risk of excessive use and the development of social media addiction emerges. The aim of the present study was to explore the psychometric properties of the Slovenian version of the Bergen Social Media Addiction Scale, and to explore how psychological resilience affects social media addiction symptoms directly and indirectly through symptoms of depression, anxiety and mental distress. A large online cross-sectional study was conducted in March 2021 among Slovenian tertiary students (N = 4868). The results showed the high reliability, unidimensionality and criterion validity of the Slovenian Bergen Social Media Addiction Scale. The proposed structural model fit the data well and showed a significant direct positive effect of depression and stress on social media addiction. Moreover, the majority of the negative effects of psychological resilience on social media addiction (87.2%) were indirect, through depression and stress symptoms, whereas resilience had a significantly smaller impact on social media addiction by reducing anxiety symptoms. The overall prevalence of social media addiction symptoms was 4.6%, with females exhibiting higher proportions than men. Additionally, female social media users reported a complete absence of social media addiction symptoms less often compared to males. Future research should further explore the mechanisms behind social media addiction, in order to gain a better understanding of the apparently different risk levels for both genders.

Symptom profiles of women at risk of mood disorders: A latent class analysis

BACKGROUND

Depression is the leading cause of disease burden among women worldwide. However, an understanding of symptom profiles among women at risk of mood disorders is limited. We determined distinct profiles of affective symptoms among high risk women, along with their distinguishing characteristics.

METHODS

Women were recruited from 17 clinical sites affiliated with the National Network of Depression Centers. They completed measures of depression (Patient Health Questionnaire - 9) and anxiety (Generalized Anxiety Disorder - 7) as well as questions regarding demographics, reproductive status, behavioral/mental health history, and life stress/adversity. Latent class analysis and multinomial logistic regression were used to identify and characterize symptom profiles.

RESULTS

5792 women participated, ages 18 to 90 (M = 38). Three latent classes were identified: generally asymptomatic (48%), elevated symptoms of comorbid anxiety and depression (16%), and somatic symptoms (36%). Financial security and greater social support were protective factors that distinguished asymptomatic women. The profile of the class with elevated anxiety/depressive symptoms constituted a complex mix of adverse social determinants and potentially heritable clinical features, including a diagnosis of Bipolar Disorder. Women in the 3rd latent class were characterized by menstrual irregularity and a stronger expression of neurovegetative symptoms, especially sleep disturbance and fatigue.

LIMITATIONS

Limitations included less than optimal racial diversity of our sample and reliance on self-report.

CONCLUSIONS

Different symptom profiles may reflect distinct subtypes of women at risk of mood disorders. Understanding the etiology and mechanisms underlying clinical and psychosocial features of these profiles can inform more precisely targeted interventions to address women's diverse needs.

Mitochondrial DNA Copy Number Adaptation as a Biological Response Derived from an Earthquake at Intrauterine Stage

An altered mitochondrial DNA copy number (mtDNAcn) at birth can be a marker of increased disease susceptibility later in life. Gestational exposure to acute stress, such as that derived from the earthquake experienced on 19 September 2017 in Mexico City, could be associated with changes in mtDNAcn at birth. Our study used data from the OBESO (Biochemical and Epigenetic Origins of Overweight and Obesity) perinatal cohort in Mexico City. We compared the mtDNAcn in the umbilical cord blood of 22 infants born before the earthquake, 24 infants whose mothers were pregnant at the time of the earthquake (exposed), and 37 who were conceived after the earthquake (post-earthquake). We quantified mtDNAcn by quantitative real-time polymerase chain reaction normalized with a nuclear gene. We used a linear model adjusted by maternal age, body mass index, socioeconomic status, perceived stress, and pregnancy comorbidities. Compared to non-exposed newborns (mean ± SD mtDNAcn: 0.740 ± 0.161), exposed and post-earthquake newborns (mtDNAcn: 0.899 ± 0.156 and 0.995 ± 0.169, respectively) had increased mtDNAcn, p = 0.001. The findings of this study point at mtDNAcn as a potential biological marker of acute stress and suggest that experiencing an earthquake during pregnancy or before gestation can have programing effects in the unborn child. Long-term follow-up of newborns to women who experience stress prenatally, particularly that derived from a natural disaster, is warranted.

Psychological and behavioral responses during the COVID-19 pandemic among individuals with mobility and/or self-care disabilities

Background

The lockdowns during the COVID-19 pandemic created major obstacles for individuals with disabilities to obtain support in their daily living.

