Unit VIII Article Review
Instructions
Use the CSU Online Library to find an academic journal article that applies social psychology to stress and/or health outcomes. In researching articles, choose one that will help you complete the assignment. Be sure that the article interests you and that it presents opportunity for improving stress and/or health outcomes. Then write a paper addressing the following prompts concerning the article you selected.
Part I: Article Summary
Explain why you picked the article you selected for this assignment. Include a description of how and why the article’s focus captured your interest.
Describe the previous research related to your article. Usually, this information will be under the “Introduction” section or be in the paragraphs before the “Method” section. Here you need to summarize the information, such as introductory descriptions of previous, related research and the authors’ ideas about why the article’s study needs to be conducted. Be sure to identify how the main topic can be connected to social psychological concepts. Do not discuss the article’s study design just yet.
Describe the participants of the research article you read. In your description, include demographic information (e.g., age, gender, race, ethnicity, employment status, college status, or geographic location). You should also include whether the participants were compensated for their participation or not. You must address each of these components to the extent that they are included in the method section of your article.
Explain the research methodology utilized in the article. You will include whether the article’s study used surveys or inventories, individual or group interviews, case studies, laboratory tasks, or naturalistic observations. If your study was an experiment and/or utilized special machinery, you will also provide detailed explanation of how it was constructed and what it measured.
Summarize the findings of the article. You can find this information in the results section. Some information might display findings in tables and charts, but these should not be replicated in your essay. Be thorough and concise when describing the findings in a narrative format.
Summarize what your article’s authors said in the discussion and/or conclusion sections. This information might be found under discussion and conclusion headings, or it might be in paragraphs near the end of the article with no distinguishing heading. A discussion section is usually interpretations of findings (i.e., what do they mean), and a conclusion section is generally focused on author ideas about why the findings occurred. There could be overlaps. If your article has both sections, you will summarize them both.
Part II: Application and Extension
Describe three different theories, concepts, or principles that were covered in your selected article and in the course textbook. The information can be from any chapter in the textbook, but you must reflect influence of the social environment and only one can be directly stress and/or health related. The other two need to come from previous units. Additionally, these three should be distinct, and they must be described in clear and succinct statements with accompanying explanations of how they relate specifically to the article.
Explain one way that your article has real-world application. To have real-world impact means that a study’s findings are used to make a difference, not that they can be related to phenomena that exist in the real world. You will need to provide specifics about what might be done with the findings.
Describe one way that positive psychology concepts could be used to improve the stress and/or health issues in your article. Your answer should emphasize how to enhance one’s subjective well-being using aspects of the PERMA approach.
Explain something related to your selected article’s focus that the researchers did not cover in their study and that you would like to learn more about. Your answer should not be a critique of the article, but a way to extend it. Be sure to describe what you want to learn more about, why you are interested in it, and how it relates to the article’s focus.
Your paper should be at least three pages in length. You must use the article you are discussing as an external reference in your paper. In addition, you must use your textbook and at least one other source as a reference. All sources used, including the textbook, must be referenced; paraphrased and quoted material must have accompanying citations. Please format your paper and all citations in accordance with APA guidelines.
Stigma on First Responders During COVID-19
Tara Rava Zolnikov
National University and California Southern University
Frances Furio
California Southern University
During the pandemic, first responders were at an increased risk of being stigmatized because of their
direct exposure to COVID-19; stigmatization is an undesirable stereotype that can contribute to a myriad
of adverse effects, including, but not limited to, anxiety, depression, devaluing, rejection, stress, health
problems, exposure to risks, and limiting protective factors. The objectives of this research were to
understand stigma on first responders during the COVID-19 pandemic as well as the consequences of
stigma on first responder’s mental health. A qualitative phenomenological study used semistructured
interviews to understand the experiences of first responders during the pandemic. This study included a
convenience sampling of 31 first responders (e.g., physicians, nurses, paramedics, police officers,
firefighters, etc.) located worldwide. First responders reported feelings of isolation, lack of support and
understanding by family or friends, decreased or forced removal in immediate social interaction (e.g.,
within family and friend circles), sentiments of being infected or dirty, increased feelings of sadness and
anxiety, and reluctance to ask for help or get treatment (e.g., self-approval of being isolated). By
answering these research questions, this information highlighted additional challenges that may be faced
by first responders aside from being a frontline worker during a pandemic, which is equally stressful. By
understanding the role of stigma, public health practitioners during pandemics or emergency situations
can seek to diminish it.
Keywords: COVID-19, coronavirus, first responders, health care workers, stigma
On March 11, 2020, the World Health Organization (2020)
characterized the newly emerging respiratory illness, coronavirus
2019 (COVID-19), as a global pandemic. COVID-19 had rapidly
spread across the world, creating a surge of cases in countries like
Italy, Iran, South Korea, and the United States. Pandemics and
disease outbreaks pose significant threats to human health as well
as contribute to adverse mental health effects because of drastic
life changes along with the inability to predict daily events (Pike,
Tomaney, & Dawley, 2010). Anxiety, stress, and fear felt by
people during the coronavirus pandemic was real and overwhelm-
ing, resulting in strong emotional reactions in adults and children
(Centers for Disease Control and Prevention, 2019). The culmina-
tion of these reactions could be directed at first responders, who
were at the forefront of treating people affected by the disease and
sequentially considered the most exposed population (Adhanom
Ghebreyesus, 2020; Ehrlich, McKenney, & Elkbuli, 2020).
During the pandemic, first responders were at an increased risk
of being stigmatized (Adhanom Ghebreyesus, 2020; Ehrlich et al.,
2020), which is an undesirable stereotype that reduces an accepted
person to a tainted one (Goffman, 1963). Stigma has several
components, including stereotyping, discrimination, labeling, sta-
tus loss, and separation (Link & Phelan, 2001). Stigmatization can
negatively impact individuals faced with it, especially if stigma has
become internalized (Drapalski et al., 2013). Stigmatization is
problematic and can contribute to a myriad of adverse effects,
including, but not limited to, anxiety, devaluing, rejection, expo-
sure to risks, and limiting protective factors (Link & Phelan, 2006).
Stigma has been shown to increase stress among the individuals
who experience it (Major & O’Brien, 2005) as well as depression
(Benoit, McCarthy, & Jansson, 2015). Stigma can impact an
individual’s self-esteem and their overall achievements (Major et
al., 2005). Studies have shown that low self-worth and negative
health outcomes are both potential outcomes of stigma (Benoit et
al., 2015).
During the COVID-19 pandemic, health care workers and first
responders described experiencing stigma in their communities.
Amid this crisis, a qualitative phenomenological study was con-
ducted to understand the experiences of first responders during the
pandemic; this is the first study of its kind to review the effects of
stigma on first responders in any pandemic. This study used a
convenience sampling of first responders (e.g., physicians, nurses,
Editor’s Note. This article received rapid review due to the time-sensitive
nature of the content. Our standard high-quality peer review process was
upheld throughout.—PWC
This article was published Online First September 17, 2020.
X Tara Rava Zolnikov, Department of Community Health, National
University, and Department of Behavioral Sciences, California Southern
University; X Frances Furio, Department of Behavioral Sciences, Cali-
fornia Southern University.
The authors have nothing to declare in the conception, development,
writing, and submission of this research.
The authors acknowledge and thank all the first responders that are
sacrificing so much to combat the pandemic.
This research and manuscript did not receive funding.
Correspondence concerning this article should be addressed to Tara
Rava Zolnikov, Department of Community Health, National University,
678 Aero Court, San Diego, CA 92123. E-mail: [email protected]
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Stigma and Health
© 2020 American Psychological Association 2020, Vol. 5, No. 4, 375–379
ISSN: 2376-6972 http://dx.doi.org/10.1037/sah0000270
375
https://orcid.org/0000-0002-0106-1214
https://orcid.org/0000-0002-0810-8097
mailto:[email protected]
http://dx.doi.org/10.1037/sah0000270
paramedics, police officers, firefighters, etc.) who discussed their
personal experiences during the pandemic. Highlighted topics of
discussion focused on treatment, stigma, feelings, and mental
health. The expectation of this research was to upend aspects
related to adverse mental health in a vital working population
during the pandemic.
