Assignement introduction Relationship Between Stress and Young Adults Complementary

Chapter 1: Introduction

This study was designed to determine whether young adults aged 18-30 years use

complementary and alternative medicine (CAM) modalities in their stress management

practices. Although CAM modalities have become increasingly popular for variety of

purposes, especially in the context of adult users, few researchers have sought the

perspective of young adults. In particular, there is a lack of research on how CAM is used

among young adults, a generation facing high levels of stress (Sifferlin, 2013).

This chapter includes the background of the study; the problem that encouraged

this study; the purpose of the study; the research questions and hypotheses; the theoretical

foundation of the study; the definitions of key terms; the nature of the study; the

assumptions, limitations, scope, and delimitations; as well as the significance of the

study.

Background of the Study

According to the National Center for Complementary and Alternative Medicine

(2008), CAM refers to a group of diverse medical and healthcare systems, practices, and

products not treated as conventional medicine. Complementary and alternative medicine

modalities involve complementary medicine used together alongside conventional

medicine, as well as alternative medicine used in lieu of traditional medicines. In the

United States, around 38% of adults are using CAM modalities (NCCAM, 2008). Around

one of every nine children, or 12%, utilizes CAM (NCCAM, 2008). People from

different backgrounds use CAM, but statistics have shown that these methods are mostly

used by adults, women, and those with higher income and education levels (NCCAM,

2008). Among the different CAM modalities, non-mineral natural products and non-

vitamins are most frequently used for enhancing therapies such as deep breathing

exercises and meditation (NCCAM, 2008).

People may use CAM for different reasons, and these modalities are used to

respond to an array of diseases and conditions. American adults in particular are likely to

turn to CAM modalities in order to treat musculoskeletal problems such as back, neck, or

joint pain. The use of CAM therapies for head and chest colds increased from 2002 to

2007. Researchers have also noted several trends regarding CAM use among young

people and children (NCCAM, 2008). The 2007 NHIS surveyed adult respondents

regarding CAM use by children within their families or households. The survey found

that 12% of young people use some form of CAM modalities. In particular, young people

whose parents also use CAM use CAM the most frequently. Among the surveyed, 23.9%

parents said that their children also use CAM in a similar manner. Adolescents from ages

12 to 17 years use CAM more than children younger than this range (NCCAM, 2008).

In terms of ethnic background, White children use CAM modalities more than

Hispanic or Black children. There are 5% more White children using CAM modalities

compared to Hispanic children (7.9%) and 7% more compared to Black children (5.9%).

Children whose parents also earned a higher education are also more likely to use CAM

modalities. Regarding health conditions, children with six or more health conditions, as

well as those who were not given conventional care immediately by their families, tend to

use CAM more (NCCAM, 2008).

Problem Statement

Stress and its effects have been widely studied. However, only recently have

researchers focused on the effects of stress on young adults aged 18-30. Researchers have

shown that cognitive and emotional attributes are critical in determining what coping

strategies these young adults would choose in combatting and managing their stress

levels. Researchers have defined the concept of stress in varying ways across literature.

Delahaij, Dam, Gaillard, and Soeters (2011) defined stress through a biopsychosocial

approach, claiming that it is a form of reaction to the emotional, physiological, and

cognitive state of the individual. Caltabiano, Sarfino, and Byrne (2008) described stress

as a form of discrepancy. According to these researchers, stress is the effect from a

perceived discrepancy between the demands of a situation and the available resources

that an individual can use to cater to these demands. According to this theory, a wider gap

between the demands and the resources creates a higher stress level.

Delahaij et al. (2011) defined coping as the relationship between cognitive and

behavioral processes in trying to close the gap between the demands of a situation and the

resources available to the individual. Coping strategies in general come in two major

types: emotion-focused and problem-focused. Emotion-focused strategies include

regulating an individual’s emotional response to a stressor as well as lessening

psychological discomfort. On the other hand, problem-focused strategies include

changing the situation so that the stressors could be removed or lessened (Delahaij et al.,

2011).

The effects of daily stressors can be particularly detrimental to the psychological

and physiological health of young people (Yahav & Cohen, 2008). Persike and Seiffge-

Krenke (2012) examined stressors among young people and found that academic

achievement as well as parental control tops the list. The researchers suggested that most

young people are worried about their future education and employment.

Stress and coping researchers have demonstrated that young adults use a wide

range of coping strategies (Moskowitz, Stein, & Lightfoot, 2013). According to Visconti,

Sechler, and Kochen-Ladd (2013), emotional attributes such as self-esteem can affect the

coping strategies or stress management strategies that young people choose. Visconti et

al. claimed that those with low self-esteem would not be able to deal with life stressors

independently, because they do not have the confidence. As a result, these young people

might be more inclined to choose emotion-focused coping. Despite the literature on stress

and stress management of young adults, there is a dearth in the literature regarding using

CAM modalities as stress management strategies among young adults. This is the gap

that the current study was designed to close.

Complementary and alternative medicine has been studied among young adults,

but not in the context of stress management. Seburg et al. (2012) examined the self-

reported use and correlates of CAM among adolescents with juvenile arthritis (JA). The

researchers gathered 134 adolescents with JA and asked them to complete an online

survey regarding their use of CAM, or their interest in using it. The researchers then used

the PedsQL 4.0 SF15 to measure the participants’ quality of life. They found that around

72% of the participants reported using one CAM modality. The participant CAM usage

was not affected by factors such as sex, age, race, or geographic location. Among the

CAM modalities available, the participants claimed that they use yoga and meditation the

most frequently, as well as relaxation and guided imagery. The researchers also found

that young adults who engaged in massage, meditation, relaxation, or guided imagery use

have higher psychosocial quality of life.

Among the participants who used these CAM modalities, nearly half

(46%) reported that they discuss using these modalities with their healthcare providers.

Those who are not using CAM yet claimed they are interested in doing so, and in

particular are interested in massage (Suberg et al., 2012). The researchers found that

youth with JA reported high use of CAM—however, few are open about it, and they are

unwilling to talk about these modalities with their healthcare providers. The researchers

recommended practitioners engage adolescents in discussions about this form of

treatment.

Upchurch and Dawn (2012) examined the racial and ethnic profiles of

complementary and alternative medicine use among young adults in the United States.

The researchers included variation across subgroups of Hispanics in their research.

Gathering young adults from ages 18 to 27 belonging to Wave III of the National

Longitudinal Study of Adolescent Health, the researchers examined use of 15 specific

CAM modalities, including herbs, massage, chiropractic, relaxation, and vitamins. The

researchers found that around 29% of the participants recently used these

CAM modalities. Among the participants using these modalities, the majority are Cuban

Americans. Black Americans used these modalities the least.

The use of CAM among young people has also been studied in the context of

cancer survivors. Ndao et al. (2013) investigated the prevalence of CAM use, types and

reasons for use, as well as determinants of use among young people who survived cancer

in their childhood. The researchers asked 197 survivors to complete an interview-based

survey of CAM. The survey specifically measured demographic data of those who used

CAM, the types of CAM used, the purposes behind the CAM use, and whether the

participants who used CAM discussed their use with their healthcare providers. The

majority of the cancer survivors (58%) claimed that they have used CAM in their

survivorship. Among those who used CAM, 72% claimed they utilized biologically-

based therapies. Their reasons for use were reported as to relax and manage their stress

levels. Some said they used CAM methods because their parents wanted them to try the

treatment. The majority of those who used CAM (62%) reported the therapies as

effective. Those who used CAM were split in their responses regarding disclosing or

discussing the use of these treatments with their healthcare providers. Around 51% of the

young adult CAM users claimed that they disclosed their therapies to their physicians.

Complementary and alternative modalities have been used for stress management.

Studies have been devoted to studying the effects of CAM on stress management;

however, there are limited studies looking at which populations use these modalities, and

how they are used among young adults. Most of the studies devoted to the topic have

been focused on adult CAM users. An example of such study would be that conducted by

Tsang et al. (2013). Tsang et al. designed a study to explore the efficacy of implementing

a stress management program based on a combined approach utilizing

cognitive behavioral therapy and CAM modalities for elementary school teachers in

Hong Kong. These teachers were experiencing mild forms of stress and anxiety

symptoms. The researchers found that those who underwent the combined approach of

CBT and CAM experienced positive results. The teachers experienced a

significant reduction in their depression, anxiety, as well as stress levels. The researchers

concluded the positive effects of CAM in terms of stress management practices and

treatments.

Bazzan, Zabrecky, Monti, and Newberg (2014) looked at the possible uses of

CAM approaches for the management of mood and anxiety disorders. The researchers

found that CAM interventions used for coping with stress, anxiety, and mood disorders

include taking supplements, botanical remedies, spiritual practices, and acupuncture.

Meditation and some dietary practices are also used to cope with stress. The researchers

found growing evidence of the effectiveness of CAM modalities in stress management

practices.

Purpose of the Study

The purpose of this quantitative study was to examine whether variables such as

exposure to CAM, stress level, dispositional coping style, sociodemographic variables,

and social support influence the use of CAM modalities for stress management among

young adults. I used a quantitative cross-sectional correlational study to identify whether

the factors identified in the study influence the dependent variable of the use of CAM

modalities for stress management. I used a survey methodology to gather primary data for

analyses of potential relationships.

Research Questions and Hypotheses

Research Question 1: To what extent is exposure and knowledge of CAM

associated with the use of CAM modalities for stress management among young adults

participating in the study?

H01: Exposure and knowledge of CAM is not associated with the use of CAM

modalities for stress management among young adults participating in the study.

H11: Exposure and knowledge of CAM is associated with the use of CAM

modalities for stress management among young adults participating in the study.

Research Question 2: To what extent does dispositional coping style influence the

use of CAM modalities for stress management among young adults participating in the

study?

H02: Dispositional coping style does not influence the use of CAM modalities for

stress management among young adults participating in the study.