Objectives

This study was to examine the psychological and behavioral responses of US individuals with mobility and/or self-care disabilities during the pandemic.

Methods

From a nationally representative longitudinal survey (n = 6403) administered during the pandemic, individuals were classified at baseline as having no mobility/self-care disability (ADL = 0, n = 4975), mobility or self-care disability (ADL = 1, n = 1061), and both mobility and self-care disabilities (ADL = 2, n = 367). Weighted mean of baseline mental distress scores (PHQ4), psychological risk factors (loneliness, stress, perceived COVID risk), resilience, and coping were compared among these groups. Random effects models were employed to assess the effects of disability and disability-moderated effects of risk factors on mental distress.

Results

At baseline, mental distress increased with greater ADL disabilities (Mean[95%CI] = 1.88[1.77, 1.98], 2.54[2.29, 2.79], and 3.55[3.01, 4.08] for ADL = 0, 1, and 2, respectively, p < .0001). Loneliness, stress, and perceived risk increased with ADL disabilities, but resilience and social coping decreased with it (p's < 0.0001). In the random-effects models, greater ADL disabilities, higher psychological risks, and use of cannabis and other recreational drugs were associated with greater mental distress. Greater ADL disabilities augmented the detrimental effects of risk factors on mental health, but resilience protected mental health both independently and through a buffering effect on its risk factors across all groups.

Conclusion

Individuals with mobility and/or self-care disability tend to have poorer mental health and are differentially more affected by its risk factors. Mental health professionals should address these modifiable factors in interventions.

Race, social pain minimization, and mental health

People often believe Black individuals experience less social pain and require less social support to cope with distress than White individuals (e.g., Deska, Kunstman, Lloyd, et al., 2020). However, researchers have not tested whether biases in third-person pain judgments translate to first-person experiences with social pain minimization. For example, do Black individuals feel their social pain is underrecognized to a greater extent than White individuals? The current work tested whether Black individuals felt their social pain was minimized more than White individuals and if the experience of social pain minimization was related to worse mental health and greater life stress. Data from two cross-sectional, correlational studies provide initial support for these predictions ( Ntotal = 1,501). Black participants felt their social pain was minimized more than White participants and this race difference in social pain minimization was associated with worse mental health and greater life stress. These results suggest that Black individuals feel their pain is underrecognized and this experience of social pain minimization is related to worse mental health outcomes.

Internet-based stress recovery intervention FOREST for healthcare staff amid COVID-19 pandemic: study protocol for a randomized controlled trial

BACKGROUND

The demand for care during the COVID-19 pandemic has affected the mental health of healthcare workers (HCWs), thus increasing the need for psychosocial support services. Internet-based interventions have previously been found to reduce occupational stress. The study aims to test the effects of an Internet-based stress recovery intervention-FOREST-among HCWs.

METHODS

A randomized controlled trial (RCT) parallel group design with three measurement points will be conducted to assess the efficacy of an Internet-based stress recovery intervention FOREST for nurses. The FOREST intervention is a 6-week Internet-based CBT and mindfulness-based program which comprises of six modules: (1) Introduction, (2) Detachment (relaxation and sleep), (3) Distancing, (4) Mastery (challenge), (5) Control, and (6) Keeping the change alive. We will compare the intervention against a waiting list group at pre-test, post-test, and follow-up. Stress recovery, PTSD, complex PTSD, moral injury, the level of stress, depression, anxiety, and psychological well-being will be measured.

DISCUSSION

The study will contribute to the development of mental healthcare programs for the HCWs. Based on the outcomes of the study, the FOREST intervention can be further developed or offered to healthcare staff as a tool to cope with occupational stress.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04817995 . Registered on 30 March 2021.

Three Versions of the Perceived Stress Scale: Psychometric Evaluation in a Nationally Representative Sample of Chinese Adults during the COVID-19 Pandemic