Method
A qualitative study was conducted to understand and explore the
experiences of health care workers and first responders during the
COVID-19 pandemic. This study used a descriptive phenomeno-
logical approach, which has been continuously described as a
valuable research tool and strategy to understand the lived expe-
riences of participants related to a phenomenon (Neubauer, Wit-
kop, & Varpio, 2019; Marques & McCall, 2005; Husserl, 1980);
the aim of this type of research is to identify the common themes,
factors, or components related to a phenomenon to better under-
stand the perspectives of those who have experienced it (Marques
& McCall, 2005). A phenomenological study looks at both what
was experienced and how it was experienced (Neubauer et al.,
2019). This method was utilized for this study because first re-
sponder experiences offer a unique perspective during the pan-
demic, although they are not authorities on pandemic stigma, in
general.
Health care workers and first responders were selected as the
target population. This selection was due to the fact that these
individuals have a unique position within this pandemic because
they are likely the population most exposed to COVID-19 during
this time. Inclusion criteria for this study was: above the age of 18
years, health care worker or first responder, and worked during the
COVID-19 pandemic. Participants were recruited through conve-
nience sampling, which used the Facebook platform; participants
were then screened, selected, and interviewed via Zoom (per social
distancing recommendations by the Centers for Disease Control
and Prevention) in a private setting and format, during which
questions reviewed challenges faced during the pandemic. After
interviews, the data were then analyzed via hand coding, in which
themes emerged and presented themselves through repetition.
Themes were then made into a codebook, which were used to
review all quotes related to the subject matter that directly
correlated to answering the research questions. This thematic
analysis followed the Moustakas (1994)–modified Van Kaam
(1966) method.
All qualitative research must provide measures to ensure valid-
ity of the data in the research. In this case, the researchers estab-
lished trustworthiness through credibility, multiple participant per-
spectives, peer debriefing and review, reflexive journaling, and
field notes. Credibility was gained through triangulation of sources
and member checking. Multiple participant perspectives were
sought when female and males of various ages in different parts of
the world working in different occupations were all included to
participate in the interviews. Peer debriefing and review occurred
before and after developing interview questions and analyzing
themes in the data. Reflexive journaling and field notes occurred in
a diary, which was used to report on questions related participant
reactions and impressions of each interview. That said, limitations
in all research exists. Limitations of this study included the pos-
sibility of nontransferable results to other first responders in the
world, researcher personal bias (e.g., mental health researcher),
and research participant bias.
The study protocol and ethics review were approved by Cali-
fornia Southern University. All participants signed informed con-
sent prior to the commencement of the interviews and audio
recording. Codes were immediately assigned to every participant
to ensure deidentified data collection.
Results
Participants’ answers concluded various challenges related to
treatment, stigma, feelings, and mental health. Participants de-
scribed factors that were associated with stigma, including feelings
of isolation, lack of support and understanding by family or
friends, decreased or forced removal of immediate social interac-
tion (e.g., within family and friend circles), sentiments of being
infected or dirty, increased feelings of sadness and anxiety, and
reluctance to ask for help or get treatment (e.g., self-approval of
being isolated).
Participants
A total of 31 health care workers and first responders were
interviewed for this study. The mean age was 36.129 years, with a
range between 23 and 57 years. In relation to gender, 18 partici-
pants identified as female, and 13 participants identified as male.
Participants were located worldwide, including the United States
(28), Kenya (one), Ireland (one), and Canada (one). Ethnicities
included African/Kenyan, Arab/Palestinian, Caucasian, Cauca-
sian/Russian, Caucasian/Iranian, and Caucasian/Irish. Of these, 18
of the participants were married, and 13 of the participants were
single. Sixteen of the participants had children, with an average of
2.25 children per subject, a median of 2.5 children, and a range of
one to four children.
The education levels of participants included high school (one),
some college (four), associate degrees (six), bachelor degrees (13),
graduate degrees (three), and medical school educations (four). All
participants worked within roles as health care workers or first
responders during the COVID-19 pandemic; there were physi-
cians/doctors (three), nurses (14), a nurse tech, a behavioral ther-
apist, an orthodontist, a dialysis technician, a technician in medical
surgery, a data specialist, a paramedic, firefighters and paramedics
(three), a firefighter and emergency medical technician, and police
officers (three).
Experiencing Stigma
In the cohort of interviewees, many participants discussed as-
pects of stigma, although never directly associated themselves with
stigma or being stigmatized. “I haven’t had any [stigma]. . . . I
[did] stay at the abandoned other house that we have . . . for about
2 weeks and, you know, tried not to come home” (P4.5). Partici-
pants used various negative words to describe how they felt during
the pandemic, “like I was infected, . . . like I was dirty” (P3.3) or
“contaminated” (P9.2) and how they were regarded: “They treat
me like I had the plague” (P4.1). These feelings were hard to
dismiss,
[I feel] “dirty.” My clothes are “dirty”, my hair is “dirty”, my shoes
are “dirty,” . . . everything with me has been “stained” with COVID
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376 ZOLNIKOV AND FURIO
19 . . . including my body. I know that the “dirtiness” of it all isn’t me
personally, but it is hard to turn away and not take it personal and feel
helpless. . . . I guess I just do not want to feel dirty anymore; it’s
draining. (P7.3)
Participants believed that being isolated was justified, “Well, I
mean, . . . it’s understandable. People were just scared, I think”
(P95). This negatively affected participants: “Well, initially I was
quite sad to [be treated differently] because it was all of a sudden.
But then . . . it becomes the norm” (P1.2).
Isolation and directed fear came from different layers of people,
including the general public, friends, and family. The public had an
interesting response to first responders. This reaction ranged and
included arm’s-length support. “[I received] cards, like kindness
cards, words written to us. Loved ones sending food to us. . . . And
just encouragement from the community” (P1.1). Alternatively,
the response also included aggressive behavior: “. . . She pulled
down her mask and coughed at us” (P10.3). These situations
contributed to first responders not wanting to declare their occu-
pations and place of work.
If people would ask me what I did for work, I was kind of proud to
say, you know, I work at the hospital. . . . [Now] I don’t make a habit
of telling anybody I work at the hospital, just because most people get
kind of freaked out. (P4.1)
In addition to the public, first responders most often experienced
stigma from the people closest to them—friends and family mem-
bers. “Usually people start to become very cognizant and aware
exactly where you’re standing so they don’t touch those things.
Yeah, I’m not allowed at my parent’s house. [Friends] call me, but
nobody wants me over [and] of course, nobody’s coming over”
(P1.2). And friends created a physical separation between first
responders and themselves:
. . . It’s like everyone would jump back 10 feet. Even my mom would
stay away from me. When I did come home, . . . I’d be carrying on a
conversation with [my mom], and if I took a step forward to like pick
something up, she would take a step back, kind of like reflexively, like
jumping back [and keep] this imaginary bubble. And in my house, I
wasn’t [even] allowed in the kitchen area. (P4.1)
Alienation frequently occurred because first responders found it
difficult to find safe places to go and often found comfort in
solitude:
I don’t enjoy people as much anymore; . . . like even my family will
get together and I sit there but then I’m really annoyed with all of
them. . . . I don’t want to engage. And I don’t want to have conver-
sations and I sometimes just want to go home and be like—where’s
the one place that nobody will be that I can go? I want to grab my
wine and be alone. I don’t want to talk to anybody. . . . On my ride
home, which is like a 40-min ride, no radio, no, it was just silent.
(P3.2)
Others were convinced or coerced into quarantine or separation
from immediate family:
Nobody wanted to be around you. . . . When you have [a] hard day or,
you know, there’s a lot going on, you have a lot of stress, and then you
come home and then you’re treated like you’re, you know, a leper; . . .
it doesn’t make you feel very good; . . . there’s nobody to share
[anything] with. (P7.1)
Common words to describe emotions and feelings as a result of
being stigmatized, included “sadness” (P1.1), feeling “blue”
(P7.1), and “extremely stress[ed]” (P3.3) while living in a situation
that “is so demoralizing” (P9.4). These effects could be translated
to adverse mental health effects that are commonly associated with
stigma, such as depression, anxiety, and stress. Reactions to these
feelings included alcohol use. “I feel very isolated, lonely, de-
pressed even. I found my alcohol intake increased” (P11.1).