H12: Dispositional coping style influences the use of CAM modalities for stress

management among young adults participating in the study.

Research Question 3: To what extent do sociodemographic variables influence the

use of CAM modalities for stress management among young adults participating in the

study?

H03: Sociodemographic variables do not influence the use of CAM modalities for

stress management (coping) among young adults participating in the study

H13: Sociodemographic variables influence the use of CAM modalities for stress

management among young adults participating in the study.

Research Question 4: To what extent does a difference exists in level of perceived

stress among study participants who use CAM modalities for stress management and

study participants who do not use CAM modalities for the stress management?

H04: There is no difference in the level of perceived stress among the study

participants who use CAM modalities for stress management and study participants who

do not use CAM for the stress management.

H14: There is a difference the level of perceived stress among the study

participants who use CAM modalities for stress management and study participants who

do not use CAM modalities for the stress management.

Theoretical Foundation

To understand the variables determining CAM use for stress management and the

effects of CAM use on stress levels of young adults, I deemed that the transactional

model of stress and coping would be the most appropriate theoretical framework. The

model presents an integrated framework in which the stress and coping process is

conceived as a person-environment transaction. The theory posits that when a person is

faced with an external demand or stressor, the first action that the person would take is to

evaluate the extent of threat inherent in the stressor. The person would then take stock of

the material, psychological, or social resources that are available to either eliminate the

stressor, or to manage the physical and emotional response to the stressor (Glanz, Rimer,

& Viswanath, 2008). This model will guide the exploration of whether variables such as

exposure to CAM, stress level, dispositional working style, sociodemographic variables,

and social support could impact the use of CAM modalities for stress management

among young adults. I will also use this model to examine whether CAM reduces the

stress levels of young adults.

Nature of the Study

I employed a quantitative cross-sectional correlational research design using

primary data collected via validated survey instruments to identify potential relationships

between the study variables and the use of CAM modalities for stress management

among young adults. The dependent variable in this study is the use of CAM modalities

for stress management. Independent variables will include exposure to CAM, stress level,

dispositional working style, sociodemographic variables, and social support.

Researchers may use quantitative methods when the researcher’s goal is to

determine the relationship between variables or to predict outcomes (Babbie, 2012).

Quantitative research methods focus on providing an objective measure, considering

replicable methodologies and generalizable findings (Bryman, 2012). Quantitative studies

consider the use of survey instruments to provide an objective measure of constructs such

as the variables considered in this study in order to collect data and test the hypotheses

posed in this study. As opposed to a qualitative study, a quantitative study is able to

identify relationships between variables considering statistical tests as evidence (Babbie,

2012). I designed this research to evaluate the extent to which the variables of interest are

related, using numeric measures and statistical tests of significance.

A quantitative design is appropriate when the goal of the research is to determine

the extent to which the defined input variables influence the defined outcome variables.

The researcher, therefore, assumes a positivist perspective where empirical investigation

leads to evidence reflective of the truth. In contrast, qualitative research methods focus on

identifying influential factors and understanding relationships and dynamics that have not

yet been fully explored (Cozby, 2009). Qualitative research is appropriate for

constructing conceptual realities and developing theories, as well as identifying factors

that may be numerically measured and tested in future research. Qualitative research

relies on reasoning around observational or perceptual data that is not numerically

measured. It serves as both a precursor to, and a complement of, quantitative research

(Merriam, 2009). Qualitative studies are inductive by nature and may provide a richer

understanding of the phenomenon under study (Lindlof & Taylor, 2002). A qualitative

design assumes a post positivism perspective, where truth is found in the experiences of

individuals rather than objectively measuring each component of the construct (Babbie,

2012). A qualitative design is not appropriate for this study, because the variables under

review are well-studied and have been numerically supported by prior research. The

relationships to be tested are deductive in nature and are reasonable extensions of the

current body of knowledge.

I used a nonexperimental quantitative cross-sectional correlational research

design. The purpose of this study was to examine the relationship of variables such as

exposure to CAM, stress level, dispositional working style, sociodemographic variables,

and social support to the use of CAM modalities for stress management among young

adults. The target population was young adults 18-30 years old. I utilized a purposive

sampling technique for the study. All potential participants were invited to participate in

the study. I aimed to collect at least 84 participants in order to ensure at least 80% power

for the results of the statistical analyses. In order to analyze the data collected in this

study, I conducted correlational analysis and linear regression analysis. The results of the

analyses determined which of the variables relate to the dependent variable of the use of

CAM modalities for stress management. A significance level of .05 was utilized for all

statistical analyses.

In this study, I considered the use of CAM modalities for stress management as a

dependent variable. In this study I sought to identify which of the factors identified as

independent variables are significantly related to the dependent variable. Other study

designs are concerned with comparing groups or predicting the dependent variable.

However, because the purpose of this study was to identify potential relationships

between identified variables, I deemed that a correlational design was the most

appropriate.

Definitions of Terms

Complementary and alternative medicine (CAM): According to the National

Center for Complementary and Alternative Medicine (2008), CAM refers to a group of

diverse medical and healthcare systems, practices, and products not treated as

conventional medicine

Stress: Stress is a reaction to the emotional, physiological, and cognitive state of

the individual (Delahaij et al., 2011)

Stress management: Stress management refers to closing the gap between the

demands of a situation and the available resources to the individual. Coping strategies in

general are divided into two major types: emotion-focused and problem-focused.

Emotion-focused strategies include regulating an individual’s emotional response to a

stressor as well as lessening psychological discomfort. Problem-focused strategies

include changing the situation so that the stressors could be removed or lessened

(Delahaij et al., 2011).

Assumptions

The study was based on two assumptions. First, it was assumed that the sample of

the study is representative of the greater population of young adults. I targeted young

adults aged 18-30 currently enrolled in a small university in southern California that

offers degree programs in the biological and health sciences and in CAM practice.

University students were selected for this investigation because research has

demonstrated that young adults pursing university degrees are exposed to multiple stress

factors including academic concerns, financial demands, employment considerations,

romantic encounters, and the increasing burden of adult responsibilities (Barbist, Renn,

Noisternig, Rumpold, & Hofer, 2008). Although the focus was on university students, it

was assumed that their responses would be representative of the greater young adult

population. In addition, it was assumed that stress management of young adults deals

with daily stress, and not traumatic stress. It was also assumed that a quantitative study

could capture the relationships studied.

Limitations

The study was limited by the population and sample for the study. I targeted

young adults aged 18-30 currently enrolled in a small university in southern California

that offers degree programs in the biological and health sciences and in CAM practice.

Because of this focus, it was expected that the study findings cannot be generalized. In

addition, the study was limited by the quantitative design, making it impossible to

determine the in-depth perceptions and feelings of the students in question regarding the

use of CAM in their stress management practices.

Scope and Delimitations

The study was limited to the specific university’s students. Because CAM

programs and modalities are major components of this small university’s degree offering,

students, regardless of major, are expected to be exposed to CAM tenets and practices.

However, the findings would not be able to account for the possible variances in

responses due to the students’ field of study. It was reasonable to assume that the students

majoring in the biological and health sciences were potentially less exposed to CAM than

those students who are actively pursuing a degree in a CAM-related field. Although field

of study is not an absolute indicator of CAM exposure—as students not pursing CAM

careers may have had extensive exposure to CAM outside the university setting—it did

limit the sample to a pool of candidates likely to exhibit variation on this key variable.

The study was also delimited to young adults who are aware of what CAM is. Young

adults who are completely ignorant of the nature and function of CAM were not suitable

participants for this study, in that they would lack the key variable of exposure.

Significance

The study is significant because of the detrimental effects of stress on young

people. Increased stress levels in young people’s lives are linked to higher risk of

engaging in dangerous behavior such as alcohol use and drug use (Rose & Bond, 2008).

Caltabiano et al. (2008) supported this finding, claiming that older adolescents are likely

to practice maladaptive emotion-focused coping strategies to deal with increased stress.

Rose and Bond (2008) claimed that those who are unaware of how to cope with their

increased stress in the healthy fashion may have a higher risk of substance abuse.

Young adult stress is also linked to long-term consequences. According to

Sifferlin (2013), young adults of today’s generation are the most stressed-out subset of

the population, and if the problem is left unaddressed, the consequences would be severe.

Citing a national survey by the Harris Interactive for the American Psychological

Association, Sifferlin claimed that young adults aged 18 to 33 have the highest average

level of stress of 5.4, which means they may bear the brunt of long-term stress effects

over their whole lives. Among the young adults surveyed, 39% claimed that their stress

levels are continuously increasing. Only 29% of the younger generation or 67 and older

population said the same. Alarmingly, the survey showed that young adults are also the

least-equipped to handle the stress that they are feeling.

According to Hais (as cited in Jayson, 2013), “Millennials [those ages 18 to 33]

are growing up at a tough time” (para. 6). Additionally, Hais stated:

They were sheltered in many ways, with a lot of high expectations for what they

should achieve. Individual failure is difficult to accept when confronted with a

sense you’re an important person and expected to achieve. Even though, in most

instances, it’s not their fault—the economy collapsed just as many of them were

getting out of college and coming of age—that does lead to a greater sense of

stress. (para. 6)

Researchers have also asserted that if stress is left unaddressed, it can lead to chronic

illness and ultimately escalate healthcare costs. Stress is said to be unavoidable among

young adults, but managing it is possible.

Summary

In the first chapter, I discussed the need to examine whether variables such as

exposure to CAM, stress level, dispositional working style, sociodemographic variables,

and social support impact the use of CAM modalities for stress management among

young adults. Aside from discussing the research questions and hypotheses, the

theoretical framework, the definition of terms, and the assumptions, limitations, and the

delimitations, I also provided a brief discussion of what approach was taken to achieve

the purpose of the study. I used a quantitative cross-sectional correlational study to

identify whether the factors identified in the study influence the dependent variable of the

use of CAM modalities for stress management considered. I used a survey methodology

to gather primary data for analyses of potential relationships. The second chapter will

include the review of relevant literature.