(1) Background: The COVID-19 outbreak has created pressure in people’s daily lives, further threatening public health. Thus, it is important to assess people’s perception of stress during COVID-19 for both research and practical purposes. The Perceived Stress Scale (PSS) is one of the most widely used instruments to measure perceived stress; however, previous validation studies focused on specific populations, possibly limiting the generalization of results. (2) Methods: This study tested the psychometric properties of three versions of the Chinese Perceived Stress Scale (CPSS-14, CPSS-10, and CPSS-4) in the Chinese general population during the COVID-19 pandemic. A commercial online survey was employed to construct a nationally representative sample of 1133 adults in Mainland China (548 males and 585 females) during a one-week period. (3) Results: The two-factor (positivity and negativity) solution for the three versions of the CPSS showed a good fit with the data. The CPSS-14 and CPSS-10 had very good reliability and the CPSS-4 showed acceptable reliability, supporting the concurrent validity of the CPSS. (4) Conclusions: All three versions of the CPSS appear to be appropriate for use in research with samples of adults in the Chinese general population under the COVID-19 crisis. The CPSS-10 and CPSS-14 both have strong psychometric properties, but the CPSS-10 would have more utility because it is shorter than the CPSS-14. However, the CPSS-4 is an acceptable alternative when administration time is limited.

Perception of stress by different categories of medical personnel during the first wave of the COVID‑19 pandemic in Russia

Relevance. In the context of the pandemic, the current psychological state and the likely delayed deterioration of the mental health of medical personnel, regardless of their professional duties, are of concern. Taking into account the stressful circumstances in which the pandemic has placed all medical workers, assessing the level of perceived stress, as well as identifying risk factors and factors that mitigate stress, is an urgent task, the solution of which will contribute to the effective organization of psychological support for medical personnel.

Methods. The study used a shortened version of the Perceived Stress Scale (PSS10) as the main methodology – a tool designed to study a person's attitude to stressful situations and determine the degree to which life is assessed as stressful and uncontrolled (Cohen et al., 1988). The methodology is widely used by the scientific community, including during the pandemic, and the original English version of the PSS has been translated into many languages and adapted in different countries. The study was conducted through an online survey.

Respondents. The study, conducted in the period from May 9 to June 26, 2020, when there was a steady increase in SARS-CoV 2 virus infections in Russia, involved 1,287 employees of medical institutions in various subjects of the federation (1,079 women and 208 men) aged 19 to 80 years. The sample of the study is represented by doctors, middle and junior medical staff, heads of medical departments and institutions, as well as volunteers.

Results. A high average overall index of perceived stress among employees of medical institutions was revealed. The highest level of stress is observed in the youngest age group (from 19 to 30 years), and with age, the level of stress decreases. There were no differences in the level of stress between male and female health workers in any of the considered stress indicators. Protective factors against increased stress are the presence of children and living with family members or relatives, while the presence of a spouse / partner does not affect the overall indicator of perceived stress. From different categories of medical workers, the index of perceived stress is higher in managers and doctors compared to middle and junior medical personnel. There were no significant differences in the level of stress between the staff working and not working in the "red zone". Differences in the level of stress of medical workers depending on the current situation (the number of infected and dead) in the region of residence were revealed: the level of stress is higher for those specialists who are forced to work in stressful conditions due to the complex epidemiological situation. The relationship between different beliefs about COVID19 and the level of stress is shown: the level of stress is higher in those who take its danger more seriously. In terms of the sources of stress, the most likely predictors are anxiety about exposure to COVID19 at work and the likelihood of infecting loved ones, fear of catching it yourself and getting sick, inability to meet the usual personal needs and economic instability.

Conclusions. Practical interventions, the provision of psychological support and the development of actions to reduce stress for staff during a pandemic, should take into account the role of factors in increasing stress among staff working in specific conditions and focus on the prevailing beliefs and stressors in specific categories of medical factors.

Urinary incontinence and the association with depression, stress, and self-esteem in older Korean Women

The objectives were to investigate the prevalence of urinary incontinence (UI) and its relationships with depression, stress, and self-esteem in older Korean women from the Korean Study of Women's Health Related Issues (K-Stori), a nationally representative cross-sectional survey. A total of 3000 women between 65 and 79 years were the final study subjects. We applied multiple linear regression models to analyze associations with depression, stress, and self-esteem levels in relation to UI types. Types of urinary incontinence included stress, urge, and mixed UI. UI affects at least one in two older Korean women (52.2%). The prevalences of SUI, UUI, and MUI were 45.7%, 39.6%, and 33.1%, respectively. UI was found to be adversely associated with depression, stress, and self-esteem: women with UI reported significantly higher levels of depression and stress and lower levels of self-esteem than those without UI. Women with MUI reported significantly greater impairment than the women with SUI or UUI. Our results provide an evidence base for the evaluation of mental health in older women with incontinence. The prioritization of UI detection and the identification of psychological factors may help improve the diagnosis and management of UI and potentially yield significant economic and psychosocial benefits.