Participants described several solutions related to the stigma that
was faced during the COVID-19 pandemic. Participants mentioned
how communication was an important component to consider.
This included communication among colleagues: “Talk to your
colleagues or talk to somebody that you trust about what you’re
going through mentally, emotionally” (P1.1). This also included
communication among those in supervisor or managerial roles: “I
think there needs to be a lot more communication and honesty”
(P4.2). Participants also described the importance of health care
workers and first responders maintaining a connection with those
outside their professional roles, including other members of the
general population and those in their communities: “Just keep in
touch with these people, like they’re not diseased, . . . continue to
call them and keep talking with them; . . . people should make an
effort to continue to speak to these people” (P1.2).
Many participants described improvements related to education
and dissemination of science-based information related to the
COVID-19 pandemic as an important potential solution. “More
real education and less completely false news would be great”
(P3.3). “I think education could definitely help next time” (P6.2).
Participants stated that “more facts” would be helpful (P3.4). “The
biggest thing is misinformation” (P6.2). “Public awareness cam-
paigns and things like that could do a lot of good” (P7.2). “Public
health education, educating the public on the modes of transmis-
sion of some conditions like this one” (P9.4). “I don’t think there
really is anything you can do aside from educating the public”
(P10.4).
Even when discussing potential solutions, participants still ac-
knowledged the challenges and difficulties that came to stigma
faced by health care workers and first responders. “How do you
simultaneously convey the message that this is something that
needs to be taken seriously as well as then downplay the effect of
people who are most exposed?” (P4.4). The messages conveyed
how difficult it would be tackling stigma in first responders:
“You’re always gonna have people that are gonna be rude; . . .
there’s always gonna be the people that think that you’re icky and
infected, and I don’t think we’ll ever get away from that” (P5.1).
Discussion
First responders have a unique position as first-line response to
COVID-19 patients, which results in an increased likelihood for
exposure to the virus. Because of this position, mental health
problems, such as anxiety, depression, insomnia, and stress, have
been revealed in this population (Liu et al., 2020). A 2-fold mental
health problem occurs when adding stigma as well; the first layer
of adverse mental health occurs because of direct exposure to the
disease within a work setting, and the second layer occurs with
stigmatization faced outside the work setting. Poor mental health
for the most important line of defense against the pandemic is
important to address because it is responsible for long-term work
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377STIGMA ON FIRST RESPONDERS DURING COVID-19
absence, which makes it difficult to tackle and curb the results of
the pandemic (Blank, Peters, Pickvance, Wilford, & Macdonald,
2008).
In addition to the negative effects experienced, major issues
described in this study were lack of support and isolation, which
have been linked to anxiety, restlessness, emptiness, marginality,
decreased sleep, decreased immunity and inflammatory control,
and higher morbidity rates (Cacioppo, Hawkley, Norman, & Bern-
tson, 2011; Weiss, 1973). Finally, stigma can upend self-esteem
and sense of meaningful existence or belonging and can result in
social pain and distress (Almutairi, Adlan, Balkhy, Oraynab, &
Clark, 2018).
It is important to delve into the depth of stigma. Individuals
perceiving stigma from community versus internalizing stigma can
contribute to various mental health outcomes. In this study, public
stigma occurred in various places with participants (e.g., grocery
stores, gas stations, driving, etc.). This is important to discuss
because it became internalized by participants, who described
feeling dirty or infected and believed social outcasting was war-
ranted. Internalized stigma is a self-agreement with negative ste-
reotypes and often results in personal rejection and distress (Quinn
et al., 2014). Adverse mental health outcomes that can arise from
internalizing stigma include depression, avoidant coping, social
avoidance, decreased hope and self-esteem, psychiatric symptoms,
and decreased mental health support (Drapalski et al., 2013).
Moreover, internalized stigma can mediate the relationship be-
tween public stigma and mental health treatment (Brown et al.,
2010). As a result, suggesting internalized stigma occurred in first
responders during the pandemic is of utmost concern because this
can contribute to the development of negative attitudes and lack of
mental health treatment in an at-risk population.
In regard to reducing stigma, many participants described
improvements needed related to the lack of accurate informa-
tion being shared with the media. Interviews with health care
workers and first responders demonstrated the need for im-
provements related to education and dissemination of science-
based information related to the COVID-19 pandemic as an
important potential solution. Literature has described the pro-
liferation of misinformation related to the COVID-19 pandemic
(Pennycook, McPhetres, Zhang, Lu, & Rand, 2020). Many
individuals receive information related to important global is-
sues from social media outlets, including, but not limited to,
YouTube, Twitter, and Instagram (Cinelli et al., 2020). Litera-
ture has described the panic related to the COVID-19 pandemic
as spreading faster among media outlets than it has as a virus in
the community (Depoux et al., 2020).
Reporting in the media is said to have a significant impact on the
public (Depoux et al., 2020). When faced with inaccurate infor-
mation, individuals can be more likely to overreact, underreact, or
turn to infective solutions and remedies (Pennycook et al., 2020).
Literature has shown that increases in media exposure related to
COVID-19 content is correlated with increases in stress and anx-
iety among individuals, in general (Garfin, Silver, & Holman,
2020). This is a likely scenario that contributes to the stigma of
first responders during the pandemic.
Solutions to this problem could include real-time and urgent
information being conveyed to the public while being mindful
of untoward exposure to the media (Garfin et al., 2020). The
goal is to reduce hysteria and mitigate the transmission of
misinformation (Depoux et al., 2020; Garfin et al., 2020).
Detecting inaccurate rumors, attitudes, and perceptions related
to COVID-19 will be required to effectively respond (Depoux
et al., 2020). Turning to health care providers, specifically, for
critical information related to the topic at hand could also be
helpful (Garfin et al., 2020). The acknowledgment of inaccurate
information and dissemination of science-based information
related to COVID-19 could potentially improve communication
and reduce the stigmatization that health care workers and first
responders have described in this study.
Conclusion
Facing stigma is often invisible, in that the effects are not often
recognized; despite the inability to see it, experiencing stigma can
be dangerous to health while also diminishing the value of a person
through discrimination and loss of status by being devalued, re-
jected, and excluded (Link et al., 2006). The compounding adverse
mental health effects in an essential population used to fight the
pandemic turns an already challenging situation dire. By under-
standing how stigma affects first responders, blurred lines can start
to become visible, and public health practitioners now and in
future pandemics or emergency situations can seek to diminish it.
Future research could focus on understanding stigma, both within
individuals and perceived stigma through the community. This
research can highlight areas for interventions to modify and de-
crease negative attitudes that may exist (Rost, Smith, & Taylor,
1993). Other areas of interest can focus on understanding the
relationships between internalized stigma, coping strategies, and
mental health services used. For example, another qualitative study
could be implemented to reveal a baseline of information describ-
ing coping strategies and accessed mental health treatment in first
responders. Ultimately, this type of information could then be used
to support mental health needs in first responders during the
pandemic.
References
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CoV in Saudi Arabia. Journal of Infection and Public Health, 11,
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Parent Engagement in an Integrated Care Parenting Intervention to
Prevent Toxic Stress
Briana Woods-Jaeger, Julia E. Thompson, Angelique Foye-Fletcher, Emily Siedlik,
Ayanda Chakawa, Katie Dalbey, and Rupal C. Gupta
Children’s Mercy, Kansas City, Kansas City, Missouri
Objective: This study assessed parent engagement and satisfaction with an evidence-
based parenting intervention delivered within a pediatric primary care clinic serving
families at-risk for toxic stress. Method: Ten pilot study parent participants (all female;
80% African American; mean age � 26.1 years) completed sociodemographic, adverse
childhood experiences (ACEs) history, depression, social support, and session satis-
faction measures to assess parent characteristics and intervention satisfaction. Parent
attendance was assessed and thematic analysis of session notes was conducted to assess
parent engagement in intervention sessions. Results: Sixty percent of respondents had
elevated ACE scores (Total Score �4), and 27% of respondents had elevated Edin-
burgh (Total Score �10). Attendance in intervention sessions was inconsistent. The-
matic analysis indicated that parents demonstrated several engagement behaviors
during sessions they attended, including sharing opinions/disclosing information and
providing one’s point of view. Follow-through with activities recommended during
intervention sessions was more likely when linked to parents’ personal strengths or
concerns. Parents reported all session content as “helpful or “very helpful” and would
recommend the program to others. Conclusions: Parents experiencing risk factors for
toxic stress may face challenges in consistently attending integrated care parenting
intervention sessions but engage in sessions they attend. Strategies for engaging parents
at risk for toxic stress in a primary care-based parenting program include building from
parent strengths, addressing identified parent concerns, offering proactive support
including parent mental health promotion, and building trusting relationships.