Chapter 2: Review of the Literature

Introduction

The American Psychological Association’s (APA, 2012) survey Stress in America

provided recent data on perceived stress in the United States. According to the report,

survey respondents (n = 2,020) across all age groups indicated that they routinely

experienced significantly more stress than they perceived to be healthy. In addition, 20%

of the sample rated their stress as extreme, 37% of the sample reported feeling

overwhelmed, and 63% of the sample indicated they were doing an average or poor job

of managing their stress load. Given that perceived stress is a more sensitive measure of

the impact of stress on the individual than objectively determined stress (Antonovsky,

1980; Lazarus & Cohen, 1977; Scheier & Bridges, 1995), these perceptions presented a

compelling depiction of a nation at risk for a growing burden of stress-related physical

and mental illness.

Of particular concern are the study findings that younger adults, ages 18 to 33,

experience the highest average levels of stress and report the lowest capacity to

effectively cope with that stress of any participating age group. This age group is

uniquely disadvantaged with respect to stress, and they have the highest potential for

stress-related illness as they transition to independent adulthood, establish themselves in a

career, and launch a family during a period of rapid social change. Researchers have

demonstrated that the pressures associated with a constantly-shifting social milieu strike

hardest at the segment of society most invested in attaining workforce and family

stability (Coreil, Bryant, & Henderson, 2001; Krieger, 2001). Further, the rapid pace of

technological advancements, coupled with the ongoing restructuring of the American

workforce, suggests that this age group will continue to experience the effects of social

turbulence throughout their young adult years, and take the residual effects of that stress

forward into middle age (Massimini & Peterson, 2009).

The physical and mental health risks associated with this scenario are three-fold

(Gerr et al., 2002; Thomée, Eklöf, Gustafsson, Nilsson, & Hagberg, 2007). First, lifespan

investigations have demonstrated that the negative impacts of stress accumulate over time

(Contrada & Baum, 2011; Turner & Schieman, 2008; Weiten, 2009). The field of

psychoneuroimmunology has further demonstrated that such long-term exposure to

chronic stress results in a prolonged physiological response, termed general adaptation

syndrome, which depletes the body’s resistance to disease and sets the stage for the onset

of illness states; these illnesses are called diseases of adaptation (Craighead & Nemeroff,

2004; Selye, 1936). More recent investigations have identified prolonged stress as an

etiologic agent in cardiovascular disease, cancer, and a host of other ailments most likely

to present in middle age (Antonucci & Jackson, 2010; Kemeny & Schedlowski, 2007;

van der Kolk, McFarlane, & Weisaeth, 1996; Ziegelstein, 2007). These findings

suggested that young adults may be at even higher risk for incurring these illnesses in

midlife than the aging Baby Boomer generation.

The second critical issue is the overwhelming evidence that young adults are more

likely to adopt risky health behaviors as a means of coping with stress. Stress levels in

young adults have been implicated in smoking (Bricker, Schiff, & Comstock, 2011;

Lapointe, 2008; Olpin & Hesson, 2012), alcohol use (Hussong & Chassin, 2004),

substance abuse (Cooper, Wood, Orcutt, & Albino, 2003; Grant, Potenza, Weinstein, &

Gorelick, 2010; McNamara, 2000) and other high-risk behaviors that offer immediate

short-term solace. These findings were reconfirmed in the Stress in America survey,

where young adult respondents (n = 340) indicated that they were more likely to eat,

smoke, and drink alcohol in response to stress than adults aged 48 and older (APA,

2012). High-risk behaviors carry their own negative health impacts into middle age, and

may also establish addictive or habit-forming behaviors that may impact both short-term

and long-term quality of life (Edelman & Mandle, 2002; Hoeger & Hoeger, 2009; Potts

& Walsh, 2003).

Finally, stress has been consistently negatively associated with mental health

(Bovier, Chamot, & Perneger, 2004; Ensel & Lin, 1991). Among young adults, stress has

been associated with such negative mental health outcomes as depression, somatic

illness, and suicidal ideation (Kail & Cavanaugh, 2010; Stecker, 2004; Turner, Perkins, &

Bauerle, 2008). Consistent with the biopsychosocial model of illness (Engel, 1978),

mental reactions and physical reactions interact to form a potentially toxic brew for

young adults in the United States. Just as perceived stress pushes this age group to

embrace risky health behaviors, the debilitating aspects of the mental response to stress

reduce the likelihood that young adults will select more salubrious coping techniques to

deal with high stress levels. Survey results have indicated that not only are young adults

more likely to engage in high-risk health behaviors as a response to stress, they are less

likely to engage in more positive and health-promoting behaviors to cope with stress

(e.g., exercising or engaging in quiet pastimes) than older age groups (APA, 2012).

The existing information on the impact of stress on the nation’s young adults has

suggested a collaborative call to action among those engaged in public health, medical

care, and mental health services is necessary. In addition to assessing perceived stress,

sources of stress, and responses to stress, Stress in America gathered information on the

perceptions of Americans on how to address the stress crisis in the United States.

According to the survey section entitled “Missing the Healthcare Connection,” survey

respondents indicated that they favored more input from their healthcare providers to help

manage stress and improve lifestyle behaviors (APA, 2012). This finding led to the

following declaration from APA CEO Norman B. Anderson:

Unfortunately, our country’s healthcare system often neglects psychological and

behavioral factors that are essential to managing stress and chronic diseases. In

order for our nation to get healthier, lower rates of chronic illness, and lower

healthcare costs, we need to improve how we view and treat stress and unhealthy

behaviors that are contributing to the high incidence of disease in the U.S. (APA,

2013)

In actuality, there has been a growing movement to embed effective stress

reduction services in the United States healthcare sector. CAM offers a variety of

prevention and treatment modalities that have proven successful in stress reduction,

including yoga, breathing exercises, meditation, guided imagery, aromatherapy,

acupuncture, massage, progressive relaxation, and Tai Chi. In addition, CAM therapies

are advocated within a holistic wellness viewpoint, rooted in ancient philosophies of

mind-body balance and integration; such an approach has implications for positive

lifestyle choices (Krebs, 2001; Sanghani et al., 2010; Smeeding, Bradshaw, Kumpfer,

Trevithick, & Stoddard, 2010).

CAM practitioners frequently operate independent practices and accept referrals

from conventional medical care providers (Ehrlich, Callender, & Gaster, 2013). Various

academic medicine health centers across the United States offer a broad array of services

that unite traditional medical services and CAM techniques, using a novel approach to

practice termed integrative medicine (Edwards, 2012; Ehrlich et al., 2013). Examples of

successful public health interventions include the development of a CAM-based

employee wellness clinic for military hospital personnel (Duncan, Liechty, Miller,

Chinoy, & Ricciardi, 2011), and a quick low-cost health promotion stress reduction

program (Sanghani, Deavenport, Herring, Anderson, & Medina, 2008). CAM represents

a stress reduction option with the potential to augment conventional public health,

medical care, and mental health service to address the concern that Americans receive

minimal assistance in their stress management efforts.

The Problem

Although the above scenario has significant appeal, research into the maturation

of the human mind has suggested that the greater inclusion of stress-directed CAM

techniques into the current healthcare system may or may not offer significant

improvements to stress management in young adults. The brain of the adolescent and

young adult is a work in progress, and is not fully developed until the individual reaches

their late 20s (National Institute of Mental Health, 2011; Weinberger, Elvevag, & Giedd,

2005). In addition, the frontal cortex, the seat of decision-making and emotional

regulation, is the last component of the brain to reach maturity (Caspi, Moffitt, Newman,

& Silva, 1996; Huffman, 2012; Steinberg, Vandell, & Bornstein, 2010). Consequently,

young adults are less capable of making sound decisions and choices than are older

adults.

Additionally, young adults are more likely to be influenced by their emotional

reaction to a situation or by the prompting of their peer group, and are more likely to

allow emotion to bias judgment. Further, young adults have less life experience than

older adults, and are therefore less able to draw on lessons learned under parallel

circumstances to improve response choices. These findings have suggested that high

levels of stress may make it difficult for young adults to select and apply new and

effortful stress reduction strategies into their daily routines. As a counterpoint to this

reasoning, researchers have established that young adults are more open than older adults

to unconventional and holistic therapies (Zimmerman & Kandiah, 2012).

These findings have suggested that alternative healthcare strategies may hold an

emotional appeal for young adults that may facilitate the adoption and maintenance of

CAM techniques, even under conditions of high stress. It is also possible that the

emotional appeal of the CAM philosophy may resonate with young adults and lead to

healthier coping strategies overall. This assessment of human cognition raises the

question of whether or not exposure to CAM techniques and tenets is sufficient to

stimulate the adoption and maintenance of CAM therapies, and to encourage a

substitution of those therapies for potentially-harmful coping behaviors in young adults.

The Purpose

The purpose of the current investigation was to examine whether stress levels

moderate the relationship between exposure and commitment to CAM therapies, and the

adoption of a pattern of healthier coping strategies among young adults. I targeted young

adults aged 18 to 30 currently enrolled in a local university that offers degree programs in

CAM. Researchers have demonstrated that young adults pursing university degrees are

exposed to multiple stressors, including: academic concerns, financial demands,

employment considerations, romantic encounters, and the increasing burden of adult

responsibilities (Barbist et al., 2008; Goldin, Ziv, Jazaieri, Hahn, & Gross, 2012). To

ensure variation in the independent variable of exposure, I culled study participants from

students who have had extensive, moderate, and no exposure to CAM or CAM

coursework. I assessed stress levels for all study participants, and measured the

dependent variable as the extent to which students either intend to, or have incorporated,

CAM techniques into their stress management routines.