Efficacy of team-based collaborative care for distressed patients in secondary prevention of chronic coronary heart disease (TEACH): study protocol of a multicenter randomized controlled trial

BACKGROUND

Coronary heart disease (CHD) is the leading cause of death and years of life lost worldwide. While effective treatments are available for both acute and chronic disease stages there are unmet needs for effective interventions to support patients in health behaviors required for secondary prevention. Psychosocial distress is a common comorbidity in patients with CHD and associated with substantially reduced health-related quality of life (HRQoL), poor health behavior, and low treatment adherence.

METHODS

In a confirmatory, randomized, controlled, two-arm parallel group, multicenter behavioral intervention trial we will randomize 440 distressed CHD patients with at least one insufficiently controlled cardiac risk factor to either their physicians' usual care (UC) or UC plus 12-months of blended collaborative care (TeamCare = TC). Trained nurse care managers (NCM) will proactively support patients to identify individual sources of distress and risk behaviors, establish a stepwise treatment plan to improve self-help and healthy behavior, and actively monitor adherence and progress. Additional e-health resources are available to patients and their families. Intervention fidelity is ensured by a treatment manual, an electronic patient registry, and a specialist team regularly supervising NCM via videoconferences and recommending protocol and guideline-compliant treatment adjustments as indicated. Recommendations will be shared with patients and their physicians who remain in charge of patients' care. Since HRQoL is a recommended outcome by both, several guidelines and patient preference we chose a ≥ 50% improvement over baseline on the HeartQoL questionnaire at 12 months as primary outcome. Our primary hypothesis is that significantly more patients receiving TC will meet the primary outcome criterion compared to the UC group. Secondary hypotheses will evaluate improvements in risk factors, psychosocial variables, health care utilization, and durability of intervention effects over 18-30 months of follow-up.

DISCUSSION

TEACH is the first study of a blended collaborative care intervention simultaneously addressing distress and medical CHD risk factors conducted in cardiac patients in a European health care setting. If proven effective, its results can improve long-term chronic care of this vulnerable patient group and may be adapted for patients with other chronic conditions.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00020824, registered on 4 June, 2020; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020824.

Psychometric data on knowledge and fear of coronavirus disease 2019 and perceived stress among workers of filipino origin in Hong Kong

Data on knowledge and fear of coronavirus disease 2019 (COVID-19) and perceived stress were collected in July 2020 from a convenience sample of Filipino domestic workers in Hong Kong by asking participants to take part in three questionnaires. First, twelve questions related to knowledge associated with the prevention and identification of COVID-19 were used to assess participants’ knowledge regarding COVID-19. Second, the Fear of COVID-19 Scale (FCV-19S) was used to assess participants’ perceived fear of infection. Third, the Short Form Perceived Stress Scale (PSS-4) was used to measure participants’ perceived stress. Pearson product-moment correlation coefficients were obtained to assess the relationships between the total scores of the three questionnaires. The relationship between knowledge of COVID and fear of COVID was significant, r(108) = +0.23, p = .02; the relationship between fear of COVID and perceived stress was not statistically significant, r(108) = +0.17, p = .08; the relationship between knowledge of COVID and perceived stress was not statistically significant, r(108) = -0.11, p = .26. Cronbach's alpha coefficients were obtained for each of the three questionnaires to assess internal consistency reliability.

Using Electronic Data Collection Platforms to Assess Complementary and Integrative Health Patient-Reported Outcomes: Feasibility Project

BACKGROUND

The Veteran Administration (VA) Office of Patient-Centered Care and Cultural Transformation is invested in improving veteran health through a whole-person approach while taking advantage of the electronic resources suite available through the VA. Currently, there is no standardized process to collect and integrate electronic patient-reported outcomes (ePROs) of complementary and integrative health (CIH) into clinical care using a web-based survey platform. This quality improvement project enrolled veterans attending CIH appointments within a VA facility and used web-based technologies to collect ePROs.

OBJECTIVE

This study aimed to (1) determine a practical process for collecting ePROs using patient email services and a web-based survey platform and (2) conduct analyses of survey data using repeated measures to estimate the effects of CIH on patient outcomes.

METHODS

In total, 100 veterans from one VA facility, comprising 11 cohorts, agreed to participate. The VA patient email services (Secure Messaging) were used to manually send links to a 16-item web-based survey stored on a secure web-based survey storage platform (Qualtrics). Each survey included questions about patient outcomes from CIH programs. Each cohort was sent survey links via Secure Messaging (SM) at 6 time points: weeks 1 through 4, week 8, and week 12. Process evaluation interviews were conducted with five primary care providers to assess barriers and facilitators to using the patient-reported outcome survey in usual care.