Implications for Impact Statement
This is a small pilot study that assessed parent engagement in a parenting program
connected to infant well-child visits. The intervention was designed to promote respon-
sive caregiving by strengthening parents’ understanding of their infant’s behavior and
supporting parents in responding to their child’s emotional and physical needs. The
study found that building from parent strengths, responding to identified parent con-
cerns, offering proactive support (including parent mental health referrals), and building
trusting relationships may promote parent engagement.
Keywords: toxic stress, integrated primary care, parenting intervention, racial health
disparities, parent engagement
Supplemental materials: http://dx.doi.org/10.1037/cpp0000361.supp
Briana Woods-Jaeger, X Julia E. Thompson, X Angelique
Foye-Fletcher, Emily Siedlik, X Ayanda Chakawa, X Katie
Dalbey, and X Rupal C. Gupta, Children’s Mercy, Kansas City,
Kansas City, Missouri.
Katie Dalbey is now at the Operation Breakthrough,
Inc., Kansas City, Missouri.
This work was supported by the David Woods Kem-
per Foundation. The authors are grateful to the Two
Generations Thrive Community Advisory Board mem-
bers; Operation Breakthrough, Inc.; and, most impor-
tantly, the parents who willingly contributed their expe-
riences to inform this work.
Correspondence concerning this article should be ad-
dressed to Briana Woods-Jaeger, who is now at the De-
partment of Behavioral Sciences and Health Education, Em-
ory Rollins School of Public Health, 1518 Clifton Road NE,
Atlanta, GA 30322, USA. E-mail: [email protected]
.edu
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Clinical Practice in
Pediatric Psychology
© 2020 American Psychological Association 2020, Vol. 8, No. 3, 298–303
ISSN: 2169-4826 http://dx.doi.org/10.1037/cpp0000361
298
http://dx.doi.org/10.1037/cpp0000361.supp
https://orcid.org/0000-0001-9462-1227
https://orcid.org/0000-0001-5104-8184
https://orcid.org/0000-0001-5104-8184
https://orcid.org/0000-0001-6718-2433
https://orcid.org/0000-0002-7846-4871
https://orcid.org/0000-0002-7846-4871
https://orcid.org/0000-0002-3387-1879
mailto:[email protected]
mailto:[email protected]
http://dx.doi.org/10.1037/cpp0000361
Infancy is a critical period in a child’s life.
Early adverse childhood experiences (ACEs)
that put children at risk for toxic stress or “pro-
longed activation of stress response systems in
the absence of protective relationships” (Na-
tional Scientific Council on the Developing
Child, 2017) can have immediate and long-term
impacts on development, health, and quality of
life (Danese & McEwen, 2012). Children of
parents with histories of ACEs are at greater
risk for ACEs themselves (Randell, O’Malley,
& Dowd, 2015). The intergenerational cycle of
toxic stress can contribute to socioeconomic
and racial disparities in behavior, health, and
learning (Dawson-McClure, Calzada, & Brot-
man, 2017).
Responsive caregiving early in life, which is
characterized by attention to children’s emo-
tional and physical needs (Morris et al., 2017),
can prevent some of the damaging effects of
toxic stress (Garner, 2013). However, many ra-
cial minority parents living in poverty are nav-
igating the demands of child rearing while con-
fronted with compounding chronic stressors,
such as low-quality educational environments,
dangerous neighborhoods, lack of adequate and
accessible public services, and discrimination,
which can hinder responsive caregiving (Lakind
& Atkins, 2018). In addition, mothers and chil-
dren of color and lower socioeconomic status
experience numerous health disparities includ-
ing lower rates of breastfeeding, higher parent-
ing stress, higher infant disease burden, and
higher rates of maternal and infant mortality
(Bartick et al., 2017; Nomaguchi & House,
2013). Effective and accessible parent support
interventions have the potential to reduce socio-
economic and racial disparities for families of
color living in poverty (Dawson-McClure et al.,
2017).
Integrated primary care emphasizes coordi-
nation between behavioral health and primary
care providers in a patient-centered model of
care (McDaniel et al., 2014). A meta-analysis of
interventions for parents of young children in
the primary care setting indicated overall im-
provements in parent– child interactions and
cognitively stimulating activities across inter-
ventions (Shah, Kennedy, Clark, Bauer, &
Schwartz, 2016). The integrated care model can
reduce barriers to parenting interventions, en-
hance intervention reach, and improve parent
engagement for families in poverty (Lakind &
Atkins, 2018).
Incredible Years Well-Baby (IYWB) is an
evidence-based parenting intervention specifi-
cally designed for use in primary care settings
(Webster-Stratton & Reid, 2010; see online sup-
plemental material for additional information
on IYWB). The purpose of this study was to
examine parent engagement and satisfaction
with IYWB within a pediatric clinic serving
families living in urban poverty with high levels
of ACEs. Engagement was defined as meaning-
ful participation both in interactions with pro-
viders and follow-through with intervention
recommendations (Haine-Schlagel & Walsh,
2015). Better understanding of engagement
within this population may guide implementa-
tion of integrated care parenting interventions in
pediatric settings that aim to reduce behavior,
health, and learning disparities among racial
minority families living in urban poverty.
Method
Study Design
The IYWB intervention was initiated as a
universal primary prevention intervention in a
pediatric clinic colocated with a Head Start in
the Midwest with approximately 90% of pa-
tients insured under Medicaid. To better under-
stand parent engagement in this integrated care
parenting intervention, we initiated the IY Well-
Baby pilot study. The hospital institutional re-
view board approved all study procedures.
Recruitment
Primary care providers in the clinic discussed
IYWB with caregivers at well visits and offered
a recruitment flyer describing the pilot study. If
parents expressed interest, they met with a
member of the research staff who reviewed the
study letter, enrolled the patient, and obtained
verbal consent. Once enrolled in the pilot study,
the caregiver participated in IYWB at each sub-
sequent well-child visit through 9 months of
age. IYWB interventionists included licensed
psychologists and licensed social workers. Pa-
tients were scheduled in-person or by phone for
their well visit and received a personal phone
reminder the business day before the appoint-
ment to encourage appointment attendance. Par-
299PARENT ENGAGEMENT IN INTEGRATED PRIMARY CARE
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ticipants received $20 for the baseline assess-
ment, a booklet on topics covered in the
sessions, and a small toy for each subsequent
visit. Participants received $30 for the postint-
ervention assessment.
Data Collection
Data sources include self-report baseline as-
sessments with IYWB pilot study participants,
self-report session satisfaction data, and inter-
vention session progress notes. Participants
completed self-report questionnaires before,
during, and after intervention completion elec-
tronically or on paper. Baseline questionnaires
included a sociodemographic questionnaire, the
Expanded ACE Questionnaire for parent partic-
ipants (Cronholm et al., 2015), the Multidimen-
sional Scale of Perceived Social Support
(MSPSS; Zimet, Dahlem, Zimet, & Farley,
1988), and the Perceived Stress Scale (PSS;
Cohen, Kamarck, & Mermelstein, 1983). At
each well-visit, parents completed the Edin-
burgh Depression Scale (EPDS; Cox, Holden,
& Sagovsky, 1987) and the IYWB Session Sat-
isfaction Questionnaire. The licensed psycholo-
gist and social worker IYWB interventionists
were qualified to respond to any safety concerns
(i.e. suicidality) that were indicated by the
EPDS. Postintervention questionnaires were the
same as baseline with the exception of the Ex-
panded ACE Questionnaire, which was only
given at baseline. See online supplemental ma-
terial for additional information on specific
measures.