In this chapter, I detail the literature search strategy and the origins, applications,

and appropriateness of the transactional model of stress and coping to the investigation. I

follow the theoretical framework with an evaluation of the applicability of CAM

techniques to stress management in young adults. Next, I will present the literature on

stress and coping in young adults, including an examination of the determinants of stress

in young adulthood, coping and coping dispositions in young adults, an assessment of

college students as representative of the young adult population relative to stress and

coping, and stress management in young adults.

Literature Search

To access the literature related to stress and coping among younger adults, I

designed a search strategy. Initially, I located articles using Google Scholar and the

Walden Library, using the same key terms. I accessed the Sage Premier, PubMed, and

ProQuest databases through the Walden University Library. I conducted searches using

Walden’s search service that allows the user to search by topic. This topical search

supported access to databases including Academic Search Premier, CINAHL, and

MEDLINE simultaneously, with “full text,” “written in English,” and “peer-reviewed” as

filtering criteria.

I then reviewed article references to identify relevant articles. When full text

articles were not available through the search engine, I requested these articles through

the document delivery system of the Walden Library system. When multiple studies by

the same researcher were identified, I selected the most recent articles for inclusion. I also

used several textbooks in psychology as research sources. The search terms used were

stress theories, primary appraisal, secondary appraisal, perceived stress, problem

management, emotional regulation, meaning based coping, social support, dispositional

coping styles, stress management, complementary and alternative medicine and stress

management, and younger adults.

Theoretical Foundations

In this study, I adopted the transactional model of stress and coping. The trans

theoretical model of stress and coping is a psychosocial perspective derived from social

epidemiology. Social epidemiology investigates the causal role of social factors in the

development of disease and chronic illness (Kisch & Reeder, 1969). Research using the

psychosocial perspective is a multi-disciplinary blend of sociology, psychology, and

medicine that examines the cognitive and physical impact of socially-derived stressors on

the incidence and distribution of disease (Krieger, 2001).

Cassel (1974) established the psychosocial perspective as the recognition that a

significant exposure to psychosocial stressors, in the absence of a corresponding set of

psychosocial supports, increases an individual’s susceptibility to disease and chronic

health conditions. Krieger (2001) acknowledged the dynamic nature of the psychosocial

perspective, observing that it “directs attention from endogenous biological responses to

human interactions. Its focus is on responses to ‘stress’ and stressed people in need of

psychosocial resources” (p. 670). This perspective originated from research into the

physical impacts of stress on the body (Cannon, 1932; McEwen, 1998; Selye, 1978;

Sterling & Eyer, 1988); the research focusing on the psychosocial perspective emerged

from the Freudian tradition, and matured into an examination of the strategies and social

resources people employ to cope with conditions of stress (Antonovsky, 1980; Lazarus,

1993; Lazarus & Folkman, 1984).

Origins of Stress Theories

Cannon’s (1932) work into physiologic homeostasis clarified the fight-or-flight

response in humans and other animals, and was an early examination of the stress

response. Cannon characterized fight or flight as the body’s rapid preparation to either

flee from a dangerous situation or confront the peril if escape is not feasible. Selye (1936)

examined the impact of stress on health by building on Cannon’s insights and extending

them to characterize the body’s generalized physiologic response to internal and external

demands. Selye used the term stress as a label for this physiologic dynamic, and

recognized stress as an omnipresent stimulus that flows from multiple sources or

stressors. Selye further recognized that short-term stress, leading to positive

accomplishments, could be beneficial, but that stress that is not positively resolved is

threatening and potentially harmful to the organism.

Selye (1978) later argued that the physiological changes caused by stressful

stimuli constituted a systemic response that the author labeled the General Adaptation

Syndrome (GAS). Selye proposed that stress has differential impacts on the body over

time, and these impacts occur in three stages. In the first stage, the alarm reaction is

triggered by an initial shock that stimulates adrenaline production in preparation for fight

or flight. The resistance stage that follows increases the immune response and extends the

chemical outpouring associated with resisting the threat. If the threat or stress is resolved

at this stage, the body returns to a resting state; if not, the physiological response to stress

ultimately leads to adaptive physical changes that presage the physical and cognitive

illnesses associated with long-term stress, such as hypertension and memory impairment.

In the final stage, exhaustion, the body reserves are depleted and the body becomes

vulnerable to serious illness and death.

Sterling and Eyer (1988) and McEwen (1998, 2005) further clarified the harmful

effects of chronic exposure to stress through their work in allostatic overload. This model

emphasized the relationship of stress and disease, and underscored the need to manage

stress levels. In the absence of a successful adaptive response to stressful stimuli, the

body fails to successfully terminate the neural and endocrine cascade triggered by the

emotional and physical response to extreme or chronic stress, even after the stressful

stimuli have been removed. These findings were supported by the work of lifespan

investigators, who demonstrated that the negative impacts of stress accumulate across the

years (Contrada & Baum, 2011; Turner & Schieman, 2008; Weiten, 2009). Further,

recent investigations by psycho-neuro-immunologists have identified prolonged stress as

an etiologic agent in cardiovascular disease, cancer, and a host of other ailments

(Antonucci & Jackson, 2010; Kemeny & Schedlowski, 2007; van der Kolk et al., 1996;

Ziegelstein, 2007).

Just as physiologists have been key researchers into the physical impact of stress

and have linked its impact to acute illness and chronic disease, psychologists have been

key researchers into the impact of stress on mental health and emotional well-being and

have linked that impact to anxiety disorders and cognitive dysfunction (Bard, 1934;

Horney, 1945; James, 1890). James (1890) first conceived of connections between

cognition, emotion, physical sensations, and behavior by postulating that when an

individual perceives an event, he or she reacts physiologically—a sensation the mind

reinterprets as a corresponding emotion that, in turn, arouses the individual and drives

behavior.

Bard (1934), a contemporary of Cannon (1932), provided the first convincing

evidence of emotional arousal in the face of danger, supporting James’ (1890) postulated

link to emotions in the overall response inherent in the fight or flight reaction. Horney

(1945) linked a perceived lack of parental nurturing to feelings of powerlessness and

uncertainty that the author termed basic anxiety, thereby linking stress emotions to

circumstances that are not readily construed as dangerous.

Arnold (1960) introduced the idea of cognitive appraisal into emotion research by

suggesting that cognitive assessment influences emotional states. Schachter and Singer’s

(1962) experiments expanded on Arnold’s work by demonstrating that cognitive

assessment is influenced by subtle external cues and complex emotions such as grief,

love, or stress, while simpler emotions such as fear are generated through internal cues

that trigger more immediate behaviors without the need for cognitive processing.

Lazarus (1966) applied these concepts to stress processes by suggesting that a

cognitive assessment of danger actually posed by a given stressor moderates the

emotional and physiologic reaction to that stressor. If the threat is appraised as

inconsequential, the stress response is reduced or suppressed; if the threat is appraised as

consequential, the stress response is heightened. In later work, Lazarus linked appraisal to

situational and environmental variables, suggesting that cognitive appraisal is activated

when personal utility is endangered in the form of circumstances that threaten goals,

motivators, or outcome expectations (Lazarus & Folkman, 1984; Lazarus & Launier,

1978). More recently, Lazarus (1991) differentiated between two forms of appraisal,

defining primary appraisal as the cognitive assessment of the personal relevance of the

threat associated with a given stressor, and secondary appraisal as the cognitive review of

those resources available to control the stress-related outcomes or deflect the emotional

strain associated with the threat. This conceptualization ultimately linked stress theory to

the concept of coping, and formed a core set of constructs in Lazarus’ transactional

model of stress and coping (Glanz et al., 2002).

Origins of Coping

Coping has been characterized as a multifaceted response to stress that is

connected to internal and external demands, the environmental context, available

resources, and personality dispositions or traits (Freud, 1936; Haan, 1978; Lazarus, 1966;

Lazarus & Folkman, 1984). The origins of coping are rooted both in Freud’s (1936)

school of psychoanalytic therapy and in the cognitive-psychological paradigm (Folkman,

1991; Somerfield & McCrae, 2000; Suls, David, & Harvey, 1996). The concept of coping

originated with Freud (1895), who concluded that humans employed defense mechanisms

to deal with tensions arising among the rational self (known as the ego), the pleasure-

seeking self (known as the id), and the conscience, (the superego). Freud further

hypothesized that defense mechanisms, including humor, displacement, rationalization,

projection, repression, sublimation, and denial reduce anxiety by distorting reality to

prevent people from becoming emotionally overwrought (Moos & Schaefer, 1986).

Freud’s (1936) major concepts were extended and expanded by a series of

psychoanalytic scholars. Anna Freud augmented her father’s work by noting that

individuals used preferred defensive styles to reduce internal conflict (Freud, 1936). Haan

(1978) and others broadened the concept of defensive conflict management to include

external demands (Menninger, 1967; Vaillant, 1995). Goldstein (1993) was instrumental

in expanding the Freudian defense mechanisms to include personality traits and

behavioral responses. Researchers have observed that coping strategies are very helpful,

and at the same time portray defensiveness that contributes to the maturity of an

individual’s moral behavior (Haan, 1978).

The psychoanalytic ego defense paradigm remained the major conceptual model

of coping until the late 1960s, when it was supplanted by Lazarus’ cognitive approach.

Lazarus (1984) conceived of coping as part of a decision-making model that included

elements of information processing interwoven with many of the concepts that had been

proffered by Freud’s followers (Folkman & Moskowitz, 2004; Lazarus, 1966, 1993;

Lazarus & Folkman, 1984; Suls et al., 1996). By emphasizing cognition, Lazarus moved

coping out of the realm of the subconscious, and showcased the concept as a considered

response to a stressful situation (Leventhal, Meyer, & Nerenz, 1980).