RESULTS

This quality improvement project demonstrated the usability of SM and Qualtrics for ePRO collection. However, SM for ePROs was labor intensive for providers. Descriptive statistics on health competence (2-item Perceived Health Competence Scale), physical and mental health (Patient-Reported Outcomes Measurement Information System Global-10), and stress (4-item Perceived Stress Scale) indicated that scores did not significantly change over time. Survey response rates varied (18/100, 18.0%-42/100, 42.0%) across each of the 12 weekly survey periods. In total, 74 of 100 participants provided ≥1 survey, and 90% (66/74) were female. The majority, 62% (33/53) of participants, who reported the use of any CIH modality, reported the use of two or more unique modalities. Primary care providers highlighted specific challenges with SM and offered solutions regarding staff involvement in survey implementation.

CONCLUSIONS

This quality improvement project informs our understanding of the processes currently available for using SM and web-based data platforms to collect ePROs. The study results indicate that although it is possible to use SM and web-based survey platforms for ePROs, automating scheduled administration will be necessary to reduce provider burden. The lack of significant change in ePROs may be due to standard measures taking a biomedical approach to wellness. Future work should focus on identifying ideal ePRO processes that would include standardized, whole-person measures of wellness.

Psychometric properties of the perceived stress scale in a community sample of Chinese

BACKGROUND

The Perceived Stress Scale (PSS) is a globally used and self-report scale measuring perceived stress. Three versions of PSS (PSS-14, PSS-10 and PSS-4) are available which comprise 14, 10 and 4 items respectively. However, the Chinese version of the PSS has not yet been validated in a large community-based general population. The aims of this study were to evaluate the psychometric properties of the Chinese PSS in a large community-based general population and to compare the appropriateness of the three versions of PSS.

METHODS

A total of 9507 adults with at least a junior high school education and completed PSS-14 from the China Health and Nutrition Survey were involved in this study. The internal consistency reliability of PSS was assessed using Cronbach's alpha coefficient and confirmatory factor analysis was employed to test the construct validity. Modification index was used for model extension and the critical ratio was used for model restriction.

RESULTS

The internal consistency coefficients were satisfactory for PSS-14 and PSS-10, but not for PSS-4. The corresponding Cronbach's alpha were 0.830, 0.754 and 0.473 respectively. A 2-factor structure was confirmed for the PSS-14 and PSS-10, and all items' standardized factor loadings exceeded 0.4 for either negative or positive factors. Given that item 12 loaded on both negative and positive factors for PSS-14 and the goodness of fit for PSS-14 was not acceptable, PSS-13 (PSS-14 excluding item 12) was studied. The construct validities of PSS-13 and PSS-10 were satisfactory, but the goodness of fit for PSS-10 were better than that for PSS-13.

CONCLUSIONS

PSS-13 (PSS-14 excluding item 12) and PSS-10 have satisfactory psychometric properties. PSS-10 are more applicable to measure the perceived stress than PSS-13 in a large community-based general population in China.

Cohort profile: the Neonatal Intensive Care Unit Hospital Exposures and Long-Term Health (NICU-HEALTH) cohort, a prospective preterm birth cohort in New York City

PURPOSE

The Neonatal Intensive Care Unit Hospital Exposures and Long-Term Health (NICU-HEALTH) longitudinal preterm birth cohort studies the impact of the NICU exposome on early-life development. NICU-HEALTH collects multiple biospecimens, complex observational and survey data and comprehensive multisystem outcome assessments to allow measurement of the impact of modifiable environmental exposures during the preterm period on neurodevelopmental, pulmonary and growth outcomes.

PARTICIPANTS

Moderately preterm infants without genetic or congenital anomalies and their mothers are recruited from an urban academic medical centre level IV NICU in New York City, New York, USA. Recruitment began in 2011 and continues through multiple enrolment phases to the present with goal enrolment of 400 infants. Follow-up includes daily data collection throughout the NICU stay and six follow-up visits in the first 2 years. Study retention is 77% to date, with the oldest patients turning age 8 in 2019.

FINDINGS TO DATE

NICU-HEALTH has already contributed significantly to our understanding of phthalate exposure in the NICU. Phase I produced the first evidence of the clinical impact of phthalate exposure in the NICU population. Further study identified specific sources of exposure to clinically relevant phthalate mixtures in the NICU.