The IYWB interventionist completed a stan-
dardized session note for each IYWB encoun-
ter. Drawing from Haine-Schlagel and Walsh’s
(2015) work, these notes were used to explore
parent engagement using the following behav-
ioral indicators of engagement: sharing opin-
ions or disclosing information, asking ques-
tions, providing one’s point of view on a
problem or solution, engaging in therapeutic
activities such as games and role plays, and
following through with suggested at-home ac-
tivities and techniques. Coding was completed
by one of the IYWB interventionists after the
completion of the study. A coding key with
operational definitions for each parent engage-
ment indicator was used to thematically analyze
behavioral descriptions of in-session parent en-
gagement recorded in the session notes. The
coder was not blind to session number or inter-
ventionist.
Data Analysis
Descriptive statistics summarized key so-
ciodemographic characteristics and mean sur-
vey scores for all participants at baseline. Due
to a high rate of attrition, within-group analyses
were not conducted to evaluate changes from
baseline to postintervention. To assess parent
attendance, we calculated the percent of ses-
sions attended. Participant satisfaction re-
sponses were summarized at each session and
for the program overall. To assess parent en-
gagement, we conducted a deductive thematic
analysis on session notes by coding parent par-
ticipation during the session using the behav-
ioral indicators outlined above (Haine-Schlagel
& Walsh, 2015).
Results
Participant Descriptives
Eleven participants enrolled and completed
some or all baseline surveys. Only 10 of the 11
enrolled participants provided sociodemo-
graphic data. See Table 2 in the online supple-
mental materials for further details regarding
sociodemographic characteristics and baseline
indicators of IYWB research participants. Of
the 10 caregiver participants who provided so-
ciodemographic data, all were female, with a
mean age of 26.1 years old (SD � 4.0). Eighty
percent (80%) of participants identified as Af-
rican American or Black, and 10% identified as
Hispanic. Seventy percent reported high school
graduate or less as the highest degree of educa-
tional attainment and 60% were unemployed.
Sixty percent of participants had 1–3 children
under 18 years of age in the household. The
remaining 40% had 4–6 children under 18
years of age in the household. Sixty percent of
respondents had elevated ACE scores of 4 or
higher at enrollment (See Table 3 in the online
supplemental materials for further details), and
27% of respondents had elevated Edinburgh
scores of 10 or higher. The mean total Perceived
Stress Scale (PSS) score for all participants was
15.1 (SD � 5.6), which is above the norm table
mean for females of 13.7 (SD � 6.6). Respon-
dents reported high support on the Multidimen-
300 WOODS-JAEGER ET AL.
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sional Scale of Perceived Social Support
(MSPSS; M � 5.5, SD � 1.3).
Parent Engagement
Overall, the thematic analysis indicated that
parents engaged in the IYWB visits primarily
through (a) sharing opinions or disclosing infor-
mation and (b) through providing one’s point of
view on a problem or solution. For example,
one note indicated how a parent shared infor-
mation and indicated how she could use IYWB
tools to support a solution:
Parent expressed some concern that the daycare was
overfeeding the baby. She set a goal to use the IY home
activity handout “A Typical Day with your Baby” to
record feeding, diaper changes, fussy times, play and
alert times, and bowel movements in order to educate
the baby’s day care workers about her needs.
Another parent disclosed mental health chal-
lenges she was having, thus providing an op-
portunity for the IYWB interventionist to col-
laboratively problem-solve with her:
Parent also described struggles with fatigue, competing
demands, limited social support, and depressive symp-
toms. IYWB interventionist provided psychoeducation
about depression and assessed if Parent has adequate
professional resources to support dealing with these
issues and determined that Parent does not attend
standing weekly appointment with a therapist. After
some problem solving with IYWB interventionist, Par-
ent reported planning to attend next therapy session
scheduled for next week.
The thematic analysis also indicated that par-
ents followed through with suggested at-home
activities or techniques that were linked to per-
sonal concerns/problems or strengths that were
directly discussed during the visit, versus gen-
eral recommendations/strategies. Examples of
follow through included:
(1) Parent reported completing the “Supports Hand”
home practice activity with her niece over the holidays
as an activity. (Prior visit: Parent described a number
of positive social supports, including her boyfriend,
mother, and step-mother.)
(2) Parent states utilizing her deep breathing in mo-
ments of stress and/or anxiety. (Prior visit: Parent set a
goal to utilize deep breathing technique when [Parent]
feels overwhelmed by crying and chaos in the home.)
The session note documentation typically
noted that parents were engaged in watching the
video vignettes (e.g., made comments on points
of interest or relatable content, answered fol-
low-up questions about the content presented,
highlighted examples of problem solving pre-
sented in the vignette). However, parents asking
questions and engaging in therapeutic activities
such as games and role plays was rarely noted in
the encounter documentation.
Parent Attendance
Overall, 73% percent of parents attended
50% or more of the six IYWB visits. While all
participants were recruited at their newborn
visit, only 82% participated in the IYWB new-
born session (two participants were able to com-
plete the enrollment assessments but not the
IYWB session at the time of newborn visit),
36% participated in the 1 month session, 55% in
the 2 months session, 55% in the 4 months
session, 45% in the 6 months session, and 45%
in the 9 months session. The mean number of
sessions attended was 3 (SD 1.3). No parents
completed all sessions.
Parent Satisfaction
Parents reported finding all session content to
be “Helpful” or “Very Helpful,” with the ex-
ception of the 6 months session for which one
participant felt “Neutral” about the content. Par-
ents reported finding the video examples to be
“Helpful” or “Very Helpful” across all sessions
without exception. Parents endorsed high levels
of satisfaction with the interventionists’ teach-
ing of the program (80% reported intervention-
ist(s) teaching was “Excellent”) and their rela-
tionship with the interventionists (80% reported
relationship was “Above Average” or “Excel-
lent”). Eighty percent (80%) of participants in-
dicated that the feeling of overall support and
connectedness they felt since taking the pro-
gram was “Slightly Improved” or “Greatly Im-
proved.” All parents said they would recom-
mend IYWB to a friend or relative with a baby.
Discussion
For children at-risk for toxic stress due to
high levels of parent ACEs and living in pov-
erty, responsive caregiving early in life has the
potential to prevent toxic stress. Developing
effective parenting intervention engagement
strategies for racial minority parents with ACE
histories living in poverty provides an opportu-
nity to mitigate disparities in behavior, health,
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and learning through early intervention (Lakind
& Atkins, 2018). Data from the current study
support that building from parent strengths, re-
sponding to identified parent concerns, offering
proactive support (including parent mental
health referrals), and building trusting relation-
ships may promote parent engagement in struc-
tured behavioral health interventions and should
be examined in future parent engagement stud-
ies. Future research should also assess strategies
to promote other aspects of parent engagement
such as asking questions and engaging in ther-
apeutic activities such as games and role plays.
Potential strategies include providing more op-
portunities for brief, open discussion guided by
parents’ questions or concerns and setting aside
time for rehearsal of techniques.
Satisfaction and session attendance data indi-
cate that while intervention session attendance
is inconsistent, the majority of parents in our
sample participated in more than one session
and reported benefit and satisfaction from this
engagement. This suggests that providing par-
enting interventions flexibly (e.g., not requiring
attendance at all sessions) and offering them
universally to all parents within the pediatric
primary care setting may improve access. Fu-
ture research should examine the adequate dose
of IYWB to reduce risk and promote protective
factors among parents with ACE histories living
in poverty.
Limitations of the study include small sample
size and participant attrition which prevented
within-group analyses from being conducted.
Future research should examine recruitment and
retention strategies for research studies with this
population. We also did not measure exposure
to other interventions which may have modified
results. Despite these limitations, this study sug-
gests that while parents experiencing risk fac-
tors for toxic stress face challenges in consis-
tently attending integrated care parenting
intervention sessions, they report high satisfac-
tion with the intervention and engage in ses-
sions they attend. Strategies identified in this
study are promising approaches to improve ac-
cess and engagement in parenting interventions
for racial minority parents with ACE histories
living in poverty. Future studies should examine
if implementing these strategies improves out-
comes for parents and infants and reduces so-
cioeconomic and racial disparities for families
of color living in poverty.