According to Lazarus, coping is linked to stress both cognitively and

emotionally—a relationship that mirrors the conceptual physiologic outcomes of stress as

conceived by the stress theorists (Holmes & Rahe, 1967; Lazarus & Launier, 1978;

Scheier, Weintraub, & Carver, 1986). Lazarus provided a context for the stress-coping

dynamic by suggesting that stress is evaluated or appraised by the individual to determine

the extent of personal threat posed by the stressful situation, and the extent to which

resources are available to either deal effectively with the stressful circumstances or to

restore a sense of well-being within the stressful context (Zeidner & Saklofske, 1996).

Coping is then viewed as a mobilization of internal or external resources to manage the

stressful demands (Leventhal et al., 1980).

Lazarus (1977) further married concepts from the psychoanalytic perspective of

coping to the cognitive paradigm by acknowledging that coping manifests in an

emotional environment, and that coping choices may be roughly divided into two modes:

the problem-focused mode, consistent with the cognitive school of thought, and the

emotion-focused mode, directed toward emotional relief and consistent with the

defensive mechanisms originally explored by Freudian scholars (Aldwin & Revenson,

1987). In addition, Lazarus acknowledged the predispositional trait theories espoused by

Anna Freud and Byrne (1936) by indicating that the choice among potential coping

behaviors is a function of individual predisposition style (Brandtstädter, 1992).

Since Lazarus (1966) first introduced the basic elements of the cognitive model,

coping research has burgeoned with researchers examining each element of the model, as

well as the model as a whole, to better understand the complexity, structure, and

interrelatedness of the constructs (Folkman, Lazarus, Dunkel-Schetter, DeLongis, &

Gruen, 1986). The model, consequently, has continued to evolve; however, the

transactional premise remains the major conceptual framework through which stress

management efforts continue to be evaluated (Hobfoll, 2001; Piko, 2011; Scheier et al.,

1986). The most current adaptation of the model is presented below.

The Theory

The transactional model of stress and coping is the culmination of Lazarus’s

(1984) examination of the cognitive and emotional relationship between stress and

coping. The model presents an integrated framework in which the stress and coping

process is conceived as a person-environment transaction. According to this

conceptualization, when a person is faced with an external demand or stressor, the person

responds by first evaluating the extent of threat inherent in the stressor, and second by

taking stock of the material, psychological, or social resources that are available to either

eliminate the stressor, or to manage the physical and emotional response to a significant

threat (Antonovsky & Kats, 1967; Cohen & Wills, 1985; Lazarus & Cohen, 1977). The

most current version of the model, the Lazarus and Folkman rendition (1984), is

presented in Figure 1 (Glanz, Rimer, & Viswanath, 2008).

Figure 1. Transactional model of coping stress. From Health behavior and health

education: Theory, research, and practice (4th ed.), by Glanz et al., 2008.

Key Concepts of the Model

The transactional model of stress is comprised of three primary elements: (a)

primary appraisal, (b) secondary appraisal, and (c) coping efforts. Coping efforts are

directed toward problem management, emotional regulation, or meaning-based

interpretations. The model also includes the outcomes of coping and the role of

dispositional coping in supporting optimism and promoting information seeking

behaviors. Table 1 depicts the key components of the transactional model. Each of these

elements is explored in detail in the subsequent sections.

Stress appraisal. The stress appraisal process is the component of the model that

evaluates the level of the threat posed by a given stressor or set of stressors (Glanz et al.,

2008). The appraisal process is divided into two parts: the assessment of the personal

significance of stressors, termed the primary appraisal, and the personal resource review,

termed the secondary appraisal. Together, these two appraisals constitute the magnitude

and controllability of the perceived threat (Bandura, Cioffi, Taylor, & Brouillard, 1988).

Researchers have frequently measured the magnitude of the physical and emotional

reaction to this threat as the perceived stress level (Cohen & Williamson, 1991). Most

researchers have examined these two variables in conjunction with each other; however,

a few studies have highlighted the individual contributions of each appraisal component.

Table 1

Key Concepts of the Model

Concept

Definition

Application

Primary appraisal

Evaluation of the

significance of a stressor or

threatening event

Perception of an event as

threatening can cause

distress. If an event is

perceived as positive,

benign, or irrelevant, little

negative threat is felt

Secondary appraisal

Evaluation of the

controllability of the

stressor and a person’s

coping resources

Perception of one’s ability

to change the situation,

manage one’s emotional

reactions, or cope

effectively can lead to

successful coping and

adaptation

Coping efforts

Problem management

Emotional regulation

Meaning-based coping

Actual strategies used to

mediate primary and

secondary appraisals

Strategies directed at

changing a stressful

situation

Strategies aimed at

changing the way an

individual thinks or feels

about a stressful situation

Coping process that

induces positive emotions,

which in turn sustains the

coping process by allowing

reenactment of problem or

emotions focused coping

Active coping, problem-

solving and information

seeking can be used

Venting feelings,

avoidance, denial, and

seeking social support may

be used

Positive reappraisal,

revised goals and spiritual

beliefs are experiences and

positive events occur

Outcomes of coping

Emotional well-being ,

functional status, health

behaviors

Coping strategies may

results in short and long-

term positive or negative

adaptations

(Table continues)

Concept

Definition

Application

Generalized ways of

behaving that can affect a

person’s emotional or

functional reaction to a

stressors relatively stable

across time and situations

Tendency to have

generalized positive

expectancies for outcomes

Attentional styles that are

vigilant versus those that

involve avoidance

Optimists may experience

fewer symptoms or faster

recovery from illness

Monitoring may increase

distress and arousal, it may

also increase active coping.

Blunting may mute

excessive worry but may

reduce adherence

Note. From Health behavior and health education: Theory, research, and practice (4th

ed.), by Glanz et al., 2008.

Key Dimensions of the Transactional Model of Stress

Primary appraisal. Primary appraisal is a person’s conscious judgment about the

stressful situation (Glanz et al., 2008). Croyle and Sande (1988) examined the influence

of primary appraisal in threat assessment by conducting an experiment in which

intervention subjects were told that they had demonstrated abnormalities in a test for a

fictitious enzyme disorder, while control subjects were told their test results were normal.

Intervention and control subjects were then asked to assess both the seriousness of the

disorder and the accuracy of the test results.

Intervention subjects rated the disorder as significantly less serious, and the

enzyme test as significantly less valid, than did control subjects. Croyle and Sande (1998)

concluded that individuals may discount a threat during primary appraisal as a

mechanism for blunting the impact of threatening information (Croyle & Sande, 1988;

Ditto, 1995). This indicated that threats may be initially discounted by individuals during

their primary appraisal as a coping mechanism.

Smith and Lazarus (1993) examined the impact of primary appraisal on an

individual’s stress level. The investigators demonstrated that stressors appraised as

significant threats to personally important goal attainment resulted in significantly higher

levels of anxiety than stressors that did not threaten personally-important goals. The

researchers concluded that goal attainment is a major consideration in the threat-appraisal

process, and that threats to goal attainment are likely to be perceived as more stressful

than those threats that are not associated with goals (Smith & Lazarus, 1993).

Devonport and Lane (2006) noted that the perception of threat may be

exaggerated or mitigated, depending upon whether the individual perceives the threat to

be under their control. The researchers examined gender differences in the primary

appraisal process among students about to submit their dissertation. Study results

demonstrated that males considered the dissertation itself to be less challenging than did

female students; however, the male students considered the dissertation review process to

be significantly more threatening than did the female students. The researchers concluded

that male students sought to reduce their situational stress by positively evaluating

personal goal attainment, defined as the completion of the dissertation document. Male

students engaged in further emotional stress-protection by depersonalizing the source of

the stress and shifting the blame for a potentially negative outcome to the vagaries of the

review process. This strategy resulted in lower scores on the self-blame measure, and

higher scores on the personal disengagement variable, than those exhibited by the female

students (Devonport & Lane, 2006). Thus, the appraisal that resulted in the belief that the

threat was not under the students’ control blunted the emotional impact that might have

otherwise been felt as they experienced a threat to their goal attainment.

Primary appraisals have been associated with coping strategies and how threats

are framed can influence an individual’s coping strategy (Folkman et al., 1986). Franks

and Roesch (2006) examined the association between primary appraisal and coping

strategies among cancer patients. The study results showed that individuals who

appraised cancer as a threat used problem-focused coping strategies, and those who

appraised cancer as an impairment or deficiency used emotion-based avoidance coping

strategies (Franks & Roesch, 2006). The differences in primary appraisal in this study

highlighted the subjectivity associated with the appraisal, and how the appraisal itself

may then have implications for coping.

Dewe, O’Driscoll, and Cooper (2012) highlighted the role of primary appraisal in

the workplace. The researchers demonstrated that employees engage in primary threat

appraisal after most management-directed meetings. Another key trigger is performance

evaluation. Employees engage in a primary threat assessment both prior to, and as a

consequence of, performance review. These researchers highlighted the extent to which

individuals are primed to scan for personal threats, even within the context of routine

communication and evaluation processes (Dewe et al., 2012). Primary appraisals, then,

appear to be ongoing internal process, and people are primed to continually scan the

environment for threats and evaluate them.

Mohammad et al. (2013) posited that the primary appraisal process triggers the

selection of coping mechanism and the coping behaviors that an individual will exhibit.

Mohammad et al. evaluated the elements of the transactional model in a school setting by

observing stress and coping strategies with regard to teacher and student learning. The

researchers demonstrated that stress and tiredness can directly affect the efficiency of

teachers, which in turn affects student learning. The study results showed an inverse

relationship between model constructs (secondary appraisal, problem management,

emotional regulation, meaning-based coping, adaptations, and moderators) and the level

of perceived stress, except for the construct of primary appraisal. The authors concluded

that the primary appraisal serves as the catalyst for the coping behaviors that follow, and

the intensity of the coping response is a reflection of the perceived threat level established

through the primary appraisal process (Mohammad et al., 2013).