FUTURE PLANS

Follow-up from age 3 to 12 is co-ordinated through integration with the Environmental Influences on Child Health Outcomes (ECHO) programme. The NICU-HEALTH cohort will generate a wealth of biomarker, clinical and outcome data from which future studies of the impact of early-life chemical and non-chemical environmental exposures can benefit. Findings from study of this cohort and other collaborating environmental health cohorts will likely translate into improvements in the hospital environment for infant development.

TRIAL REGISTRATION NUMBERS

This observational cohort is registered with ClinicalTrials.gov (NCT01420029 and NCT01963065).

The Relationships Between Physical Health and Chronic Disease, Stress, and Resource Strain in Head Start Employees

Background: Emerging research indicates that Head Start employees often struggle with health issues and may not be able to model the healthy behaviors that they hope to instill in young children. The purpose of this study was to examine the relationships between perceived physical health and chronic disease, stress, financial-resource strain, and job type. Method: This study was conducted in a large, multi-site Head Start agency located across five counties in the American Midwest. Employees (N = 550) were invited to complete a 58-item questionnaire that assessed overall health and health behaviors, demographics, workplace environment, and interest in well-being programs. Bivariate analysis and multinomial logistic regressions were used to analyze the relationships between variables of interest and physical health. Findings: More than half (n = 295; 53.64%) responded, and one quarter of the employees (25.42%) reported poor or fair health. Poor and fair physical health was associated with the number of chronic conditions, difficulty paying for basic necessities, and perceived stress, but not job type. A high percentage of responding employees (83.34%) reported interest in well-being programs, yet interests varied significantly by health status. Employees with poor and fair health expressed interest in stress and emotional-coping programs, in contrast to the fitness interests of employees who reported good, very good, or excellent health. Conclusion/Application to Practice: To meet the needs of employees with poor or fair physical health, employers should offer health behavior modification programs that address the sources of employee stress, including financial-resource strain and mental health challenges.

Exploring the Time Trend of Stress Levels While Using the Crowdsensing Mobile Health Platform, TrackYourStress, and the Influence of Perceived Stress Reactivity: Ecological Momentary Assessment Pilot Study

BACKGROUND

The mobile phone app, TrackYourStress (TYS), is a new crowdsensing mobile health platform for ecological momentary assessments of perceived stress levels.

OBJECTIVE

In this pilot study, we aimed to investigate the time trend of stress levels while using TYS for the entire population being studied and whether the individuals' perceived stress reactivity moderates stress level changes while using TYS.

METHODS

Using TYS, stress levels were measured repeatedly with the 4-item version of the Perceived Stress Scale (PSS-4), and perceived stress reactivity was measured once with the Perceived Stress Reactivity Scale (PSRS). A total of 78 nonclinical participants, who provided 1 PSRS assessment and at least 4 repeated PSS-4 measurements, were included in this pilot study. Linear multilevel models were used to analyze the time trend of stress levels and interactions with perceived stress reactivity.

RESULTS

Across the whole sample, stress levels did not change while using TYS (P=.83). Except for one subscale of the PSRS, interindividual differences in perceived stress reactivity did not influence the trajectories of stress levels. However, participants with higher scores on the PSRS subscale reactivity to failure showed a stronger increase of stress levels while using TYS than participants with lower scores (P=.04).

CONCLUSIONS

TYS tracks the stress levels in daily life, and most of the results showed that stress levels do not change while using TYS. Controlled trials are necessary to evaluate whether it is specifically TYS or any other influence that worsens the stress levels of participants with higher reactivity to failure.

Perceptions of illness as predictive factors for perceived stress in patients participating in a cardiac rehabilitation program

Psychosocial risk factors, such as perceived stress, not only increase the risk of cardiovascular disease, but also act as barriers for treatment adherence and cardiac rehabilitation. In this study, we examined the predictive role of perceptions for illness to perceived stress in Iranian patients participating in a cardiac rehabilitation program. A cross-sectional study was conducted in 2017 to determine correlations of demographic variables and domains of illness perception with perceived stress, and to develop a predictive model for perceived stress. In total, 150 patients with cardiovascular disease, who were admitted to a cardiac rehabilitation center, completed the questionnaires. (i) demographic and health-related characteristics; (ii) the Perceived Stress Scale-14; and (iii) the Brief Illness Perception Questionnaire. The mean perceived stress was 16.2 (8.4), and five illness perception subscales - timeline, personal control, treatment control, understanding and emotional response - were associated with increased perceived stress. Variables in the multi-variate predictive model accounted for 48% of the total variance in perceived stress. The results demonstrated the value of assessing and managing the patients' perceptions of illness to reduce their perceived stress, which could support adherence to cardiac rehabilitation programs.