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Accepted June 29, 2020 �
303PARENT ENGAGEMENT IN INTEGRATED PRIMARY CARE
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…
Reduced Positive Affect on Days With Stress Exposure Predicts
Depression, Anxiety Disorders, and Low Trait Positive Affect 7
Years Later
Gavin N. Rackoff and Michelle G. Newman
Pennsylvania State University
Positive emotions serve important functions for mental health. Susceptibility to reduced positive emotions in
the context of stress may increase risk for poor mental health outcomes, including anxiety and depressive
disorders and low overall levels of positive emotion. In an 8-day daily diary study within a larger panel study
(N � 1,517), we tested whether degree of reduction in time spent experiencing positive affect on days of stress
exposure predicted lower levels of positive affect and elevated risk for major depressive and anxiety disorders
(generalized anxiety disorder or panic disorder) 7 years later. Bayesian multilevel structural equation modeling
controlling for overall levels of affect, stress exposure, leisure time, sex, age, and past year diagnoses of
depression and anxiety disorders was conducted. Participants, on average, reported less time experiencing
positive affect on days with stressors compared to days without stressors. In addition, participants varied in the
extent to which their time spent experiencing positive affect differed across days with and without stressors.
Those who reported an especially reduced proportion of the day experiencing positive affect on days with
stressors also experienced lower positive affect and greater risk for major depressive disorder and anxiety
disorders 7 years later. These prospective associations suggest that between-person differences in the
within-person association between stress and positive emotions have implications for mental health years later.
The efficacy of preventive interventions could be improved by fostering resilience of positive emotions during
common stressful events.
General Scientific Summary
Positive emotions may promote mental health, yet they are depleted during exposure to stress. In an
experience sampling study, susceptibility to lowered positive emotions on days with stressors was
associated with low positive affect and depression and anxiety disorders 7 years later.
Keywords: stress, positive affect, depression, anxiety, experience sampling
Supplemental materials: http://dx.doi.org/10.1037/abn0000639.supp
Stress is a long-recognized risk factor for psychopathology, yet
many people who experience even extreme stress do not develop
mental health problems (e.g., Pietrzak & Cook, 2013). Research on
emotional experiences in the face of stress may inform models of risk
toward psychopathology. For example, experience sampling studies
have linked susceptibility to heightened negative emotion during
naturalistic stress with future depression (Charles, Piazza, Mogle,
Sliwinski, & Almeida, 2013; Parris, Cohen, & Laurenceau, 2011) and
anxiety (Charles et al., 2013). Depression and anxiety are also asso-
ciated with greater negative emotional responses to laboratory stres-
sors (e.g., Carthy, Horesh, Apter, & Gross, 2010; Guhn, Sterzer,
Haack, & Köhler, 2018). Susceptibility to heightened negative emo-
tion during stress may contribute to the frequency and intensity of
negative emotions, as well as the perception that negative emotions
are difficult to regulate. Accordingly, negative emotional stress reac-
tivity features in etiological models of depression (Hammen, 2005)
and anxiety disorders (Newman, Llera, Erickson, Przeworski, & Cas-
tonguay, 2013), conditions characterized by excesses of and difficulty
regulating negative emotions.
Positive emotions also serve important functions for mental
health. For example, the broaden-and-build theory states that pos-
itive emotions widen the scope of thought and attention (Fredrick-
son, 2001). Positive emotions may therefore protect against psy-
chopathology by curtailing perseverative thought patterns such as
This article was published Online First September 10, 2020.
X Gavin N. Rackoff and X Michelle G. Newman, Department of
Psychology, Pennsylvania State University.
The collection and sharing of the data used in this research was approved
by the Institutional Review Board at the University of Wisconsin–Madison.
Because this study was a secondary analysis of publicly available data, no
additional Institutional Review Board approval was needed. The collection
of the data used in this research was supported by grants from the John D.
and Catherine T. MacArthur Foundation Research Network and National
Institute on Aging (P01-AG020166 and R01-AG019239). The original
investigators and funding agencies are not responsible for any analyses or
interpretations reported in this article. The authors have no conflicts of
interest or financial disclosures. We thank Michael Hallquist for assistance
in conceptualizing the data analyses for this research.
Correspondence concerning this article should be addressed to Gavin N.
Rackoff, Department of Psychology, Pennsylvania State University, 378
Moore Building, University Park, PA 16801. E-mail: [email protected]
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Journal of Abnormal Psychology
© 2020 American Psychological Association 2020, Vol. 129, No. 8, 799–809
ISSN: 0021-843X http://dx.doi.org/10.1037/abn0000639
799
https://orcid.org/0000-0003-3525-3975
https://orcid.org/0000-0003-0873-1409
mailto:[email protected]
http://dx.doi.org/10.1037/abn0000639
rumination and worry. Indeed, a positive emotion intervention
reduced worry among participants with generalized anxiety disor-
der (GAD; LaFreniere & Newman, 2019), and positive emotions
predicted later mindfulness (Brockman, Ciarrochi, Parker, &
Kashdan, 2017) and positive reappraisal (Pavani, Le Vigouroux,
Kop, Congard, & Dauvier, 2016) among healthy participants.
Positive emotions are also theorized to increase behavioral flexi-
bility (Fredrickson, 2001) and approach toward rewards (Lang &
Bradley, 2013). Thus, behaviorally, positive emotions could pro-
tect against the excessive avoidance central to depression and
anxiety (e.g., Barlow, Allen, & Choate, 2004). Supporting this
hypothesis, positive emotions predicted lower avoidance among
anxious participants (Chow et al., 2017; Trew & Alden, 2012).
Finally, positive emotions are thought to help cultivate social
relationships (Fredrickson, 2001), which reduce risk for emotional
disorders (e.g., Jacobson, Lord, & Newman, 2017; Jacobson &
Newman, 2016). Importantly, positive emotions and their concom-
itants have reciprocal associations (e.g., Fredrickson & Joiner,
2002; Pavani et al., 2016), leading some to propose that positive
emotions trigger “upward spirals” of mental health (Garland et al.,
2010). Accordingly, low levels of positive emotions are a long-
recognized risk factor for depression (Clark & Watson, 1991), and
increasing research has also linked low levels (Khazanov & Rus-
cio, 2016) and greater instability (Houben, Van Den Noortgate, &
Kuppens, 2015) of positive emotions to both depression and anx-
iety. Therefore, studying positive emotions in the context of stress
could help explain the development of depression and anxiety.
In fact, experience sampling studies have documented concur-
rent and lagged associations between daily stressors and lowered
positive emotion (Eldahan et al., 2016; van Eck, Nicolson, &
Berkhof, 1998). Positive emotions also decrease during laboratory
stress (Williams, Cribbet, Rau, Gunn, & Czajkowski, 2013) and
negative life events (Folkman, 1997). Notably, stress is also asso-
ciated with reduced subjective and physiological responding to
positive emotion-eliciting stimuli (Berenbaum & Connelly, 1993;
Lapate et al., 2014), suggesting that the association between stress
and positive emotion is due to a true reduction in positive emo-
tions, rather than a lack of opportunities for pleasurable experi-
ences. Beyond positive emotions, several other reward-related
processes are also downregulated during stress, including appetite
(Reichenberger et al., 2018) and neural reward responding (Kumar
et al., 2014). Thus, just as negative emotions are heightened,
positive emotions and a host of processes that may contribute to
positive emotions are lowered in the face of stress.
Between-person differences in the within-person association
between stress and positive emotions have also been associated
with psychopathology. Persons reporting family histories of de-
pression were most susceptible to diminished enjoyment of daily
activities and happy film clips following stress exposure (Beren-
baum & Connelly, 1993). Daily diary studies have also docu-
mented especially depleted positive emotions on stressful event
days among participants with past depression (O’Hara, Armeli,
Boynton, & Tennen, 2014) and concurrently elevated depression
symptoms (Tolpin, Cohen, Gunthert, & Farrehi, 2006). Higher
positive emotion during a laboratory stressor predicted greater trait
resilience (Corral-Frías, Nadel, Fellous, & Jacobs, 2016), and
higher positive emotion during bereavement was associated with a
less pronounced and prolonged course of distress (Bonanno &
Keltner, 1997; Folkman, 1997). Beyond lowered positive emotion,
greater stress-related downregulation of behavioral and neural
reward sensitivity has also been associated with genetic indicators
of stress vulnerability (Bogdan, Santesso, Fagerness, Perlis, &
Pizzagalli, 2011). Thus, research from diverse literatures has
linked susceptibility to lowered state positive emotion, as well as
downregulation of a range of reward-related processes, in the
context of stress to concurrent and retrospective indicators of risk
for psychopathology. Experiencing especially diminished positive
emotions during stress may therefore deplete cognitive, behav-
ioral, and social resources for mental health.