Secondary appraisal. The secondary appraisal includes both the assessment of

the coping resources perceived as available to an individual to help deflect the threat

identified through the primary appraisal process, and the options the individual considers

to actually address the resulting stress (Cohen & Wills, 1985; Glanz et al., 2008). The

secondary appraisal is often operationalized as an attempt to control stress, as in Marks,

Richardson, Graham, and Levine’s (1986) investigation of the relationship between

perceived control over the risk of cancer and the adoption of healthy behaviors. This

investigation demonstrated that individuals adopt health behaviors as both a risk- and

stress-controlling behavior in the wake of the perceived threat of illness (Marks et al.,

1986); having multiple resources available to help address the threat was found to

dampen both the intensity of the perceived threat and the associated stress. This

association has also been demonstrated relative to heart disease (Taylor, Helgeson, Reed,

& Skokan, 1991) and HIV/AIDS (Taylor et al., 1992). In each of these investigations,

perceived control over disease through the adoption of healthy behaviors improved the

overall wellbeing of the study subjects (Thompson & Spacapan, 1991).

Walinga (2008) examined the relationship between the types of resources

identified as available through the secondary appraisal and the actual ability of the

individual to affect change and deal successfully with stressful changes to a high-

performing soccer team. Walinga found that individuals who only identified resources

capable of reducing anxiety remained focused on emotional coping strategies and were

unable to effectively transform their circumstances to actually reduce the threat itself.

Individuals who identified cognitive resources during the secondary appraisal phase used

these resources to problem-solve and ultimately eliminate the source of the stress. This

study highlighted the importance of identifying the resources best suited to dealing with

the identified threat (Walinga, 2008).

Perceived stress. Perceived stress is the level of stress that is felt by an

individual. It is a function of not only objective stressors, but the extent to which the

threat contained in those stressors is of personal significance, and the extent to which the

individual can identify resources to help offset or eliminate the threat (Stawski, Sliwinski,

Almeida, & Smyth, 2008). Consequently, perceived stress encompasses Lazarus’

constructs of primary and secondary appraisal. Much research has been conducted using

perceived stress as a measure of the psychic and physical discomfort that remains after a

stressor has been adequately appraised (Stawski et al., 2008). Perceived stress, as such, is

measured as an indicator of the total anxiety that drives stress management and coping

behaviors.

Recent studies examining the validity of using perceived stress include Feizi,

Aliyari, and Roohafza’s (2012) examination of the of extent to which family conflicts and

social problems were correlated with measures of perceived stress. This study determined

a high correlation between the variables, and further found that adding financial, social,

and physical resources significantly reduced perceived stress levels. The researchers

concluded that perceived stress functioned in a manner consistent with predictions using

both the primary and secondary appraisal variables from the stress and coping model

(Feizi et al., 2012). Matheny et al. (2002) evaluated the relationship between perceived

stress, coping resources, and life satisfaction for young adults from America and Turkey.

Matheny et al. determined that, as in the investigation of Feizi et al. (2012), stress

perception differed based on the assessment of available coping resources.

Bovier et al. (2004) conducted a study of perceived stress and its relationship to

health outcomes in university students. The researchers found that higher levels of

perceived stress were associated with lower mental health, and perceived stress mediated

the positive impact of social support on mental health (Bovier et al., 2004). Kaplan,

Madden, Mijanovich, and Purcaro (2013) conducted a study to evaluate the relationship

between perceived stress and health and health behaviors. Kaplan et al. concluded that

higher levels of perceived stress were related to poorer health levels and unhealthy

behaviors in people of lower socioeconomic standing.

Stress management. The stress management component of the transactional

model of stress is comprised of two major elements: the coping strategies selected to

obviate the threat and any ensuing physical or emotional discomfort, and the moderating

factors that influence both the perceived threat level inherent in the stress appraisal

process and the preferred choice of coping strategy (Glanz et al., 2008). Understanding

the common coping strategies that are used, as well as the moderating factors that

influence perceptions of stress, can lend important insights into how stress can be

effectively managed.

Coping strategies. In the transactional model, Lazarus (1978) designated coping

strategies as those activities an individual engages in to manage the emotional or

functional consequences stemming from the threat appraisal (Lazarus, 1991; Lazarus &

Folkman, 1984). Lazarus divided coping strategies into three primary response

categories: problem management, emotional regulation, and meaning-based coping.

Problem management and emotional regulation are deemed coping efforts, and are

umbrella terms for a wide range of behavioral responses or coping strategies. Problem

management, or problem-focused coping, is designed to either alter the stressful

circumstances, or to modify the anticipated outcomes. Emotional regulation, or emotion-

focused coping, is directed toward reducing the anxiety level or emotional distress

generated by the threat appraisal process (Glanz et al., 2008; Lazarus & Folkman, 1984).

Meaning-based coping encompasses a set of coping behaviors designed to

reinterpret the threat as spiritually significant, personally significant, or otherwise

beneficial (Glanz et al., 2008). Lazarus (1984) originally conceived of meaning-based

coping as impacting the two primary coping efforts and fueling the will to sustain coping

activity; however, more recent investigations have also cast meaning-based coping as a

primary coping effort on par with problem-focused and emotion-focused efforts

(Folkman & Moskowitz, 2004; Lazarus, 1991; Lazarus & Folkman, 1984). Each of these

three coping efforts overarches specific coping strategies, which are the actual behaviors

an individual utilizes to deal with the threat (Glanz et al., 2002).

Problem management and emotional regulation. The literature on problem

management is dominated by examinations into the influence of cognitive problem-

focused coping strategies on stress level and problem resolution (Glanz et al., 2002).

Coping strategies associated with problem management efforts include information-

seeking and problem-solving approaches. A recurring finding from the problem-focused

coping literature is that cognitive problem-solving is an effective coping strategy when

the stressful circumstances are amenable to change (Glanz et al., 2002).

Emotional regulation is the ability to attenuate negative emotions, enrich positive

emotions, or otherwise maintain emotional balance (Neshat-Doost, Dalgleish, & Golden,

2008). The cognitive and behavioral processes that influence the occurrence, intensity,

duration, and the expression of emotions under stressful circumstances can be considered

emotion-focused coping activities. The ability to adopt effective strategies to control

emotion is considered a fundamental aspect of social and subjective well-being, because

it dampens the psychic pain associated with stress and restores a feeling of calm (Neshat-

Doost et al., 2008).

Recent studies have examined the complex interrelationships among problem-

solving, emotional regulation, and a sense of control over the stressful situations. This is

highlighted in the investigation that Mohammad et al. (2013) performed into the effect of

stress on teachers and teaching outcomes; the investigators found a significant and

opposite relationship between problem management, emotional regulation, and perceived

stress level. The researchers found that emotional coping strategies were used to lower

the level of stress felt by the teachers, and problem management strategies were

employed to effectively eliminate the source of stress. Mohammad et al. suggested that

emotion-focused and problem-focused coping work together to enhance stress

management.

The authors interpreted these findings as evidence that different coping strategies

serve different purposes in successful stress management. Emotion-focused strategies

were viewed as essential antecedents to problem-focused strategies, as intense emotional

and mental distress interferes with effective problem-solving. The investigators

concluded that multifaceted and well-honed evaluative capabilities are advantageous in

managing stress. Establishing a strong capacity to evaluate a range of coping options is

therefore linked to more effective stress management.

Grebner, Semmer, and Elfering (2005) examined the relationship between chronic

job stress, job control, and coping success. The researchers found that high job control

supported the use of problem-solving management strategies, which were associated with

increased levels of well-being. The researchers also found that emotional coping was not

related to job control, nor was it related to an increased sense of wellbeing. The authors

interpreted these findings to suggest that when stress levels are low, as in chronic job

stressors, emotional coping is not a necessary antecedent to effective problem-solving

coping activities.

Bell and D’Zurilla (2009) examined the capacity of high-quality problem-solving

abilities to influence the relationship between routine daily stress and anxiety levels and

cognitive impairments. The researchers found that participants with a positive problem-

solving orientation were less likely to exhibit either negative emotional or cognitive

reactions to the stress. The authors interpreted these findings to suggest that problem-

solving resources have a calming effect in low-stress situations, even without emotional

regulation activities.

Grover et al. (2009) determined that high-quality problem-solving strategies

significantly predicted suicidal ideation, but not suicidal attempts, in adolescents

suffering from high levels of stress from either an acute life event or from chronic life

stressors. Further, highly stressed adolescents with poor problem-solving capacity were

more likely to both consider and attempt suicide. The authors determined that good

problem-solving skills were able to buffer either episodic or chronic stress in the study

participants.

Creswell, Dutcher, Klein, Harris, and Levine (2013) found that among students in

chronic stress situations, high chronic stress levels were associated with impaired

problem-solving and creativity. When self-affirmation was introduced as an emotional

regulation strategy, the effects of the stress were buffered and problem-solving and

creativity improved. As in the study by Mohammad et al. (2013), emotional regulation

was interpreted as an antecedent to effective problem-solving in high-stress conditions.

While active problem-solving behaviors have been found effective in supporting

stress management without emotional regulation in conditions of low stress and in

conjunction with positive emotional regulation strategies in conditions of high stress,

other researchers have determined that the effectiveness of problem-centered strategies is

reduced when negative emotions predominate or negative emotional regulation strategies

are used. Anger has been linked with both avoidance behaviors and with a lack of

positive influence on stress management (Arslan, 2010).

Arslan (2010) examined the relationship between anger, anger expression, stress,

and interpersonal problem-solving among young adults. The results showed a negative

correlation between problem-focused coping and anger, and a positive correlation

between avoidance behavior and anger. Arslan concluded that anger is a particularly

disadvantageous reaction to stress. Anger was viewed as directing coping away from

potentially productive problem-solving techniques and anchoring it in a stagnant cycle of

emotional escape that allowed the stressful situation to either persist unabated or intensify

(Arslan, 2010).