Body Silhouette Trajectories Over the Lifespan and Insomnia Symptoms: The Paris Prospective Study 3

Insomnia symptoms are highly prevalent and associated with several adverse medical conditions, but only few determinants, including non-modifiable ones, have been highlighted. We investigated associations between body silhouette trajectories over the lifespan and insomnia symptoms in adulthood. From a community-based study, 7 496 men and women aged 50–75 years recalled their body silhouette at age 8, 15, 25, 35 and 45, and rated the frequency of insomnia symptoms on a standardized sleep questionnaire. An Epworth Sleepiness Scale ≥11 defined excessive daytime sleepiness (EDS). Using a group-based trajectory modeling, we identified five body silhouette trajectories: a ‘lean-stable’ (32.7%), a ‘heavy-stable’ (8.1%), a ‘moderate-stable’ (32.5%), a ‘lean-increase’ (11%) and a ‘lean-marked increase’ (15.7%) trajectory. In multivariate logistic regression, compared to the ‘lean-stable’ trajectory, the ‘lean-marked increase’ and ‘heavy-stable’ trajectories were associated with a significant increased odd of having ≥1 insomnia symptoms as compared to none and of having a proxy for insomnia disorder (≥1 insomnia symptom and EDS). The association with the ‘lean-marked increase' trajectory’ was independent from body mass index measured at study recruitment. In conclusion, increasing body silhouette over the lifespan is associated with insomnia symptoms in adulthood, emphasizing the importance of weight gain prevention during the entire lifespan.

End-of-day reports of daily hassles and stress in men and women with opioid-use disorder: Relationship to momentary reports of opioid and cocaine use and stress

BACKGROUND AND AIMS

Stress can be validly assessed "live" or by a summary evaluation of the very recent past. Using smartphone-based ecological momentary assessment (EMA) combined with end-of-day (EOD) entries, we assessed the association between daily hassles, stressful events and use of opioids and cocaine, in opioid- and cocaine-using men and women.

METHODS

For up to 16 weeks, 161 outpatients in opioid-agonist treatment who reported cigarette smoking carried smartphones on which they reported stressful events (SEs) and drug use (DU) and completed an EOD questionnaire to report hassles encountered throughout the day, current perceived stress, cigarettes/day, and current mood. We compared EOD responses on days with and without SE and DU reports and on days when thrice-weekly urine drug screens indicated opioid or cocaine use or abstinence.

RESULTS

Participants (N = 161) made 11,544 EOD entries; EMA SEs were reported on 861 (7.5%) days, and DUs on 1685 (14.6%) days. The most frequently reported hassles in EOD entries were "not enough money" (31.4% of daily reports) and maintaining abstinence (18.7%). Total EOD hassles showed small but statistically significant associations [odds ratios (95% CIs)] with EMA SEs [1.09 (1.06-1.13)], DUs [1.08 (1.06-1.10)], and urine-positive opioid [1.06 (1.04-1.09)] and cocaine [1.03 (1.00-1.06)] results. Men and women had similar rates (mean/day (SD)) of hassles: men 2.25 (3.55); women 2.55 (3.76) (F_1,159 = 0.53, p = 0.47).

CONCLUSIONS

Daily hassles, reported at the end of the day, are associated with both same-day stressful events and drug use. Monitoring hassles and devising specific coping strategies might be useful therapeutic targets.

When Low Leisure-Time Physical Activity Meets Unsatisfied Psychological Needs: Insights From a Stress-Buffer Perspective

Background: Few studies have tested whether the stress-buffering effects of leisure-time physical activity (LTPA) depend on other resources, such as the satisfaction of basic psychological needs. Therefore, the present study examines the interaction between perceived stress, LTPA and psychological need satisfaction (PNS) on occupational burnout symptoms in a sample of Swiss workers.

Methods: The sample consisted of 306 employees (48% women; M_age = 42.9 years, SD = 14.1). Perceived stress was assessed with the Perceived Stress Scale, LTPA with the International Physical Activity Questionnaire, PNS (autonomy, relatedness, and competence) with the Need Satisfaction Scale, and occupational burnout symptoms with the Shirom-Melamed Burnout Measure. A hierarchical regression analysis and single slopes tests were performed to examine two- and three-way interactions.