Beyond cross-sectional and retrospective studies, prospective
experience sampling investigations have found that heightened
susceptibility to reduced positive emotions on days with stressful
events predicted depressive symptoms across lags of 2 (O’Neill,
Cohen, Tolpin, & Gunthert, 2004), 12 (Ong & Burrow, 2018), and
18 months (Zhaoyang, Scott, Smyth, Kang, & Sliwinski, 2020).
These studies provide evidence for susceptibility to lowered pos-
itive emotions during stress as a risk factor for depression, yet they
are limited because they relied on relatively small samples and
lacked diagnostic assessments of major depressive disorder
(MDD). Moreover, because low positive emotions are also impli-
cated in anxiety (Khazanov & Ruscio, 2016), and positive emo-
tions may engender future positive emotions through reciprocal
links with psychological resources (Garland et al., 2010), exam-
ining associations between diminished positive emotions in the
context of stress and future anxiety disorders and future levels of
positive emotion is also warranted.
The present study tested whether susceptibility to lowered pos-
itive emotions in the context of daily stress predicted depression,
anxiety disorders, and low trait positive affect approximately 7
years later in a large community sample. Susceptibility to lowered
positive emotions in the context of stress was indexed by the
difference in the amount of time participants experienced positive
affect on days with versus without stressful events. Seven-year
outcomes included positive affect experienced over a 30-day pe-
riod, as well as the presence versus absence of MDD and presence
versus absence of an anxiety disorder (GAD or panic disorder
[PD]). Given that some models have linked low positive affect
more strongly to depression than to anxiety disorders such as GAD
and PD (e.g., tripartite model; Clark & Watson, 1991), we ana-
lyzed these disorder types separately to test whether susceptibility
to lowered positive emotions in the context of stress had common
(e.g., Khazanov & Ruscio, 2016) or unique associations with
anxiety and depression. We hypothesized that stronger negative
within-person associations between daily stress and time experi-
encing positive affect would predict lower future positive affect
and diagnosis of depression and anxiety disorders 7 years later.
Method
Participants
Participants were members of the National Study of Daily
Experiences (NSDE) project of the Midlife in the United States
(MIDUS) study (Ryff et al., 2019; Ryff & Almeida, 2017).
MIDUS includes three waves of interviews and questionnaires
administered 9 years apart, and NSDE includes 8-day bursts of
daily telephone interviews completed approximately 1.5 years
after each of the first and second MIDUS waves. Daily positive
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800 RACKOFF AND NEWMAN
emotion assessments were only completed during the second burst
within NSDE. Therefore, the sample for the present study con-
sisted of all 1,517 participants who participated in second wave of
NSDE (NSDE II) and the third wave of MIDUS (MIDUS III). Of
these participants, 847 (55.8%) were women, and 1,393 (91.8%)
identified their race as White. The average age at NSDE II was
57.11 years (SD � 11.30).
Procedure
During the second wave of MIDUS (MIDUS II), participants
completed a diagnostic interview assessing MDD, GAD, and PD.
Participants then completed NSDE II an average of 1.80 years (SD �
1.16) later. During NSDE II, participants received phone calls from
researchers once daily for 8 consecutive days. Phone calls were
conducted during the daytime (68.2%) or the evening (31.8%). Dur-
ing phone calls, participants completed the Daily Interview of Stress-
ful Events (DISE; Almeida, Wethington, & Kessler, 2002), which
asks about the occurrence of common stressful events in the past 24
hr (on the first sampling day) or since the preceding phone call (on
subsequent days). Participants also completed measures of daily ac-
tivities and positive and negative affect, in which they were asked
how much of the time on the day of the phone call they felt each of
12 emotions. Thus, stress and affect were measured concurrently, with
the time in which a stressor could occur extending slightly before the
time frame of emotion reporting. Participants completed MIDUS III
an average of 7.33 years (SD � 1.20) after NSDE II. MIDUS III
included a telephone call with a psychiatric diagnostic interview and
a mailed survey packet including a measure of affect experienced in
the past 30 days.
Measures
Stressful events. Stressful events were measured during
NSDE II using the DISE (Almeida et al., 2002). The DISE asks
about the occurrence of six common events that most people find
stressful on a given day. Respondents could also report on any
other event they experienced that most people would find stressful.
The DISE also assesses characteristics of each stressful event
reported (e.g., “How stressful was this event for you?”, “Is the
issue resolved?”). Consistent with prior use of the DISE (e.g.,
Charles et al., 2013) and to avoid confounding objective stress
exposure with subjective cognitive or emotional responses, anal-
yses treated the presence versus absence of any stressful event
(regardless of subjective stressfulness or resolution ratings) on a
given day as a binary variable. Stressful events were reported on
40.3% of sampling days. Please see Table 1 for detailed descrip-
tive statistics on stressful events.
Daily leisure time. Daily leisure time in hours was assessed
each day during NSDE II with the question, “How much time did
you spend on leisure?”
Affect. Affect was measured during NSDE II and MIDUS III
using the scale developed by Mroczek and Kolarz (1998). Participants
were asked how much of the time during a specified period they felt
each of 12 emotions, on a scale ranging from 0 (none of the time) to
4 (all of the time). Positive emotions included (a) in good spirits, (b)
cheerful, (c) extremely happy, (d) calm and peaceful, (e) satisfied, and
(f) full of life. Negative emotions included (a) restless or fidgety, (b)
nervous, (c) worthless, (d) so sad nothing could cheer you up, (e)
everything was an effort, and (f) hopeless. The time periods for
emotion reporting were different during NSDE II and MIDUS III and
are described below. Joshanloo (2017) found evidence for factorial
and criterion validity when the affect scale was administered during
MIDUS III.
NSDE II assessment of affect. Each day during NSDE II,
participants reported how much of the time during the day they felt
each emotion on the scale by Mroczek and Kolarz (1998). Reli-
ability of the positive affect items, calculated using multilevel
coefficient alpha (Geldhof, Preacher, & Zyphur, 2014), was .78
within persons and .94 between persons. Reliability of the negative
affect items was .56 within persons and .80 between persons.
Lower within-person reliability compared to between-person reli-
ability indicates that emotions within each subscale covaried with
each other less across day-to-day fluctuations than they did in
person-to-person differences.
MIDUS III assessment of positive affect. During MIDUS III,
participants indicated how much of the time during the past 30
days they felt each positive emotion on the scale by Mroczek and
Kolarz (1998). Cronbach’s alpha was .91.
Anxiety and depressive disorders. Anxiety and depressive
disorders were diagnosed during MIDUS II and MIDUS III using
the Comprehensive International Diagnostic Interview-Short Form
(CIDI-SF; Kessler, Andrews, Mroczek, Ustun, & Wittchen, 1998).
The CIDI-SF assessed whether, in the past 12 months, respondents
met criteria for MDD, PD, and GAD as defined in the Diagnostic
and Statistical Manual of Mental Disorders, 3rd ed., rev. (Amer-
ican Psychiatric Association, 1987). The CIDI-SF has excellent
interrater reliability, sensitivity, and specificity for each disorder
(Kessler et al., 1998). We treated diagnosis of MDD and diagnosis
of an anxiety disorder (either GAD or PD) as separate binary
variables.
Data Analyses
General strategy. Models were fit using multilevel structural
equation modeling (MSEM) in Mplus 8 (Muthén & Muthén, 2017)
via the R package MplusAutomation (Hallquist & Wiley, 2018).
As in multilevel modeling, MSEM estimates associations between
repeatedly measured variables (e.g., stress reported on a given day
predicting time experiencing positive affect on the same day).
MSEM accommodates random intercepts that represent differ-
ences in the overall level of repeatedly measured variables across
persons (e.g., overall levels of positive affect across the 8-day
sampling period), as well as random slopes that represent differ-
ences in the association between repeatedly measured variables
across persons (e.g., an especially strong association between daily
stress and time experiencing positive affect for a given person).