Appelhans and Schmeck (2002) conducted a study of the motivational predictors

of coping strategy choices. This study evaluated the relationships between students’ self-

reported learning styles and self-reported coping style. The researchers indicated that the

level of motivation to perform well in a course was associated with the choice of coping

strategy. High levels of motivation were correlated with the selection of problem-focused

coping strategies. The authors interpreted these findings to mean that students who coped

with stress using problem-focused strategies had more confidence in their ability to think

critically and were positively motivated to persist in their studies, even when the work

was challenging.

Hesselink et al. (2004) examined the relationship between psychosocial coping

resources and coping style with Health Related Quality of Life (HRQoL) among patients

with asthma and chronic obstructive pulmonary disease (COPD). The researchers found

that an emotional coping was associated with poor HRQoL ratings. In addition, asthma

patients with lower self-efficacy, lower mastery feelings, and an avoidant coping style

were found to have the lowest HRQoL. In COPD patients, a rational coping style was

associated with lower HRQoL. Consistent with other interpretations form the literature

Hesselink concluded that the less-severe pulmonary disease, asthma, lent itself better to

strategic control, and was therefore not well served by emotional coping techniques.

COPD, however, is severe, progressive, and irreversible, leaving little room for effective

control using problem-solving techniques. Study results suggested a significant

association between coping resources and coping style and HRQoL, indicating that

psychosocial coping resources and coping style are independently associated with health

related quality of life in asthma patients (Hesselink et al., 2004).

Nordin, Andersson, and Nordin (2010) evaluated coping strategies, social

support, and responsibility for improvement in individuals who experienced chemical

intolerance (CI). Chemical intolerance was measured by either self-report or a clinical

diagnosis of hypersensitivity to odorous or pungent substances. Individuals suffering

from CI often experience significant quality of life impairments due to limitations placed

on working, living, and social environments. Nordin et al. found that the most effective

coping strategies were avoiding irritants, which often involved confronting others and

asking them reduce or eliminate perfume or other offending substances, as well as

advanced problem-solving strategies among those with high levels of CI. Emotion-

focused strategies were most effective for those with lower CI.

These results uphold ongoing findings that effective coping is control and

situation specific. In this situation, all levels of CI can be controlled through effective

problem-solving and action-based techniques. Study findings supported the interpretation

that only severe CI is limiting enough to motivate more effortful and confrontational

problem-management coping, while less-severe CI reactivity was less stressful than

imposing on others. Less-severe CI suffers turned to positive emotional strategies,

including family support, to cope with frustrating symptoms (Nordin et al., 2010).

Yamasaki and Uchida (2006) conducted a study of undergraduates to evaluate the

correlations between adverse effects, positive affect, and negative affect, and reported use

of emotion-focused coping or problem-focused strategies. Yamasaki and Uchida revealed

a positive relationship between positive affect and both cognitive reinterpretation and

problem-solving skills among male students, while a positive relationship between

positive affect and emotional expression was revealed for female students. Women

favored more expressive coping strategies, while men focused on problem-solving

strategies.

Meaning-based coping. Frankl (1986) observed that ascribing meaning to

misfortune is a universal human need. Placing misery in a significant context promotes

strength, dignity, and hope in the face of tragedy, and often serves as a motivating

perspective to support the ongoing struggle to survive (Frankl, 1986). Antonovsky (1990)

posited that a sense of coherence, whereby individuals experience the world as

comprehensible, manageable, and meaningful, is a core variable in shaping coping

responses and is positively related to health status. Meaning-based coping strategies

include reframing or reinterpreting the problem, accepting the inevitable, or employing

spiritual guidance or philosophy (Carver et al., 1993).

Folkman (1997) suggested that reexamining a stressful problem though the lens of

a positive attitude increases the capacity to perceive positive outcomes for others who

have experienced a similar situation. This phenomenon has recently been used to

examine meaning-based coping strategies in chronic and life-threatening circumstances

(Glanz et al., 2008). Bulman and Wortman’s (1977) evaluation of individuals suffering

from spinal cord injuries revealed a common need to attach meaning to the situation.

(Bulman & Wortman, 1977). Dunbar, Mueller, Medina, and Wolf’s (1998) qualitative

study of women suffering from HIV similarly uncovered meaning-based coping themes

relative to personal relationships, self-affirmation, life-affirmation, and death. Study

participants cited these interpretive frames as important to their psychological and

spiritual well-being, suggesting the importance of reframing in meaning-based strategies.

Rinaldis, Pakenham, and Lynch (2012) used the transactional model of stress and

coping to examine the influence of meaning-based coping within a larger context of

coping with a life threatening illness. The investigators sought to explore the effect of

benefit finding (BF) among colorectal cancer patients on measures of wellbeing. Benefit

finding is the process by which individuals who have experienced a significant health

event find value in the illness to provide comfort and opportunities to improve the quality

of their lives. Rinaldis et al. classified and measured the influence of the meaning-based

BF coping strategies as personal growth and interpersonal growth and acceptance. The

authors denoted cognitive and problem-solving coping strategies as perceptual change or

reframing, acceptance-related cognitive change, palliative activities, and life

reorganization. The researchers also measured emotion-focused coping strategies as the

practice of religion, humor, rumination, and seeking out social support. The wellbeing

outcome variables were positive affect, psychological distress, cancer-related quality of

life, and general satisfaction with life.

Rinaldis et al. (2012) measured the variables at two points in time, immediately

after the initial diagnosis, and 12 months after the initial diagnosis. The researchers found

that all three coping strategies were most effective immediately after diagnosis with BF

strategies, cognitive problem-solving strategies, and social support seeking most strongly

positively associated with positive affect. The cognitive strategy of perceptual change

also reduced psychological distress and positively influenced cancer-related quality of

life, while BF strategies were strongly positively related to general life satisfaction. The

protective influence of all coping strategy variables faded over all outcome variables 12

months after diagnosis.

The researchers concluded that the effective coping response to a life-threatening

stressor changes over time, and that both meaning-based coping in the form of BF and the

cognitive strategy of reframing the problem are the strongest initial effective coping

responses. Over time, the effectiveness of all coping strategies faded, but positive

outcomes across all outcome variables at both time periods were associated with the

presence of the stress and coping model moderator variable of optimistic dispositional

coping and the resource variable of ongoing social support for the illness. The researchers

interpreted this finding to mean that successful long-term coping with a life threatening

disease is a function of personality and the resources available to address the lack of

personal control over outcomes.

Interestingly, Rinaldis et al. (2012) failed to note the compelling role that BF

played in the early stages of the coping process. In addition, the researchers defined

meaning-based coping more narrowly than other recent investigations into illness coping,

with some of the larger connotations of meaning-based coping being represented by the

cognitive reframing strategies that also proved useful in the early stages of the illness

(Rinaldis et al., 2012). A study by Guo, Gan, and Tong (2013) provided one potential

explanation of these findings.

Guo et al. (2013) examined the effectiveness of problem-focused coping,

meaning-based coping, and emotion-focused coping on the mental health of earthquake

victims following the 2008 Sichuan Earthquake. As in the Rinaldis et al. (2012) study,

the investigators found that meaning-based coping was a significantly better predictor of

positive affect and well-being than either problem-focused or emotion-focused coping

behaviors. The investigators interpreted these findings as consistent with Lazarus’ (1984)

initial view of meaning-based coping as a source of acceptance and strength to fuel either

problem-focused or emotion-focused stress management strategies. These results raised

the possibility that meaning-based coping precedes other coping measures in the wake of

tragedy. The researchers viewed meaning-based coping as a calming influence that paved

the way for more considered actions, including the assessment of the resources available

to exert control or otherwise successfully manage the situation. This interpretation is also

consistent with the findings in Rinaldis et al. (2012).

Hashim, Soliman, and Mansour (2012) examining coping in couples who

experienced a failure to conceive using reproduction-enhancing technologies, and

provided evidence that not all meaning-based coping is positive. Participants employed

both meaning-based and emotion-focused coping to deal with the stress of failure to

conceive, but meaning-based coping was not found to be an effective strategy. Heavy

dependence on meaning-based coping was strongly positively related to high fertility-

related stress in the female partner, and this stress negatively impacted the women’s

personal, marital, and social life (Hashim et al., 2012). The authors concluded that the

utility of meaning-based coping may be limited at times when a potentially effective

problem-focused solution to a stressful situation fails to produce the desired results. It is

possible that failure of the problem-focused strategy is interpreted to mean personal

failure where others have succeeded, thereby enhancing rather than reducing stress.

Moderators. The final two components of the transactional model of stress and

coping are viewed as moderating the assessment of coping resources available, the

selection of specific strategies within all three coping components, and ultimately

impacting the adaptive outcomes to stress. The two moderator variables are social

support and dispositional coping style. Each is examined below.

Social support. Social support is included in the transactional model as a multi-

faceted external resource with the potential to vary the options available for either

altering or controlling the threat (Lazarus & Folkman, 1984). Social support entails

assistance from outsiders that facilitates any of the three major coping efforts and is,

consequently, a coping mechanism moderator in the larger scheme of stress management

(Folkman & Moskowitz, 2004). Individuals include social support in stress management

activities in a variety of ways. A person’s social network may be useful in providing

factual knowledge, experiential knowledge, material resources, empathy, and

camaraderie, as well as in serving as a sounding board for the individual’s perceived

plight and offering outside perspectives on the usefulness of potential strategies to deal

with that plight (Heaney & Israel, 2002).

Consequently, social support may be used to bolster cognitive, emotional, and

meaning-based strategies directed toward the threat or the psychological repercussions of

that threat (DeLongis & Holtzman, 2005). Studies examining the impact of social support

and have demonstrated a significant positive association with personal wellbeing across

diverse populations (Coyne & DeLongis, 1986; Masten, Tusak, Zalar, & Ziherl, 2009;

Russell & Cutrona, 1991; Uchino, Uno, & Holt-Lunstad, 1999).