Results: Stress was positively correlated with burnout, and negatively correlated with LTPA and PNS levels. LTPA was positively associated with PNS, and negatively correlated with burnout. A negative association existed between PNS and burnout. In the hierarchical regression analysis, all main effects, two- and three-way interactions were significant. People who engaged in more LTPA reported fewer burnout symptoms, if they reported high stress. However, the potential of LTPA to buffer stress was particularly evident in participants who reported low PNS.

Conclusion: If adult workers are exposed to elevated stress, they are particularly likely to show increased burnout levels if they report low LTPA in combination with low PNS, specifically a lack of autonomy, competence and relatedness.

Determining Factors for Stress Perception Assessed with the Perceived Stress Scale (PSS-4) in Spanish and Other European Samples

Objective: Stress perception depends on cultural and social aspects that vary from one country to another. One of the most widely disseminated methods of assessing psychological stress is the Perceived Stress Scale (PSS-4). Therefore, in order to identify these factors and their impact on mental health, the present study compares the PSS-4 results among three European countries (Great Britain, France and Spain). This study focuses on PSS-4 results within a Spanish sample to determine: (1) normative data, reliability and validity of PSS-4 in a Spanish sample and (2) how stress perception changes depending on cultural and social factors.

Methods: The data were obtained from a website representing a service of a smoking cessation program, the study represented a service that was open to all individuals. The number of participants were 37,451. They reported their age, gender, nationality, marital status, education and employment status, and completed two psychological questionnaires (PPS-4 and the anxiety and depression scales of the Symptom Checklist-90-Revised, SCL 90-R).

Results: The PSS-4 scores could differentiate between relevant sociodemographic variables (such as sex, age, nationality, marital status, education, parental status, employment status, and income class). The PSS-4 scores showed a positive correlation with the SCL 90-R anxiety and depression scales. The normed values for interpreting the PSS-4 scores are presented. The PSS-4 showed adequate internal consistency and reliability.

Conclusions: The PSS-4 is a useful instrument for assessing stress perception levels in the general population in different countries. Its internal consistency is sufficient for a 4-item scale.

The Positive Effect of Resilience on Stress and Business Outcomes in Difficult Work Environments

OBJECTIVE

To examine whether resilience has a protective effect in difficult work environments.

METHODS

A survey of 2063 individuals measured individual resilience, stress, burnout, sleep problems, likelihood of depression, job satisfaction, intent to quit, absences, and productivity. It also measured work characteristics: job demands, job influence, and social support. Multivariate and logistic regression models examined the main effects and interactions of resilience and job characteristics.

RESULTS

High strain work environments (high demand, low influence, and low support) have an unfavorable effect on all outcomes. Resilience has a protective effect on all outcomes. For stress, burnout, and sleep, higher resilience has a more protective effect under low-strain conditions. For depression, absence and productivity, resilience has a more protective effect when job strain is high.

CONCLUSIONS

Workers with high resilience have better outcomes in difficult work environments.

The German version of the Perceived Stress Scale - psychometric characteristics in a representative German community sample

BACKGROUND

The Perceived Stress Scale Cohen (J Health Soc Behav 24:385-96, 1983) is a widely and well-established self-report scale measuring perceived stress. However, the German version of the PSS-10 has not yet been validated. Thus, the purposes of this representative study were to psychometrically evaluate the PSS-10, and to provide norm values for the German population.

METHODS

The PSS-10 and standardized scales of depression, anxiety, fatigue, procrastination and life satisfaction were administered to a representative, randomly selected German community sample consisting of 1315 females and 1148 male participants in the age range from 14 to 90 years.

RESULTS

The results demonstrated a good internal consistency and construct validity. Perceived stress was consistently associated with depression, anxiety, fatigue, procrastination and reduced life satisfaction. Confirmatory factor analysis revealed a bi-dimensional structure with two related latent factors. Regarding demographic variables, women reported a higher level of stress than men. Perceived stress decreased with higher education, income and employment status. Older and married participants felt less stressed than younger and unmarried participants.

CONCLUSION

The PSS-10 is a reliable, valid and economic instrument for assessing perceived stress. As psychological stress is associated with an increased risk of diseases, identifying subpopulations with higher levels of stress is essential. Due to the dependency of the perceived stress level on demographic variables, particularly age and sex, differentiated norm values are needed, which are provided in this paper.