In MSEM, fixed effects representing sample-pooled associa-
tions between repeatedly measured variables are represented on
the within-person level of the model, and random intercepts and
slopes representing individual differences in repeatedly measured
variables and their associations are represented on the between-
person level of the model. Random effects on the between-person
level can be modeled as predictors of individual difference out-
comes of interest. For the present study, a random slope for the
association between stress and time spent experiencing positive
affect on the same day can be considered an indicator of suscep-
tibility to lowered positive affect in the context of stress. This
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801DAILY STRESS AND POSITIVE AFFECT
variable can be modeled as a predictor of positive affect levels and
psychopathology 7 years later.
Analyses used Bayesian estimation, which incorporates prior be-
liefs (“priors”) about parameter distributions into final estimates.
Priors are updated using observed relationships among variables to
obtain a range of possible parameter values termed a posterior distri-
bution. The Bayesian estimator in Mplus performs well with low-
frequency categorical dependent variables (e.g., future MDD or anx-
iety diagnosis; Nguyen, Webb-Vargas, Koning, & Stuart, 2016), as
well as categorical dependent variables whose underlying distribu-
tions are non-normal (Liang & Yang, 2014). The Bayesian estimator
also handles missing data under the missing at random assumption (as
in full information maximum likelihood and multiple imputation).
Accordingly, all observations with missing data were retained. Please
see Table 2 for missing data frequencies.
Model building. Model building proceeded sequentially to
justify each premise of the hypotheses, namely (a) associations
between daily stress and time experiencing positive affect varied
across persons and (b) between-person differences in the within-
person association between stress and time experiencing positive
affect predicted positive affect and psychopathology 7 years later.
Models 0 and 1: Do within-person associations between daily
stress and positive affect vary across persons? We first fit a
model (Model 0) in which the within-person level included stress
reported on a given day predicting the amount of time positive
affect was experienced on the same day. To ensure that estimates
Table 1
Daily Stressful Event Frequencies
Variable Endorsed n (%)
Any stressful event 4,587 (40.3)
Specific stressful events
Did you have an argument or disagreement with anyone since (this time/we spoke) yesterday? 1,061 (9.3)
Since (this time/we spoke) yesterday, did anything happen that you could have argued about but you decided to let pass in
order to avoid a disagreement? 1,660 (14.6)
Since (this time/we spoke) yesterday, did anything happen at work or school (other than what you already mentioned) that
most people would consider stressful? 1,040 (9.2)
Since (this time/we spoke) yesterday, did anything happen at home (other than what you already mentioned) that most
people would consider stressful? 966 (8.5)
Many people experience discrimination on the basis of such things as race, sex, or age. Did anything like this happen to
you since (this time/we spoke) yesterday? 56 (0.5)
Since (this time/we spoke) yesterday, did anything happen to a close friend or relative (other than what you’ve already
mentioned) that turned out to be stressful for you? 590 (5.2)
Did anything else happen to you since (this time/we spoke) yesterday that people would consider stressful? 651 (5.7)
Subjective stressfulness ratings
Not at all stressful 490 (8.1)
Not very stressful 1,381 (22.9)
Somewhat stressful 3,030 (50.3)
Very stressful 1,119 (18.6)
Stressful event resolution
Resolved 3,273 (60.7)
Unresolved 2,123 (39.3)
Note. N � 1,517. Endorsement percentages calculated based on observations with complete data.
Table 2
Descriptive Statistics
Continuous variables M Count (%) SD between SD within ICC Missing n (%)
Daily positive affect 16.22 4.13 2.68 0.70 818 (6.7)
Daily negative affect 0.93 1.22 1.38 0.43 780 (6.4)
Daily leisure time 3.03 1.52 2.11 0.34 785 (6.5)
Mean daily negative affect 0.97 1.41 0 (0)
Proportion of days with stress 0.41 0.26 0 (0)
MIDUS III Positive affect 14.80 4.24 139 (9.2)
Age 57.11 11.30 0 (0)
Categorical variables
Daily stress 4,587 (40.3) 0.17 763 (6.3)
Past year MDD 148 (9.8) 0 (0)
Past year anxiety 119 (7.8) 0 (0)
Future MDD 144 (9.5%) 0 (0)
Future anxiety 96 (6.3) 0 (0)
Female 847 (55.8) 0 (0)
Note. N � 1,517. SD between � between-person standard deviation; SD within � within-person standard
deviation; ICC � intraclass correlation; MIDUS III � third wave of the Midlife in the United States study;
MDD � major depressive disorder.
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802 RACKOFF AND NEWMAN
of the within-person association between daily stress and time
experiencing positive affect were specific to positive affect (e.g.,
not a reflection of negative emotional stress reactivity), daily
negative affect was included as a covariate in predicting the
amount of time positive affect was experienced. Daily leisure time
was also included as a covariate in predicting the amount of time
positive affect was experienced, to ensure that the association
between daily stress and positive affect was not an artifact due to
diminished time availability on days with stressors. The between-
person level of the model included a random intercept for daily
positive affect, which was allowed to covary with the following:
(a) proportion of days in which a stressor occurred for a given
participant, (b) a participant’s average level of negative affect, (c)
past year MDD and anxiety disorder status, (d) age, and (e) sex.
Predictors on the within-person level were person-mean centered,
so that random intercepts represented a participant’s overall level
of positive affect during NSDE II. Fit was evaluated using the
posterior predictive p value (PPP), with values above .100 indi-
cating good fit (Cain & Zhang, 2019).
After evaluating Model 0, we added random slopes for the
within-person association between daily stress and daily time
experiencing positive affect. These random slopes represented
between-person differences in the degree to which time experienc-
ing positive affect differed across days with and without stressful
events. The random slopes were allowed to covary with all other
variables on the between-person level. This model (Model 1) was
compared to Model 0 using the deviance information criterion
(DIC), with lower values indicating better fit (Cain & Zhang,
2019) and indicating that within-person associations between
stress and time experiencing positive affect varied across partici-
pants. As a prerequisite for DIC, we tested if posterior distributions
were multivariate normal using the Henze-Zirkler test (HZ; Henze
& Zirkler, 1990), with p values greater than .05 suggesting DIC is
a suitable fit index. Because random effects are assumed normally
distributed in MSEM, we also examined the estimated univariate
normality of the random intercepts and slopes in Model 1. Random
effect skewness values below 1 and kurtosis values below 3 exert
minimal effects on model evaluation (Ryu, 2011) and were used as
cutoffs for random effect normality.
Models 2 and 3: Do between-person differences in the within-
person association between stress and positive affect predict
positive affect and emotional disorders 7 years later? We next
fit a model (Model 2), which was identical to Model 0 except that
all variables on the between-person level (i.e., random intercepts
for positive affect, the proportion of days on which a stressor
occurred, average daily negative affect, past year MDD, past year
anxiety disorder, age, and sex) predicted a MIDUS III outcome.
PPP values greater than .100 justified including these variables as
predictors of 7-year outcomes. This was conducted with each
7-year outcome (positive affect, MDD diagnosis, and anxiety
disorder diagnosis) tested in a separate model (Models 2a, 2b, and
2c, respectively). Binary outcomes (MDD diagnosis and anxiety
disorder diagnosis) were modeled using the probit link. Finally, we
modified Model 2 by adding random slopes reflecting between-
person differences in the within-person association between stress
and time spent experiencing positive affect and included these
random slopes as additional predictors of MIDUS III outcomes.
For the prediction of future positive affect, we examined change in
the between-person R2 between this model (Model 3a) and the
model without random slopes (Model 2a). For the prediction of
MDD (Model 3b) and anxiety disorder diagnosis (Model 3c), we
tested improvement in fit relative to Models 2b and 2c using the
pseudo-R2 index developed by McKelvey and Zavoina (1975) for
binary outcomes. An increase in R2 or pseudo-R2 indicated that a
greater percentage of variance in the 7-year outcome had been
explained, justifying the inclusion of the random slopes as predic-
tors of mental health outcomes.
Final models. If each aspect of complexity was supported, we
retained Model 3. Thus, the within-person level included daily
stress, daily negative affect, and daily leisure time predicting the
amount of time positive affect was experienced on the same day.
Predictors on the between-person level included the proportion of
days on which a stressor occurred, average daily negative affect,
past year MDD and anxiety disorder status, age, sex, random
intercepts representing overall levels of positive affect, …