Chao (2011) highlighted the value of social support in enhancing stress

management. Chao’s study of 459 college students evaluated whether social support

moderated the relationship between perceived stress and well-being. Results from the

study showed that students with higher social support had higher levels of self-reported

well-being. When the students were under stress, using problem-focused management

reduced the stress level, and having family and friends’ support on solving the problems

further improved overall well-being. The researcher interpreted these findings as

consistent with the transactional model (Chao, 2011).

Classen et al. (2011) evaluated social support among women diagnosed with

metastatic breast cancer. Study participants were offered 1 year of weekly supportive-

expressive group therapy and educational materials. The researchers found that social

support reduced distress and eased the feeling of social isolation. Classen et al. concluded

that social support reduced traumatic stress symptoms (Classen et al., 2001).

Emmelkamp, Komproe, Van Ommeren, and Schagen (2002) examined the

influence of social support on anxiety, depression, and somatic symptoms for 315 torture

victims. Researchers found a direct positive relationship between social support and

effective coping, also noting that the use of multiple coping strategies was associated

with lower levels of anxiety and depression. The authors also noted that actual social

support had a greater impact on the abatement of symptoms than did perceived social

support that was not mobilized. These findings confirmed the importance of using

multiple coping strategies and importance social support to and support services for

individuals who have experienced trauma (Emmelkamp et al., 2002).

DeLongis and Holtzman (2005) examined the relationship between social support

and personality traits on stressful life events. Study results demonstrated that although the

stress level associated with stressful life events was related to personality type, adequate

social support reduced the severity of negative stress-related health outcomes, regardless

of personality. The researchers concluded that social support is effective across

individuals in reducing the impact of stressful life events on physical wellbeing

(DeLongis & Holtzman, 2005).

Chao (2011) conducted a study to evaluate the relationship between social

support, problem-focused coping, and well-being under stress among 459 graduate

students in counseling psychology. Chao found that social support buffered the

relationship between perceived stress and psychological well-being, and this effect was

mediated by problem-focused coping. The results also showed that students who used

high avoidant coping strategies in a low social support environment had the lowest levels

of well-being under stress. Chao interpreted these findings to mean that social support

offers greater stress relief when accompanied by effective strategies to confront and deal

with the stress, and that a lack of social support contributes to the deleterious effects of

ineffective coping strategies (Chao, 2011).

Dispositional coping style. Coping styles have been regarded as stable

characteristics inherent in individuals (Gillespie & Gates, 2013). Lazarus (1993) provided

a clear distinction between coping effort and coping style, noting that coping efforts are

situation-specific behaviors, while a coping style is a general attribute that an individual

employs across situations. Coping style is a lens through which an individual generally

perceives and responds to situations and circumstances (Lowe, Norman, & Bennett,

2000). Lazarus indicated that coping style inclined the individual to rely on dispositional

compatible coping behaviors by biasing selection among competing behavioral options

within coping effort categories. Researchers have also determined that coping style

modifies the effectiveness of a given coping strategy among individuals (Lazarus, 1993).

Coping style has been operationalized in a variety of ways across the literature.

Early conceptualizations and research focused on determining why a certain segment of

the population remained physically and psychologically healthy, even in the face of

stressful life events (Guo et al., 2013). Researchers determined that these individuals

share a common attitude toward life in which they view situations as a controllable

challenge they are committed to overcoming (Punamaki et al., 2008). This coping style

has been termed resilience, and is closely related to another often cited the predisposition:

optimism. Optimism has been defined as the tendency to view situations from a positive

perspective, and is frequently examined in relation to the Lazarus transactional model

(Rinaldis et al., 2012; Taylor et al., 1992).

Another commonly-investigated predispositional style is the rational or problem-

focused style, which is characterized by a tendency toward active information-seeking

and cognitive assessment. Individuals with this tendency are inclined to evaluate

situations using logic and cognitive effort to make sense of circumstances and plan a

course of action (Shikai, Uji, Shono, Nagata, & Kitamura, 2008). A third often-

investigated predisposition is emotional style. Antonovsky (1990) posited that the

emotional style is considered a passive reaction to a stressor, and may include using

humor to deflect the pain, seeking comfort in social support and using escapist strategies

such as denial, procrastination, avoidance, and substance abuse. Rational coping is less

well used by individuals with this inclination (Antonovsky, 1990).

Recent research into dispositional styles has focused on differentiating situational

coping, which is the application of stress management strategies to a specific stressor or

set of stressors, and dispositional coping as a trait the drives situational coping choices in

times of stress. Shikai et al. (2008) examined the relationship between dispositional

coping style in adulthood and childhood experiences in Japanese undergraduates. Shikai

et al. found that an emotion-oriented coping style was found more frequently among

adults who were neglected or emotionally abused during childhood. The researchers

suggested that this finding indicates that childhood experiences shape adult coping and

that the dispositional coping style can be learned in addition to being inborn (Shikai et al.,

2008).

Punamaki et al. (2008) examined the difference between dispositional and

situational coping and psychological distress between former political prisoners in

Palestine and a matched control group. Dispositional coping was evaluated as a generic

response style to hypothetical stressors, and situational coping was assessed through the

responses of participants to their personal traumatic experiences. Ex-political prisoners

used fewer avoidant, emotion-focused, and denying strategies to both the personal and

the hypothetical scenarios. Main effects showed that low dependence on emotion-focused

strategies coping and high levels of active and constructive coping were linked with low

levels of psychiatric symptoms and psychological distress, but neither the overarching

categories of dispositional style nor situational coping buffered distress. The researchers

suggest that the overall approach is less predictive of stress reduction than the specific

strategies employed in each instance of stress, and that both dispositional and situational

approaches can be shaped by experience (Punamaki et al., 2008).

Steinhardt and Dolbier (2008) examined the origin of dispositional resilience in

stress management by providing resilience training to university students to reduce

symptomatology during periods of increased academic stress. The intervention group

demonstrated higher post-intervention resilience scores, greater situational adoption of

effective higher problem-solving strategies, and lower use of ineffective avoidance

strategies than the control group. In addition, the intervention group was more likely to

demonstrate higher levels of the protective personal traits of self-leadership, positive

affect, and self-esteem. In addition, the intervention group experienced lower levels of

perceived stress and fewer symptoms of depression than the control group. The

researchers suggested that these findings are consistent with the interpretation that a

resilient predisposition can be learned, and that improved situational stress-related

strategies are more likely to be adopted by those who have mastered this coping style

(Steinhardt & Dolbier, 2008).

Sasaki and Yamasaki (2007) conducted a study among 229 university freshman to

identify causal relationships between dispositional and situational coping and health

status. The results of this study showed that dispositional coping style could predict

situational coping practices, and that increases in predispositional emotional focused

coping are negatively linked to health status. The predispositional coping strategies of

cognitive reinterpretation and problem-solving are better predictors of health status. The

researchers noted that these results contrasted with their earlier findings (Sasaki &

Yamasaki, 2005) that a predisposition to use cognitive reinterpretation and problem-

solving leads to greater distress. The researchers also found in this more current study

that when investigating specific stressful events, the effect of predispositional style was

mediated by the specific strategies chosen within the specific context (Sasaki &

Yamasaki, 2007).

Sasaki and Yamasaki (2007) interpreted the totality of their 2005 and 2007

findings to suggest that predisposition does, indeed, bias the choice of specific coping

strategies for specific stressful events among the study population. However, the

effectiveness of the specific strategies selected is dependent on the specific stressor to

which they are applied. These findings are consistent with findings from the coping

literature that have suggested that problem-solving strategies are most useful when

circumstances are controllable (Mohammad et al., 2013), emotional coping strategies are

more effective in protecting wellbeing in situations that cannot be controlled (Grebner et

al., 2005), and meaning-based coping such as reframing is a useful antecedent to

purposeful problem-solving (Rinaldis et al., 2012). Table 2 presents the key findings

from this theoretical literature review.

In the current investigation, I will assess the extent to which young adults adopt

applicable CAM therapies to manage stress within the context of daily stressors. I will

further determine if CAM use is related to perceived stress levels, levels of exposure to

CAM philosophies and therapies, and to individual coping styles. The literature review

has demonstrated that the transactional model of stress and coping has been specifically

conceived to address the context of stress management. It provides additional evidence

that the model is a robust framework for evaluating the effectiveness of coping strategies

in reducing perceived stress and its physical ramifications under diverse circumstances

for diverse populations. Finally, the literature has established that the model has been

successfully applied in research targeting young adults. For these reasons, I will employ

the transactional model of stress and coping as an appropriate theoretical framework for

the study.

Table 2

Key Findings of the Theoretical Literature Review

Key component of

the transactional

model of stress

and coping

Major findings from the recent literature

Researchers

Stress appraisal:

Primary appraisal

 The level of stress experienced: 1)Depends

on the perceived level of control over the

stressor and 2) drives the intensity of the

corresponding coping response

 The perception of a given threat as being

either under an individual’s control or not

under an individual’s control: 1) may differ

by individual and 2) drives the choice of

coping strategy

 Individuals are primed to search for threats

to personal utility and goal achievement

Devonport et al.

(2006)

Dewe et al.

(2012)

Folkman et al.

(1986)

Mohammad et

al. (2013)

Smith et

al.(1993)

Stress appraisal:

Secondary

appraisal

 The resources identified in the appraisal

process are the resources used to cope with

the stress

 Increases in available resources reduces

stress while a lack of available resources is

associated with negative health outcomes

and high stress

Bovier et

al.(2004)

Feizi et al.

(2012)

Taylor et

al.(1991)

(table continues)

Key component of

the transactional

model of stress

and coping

Major findings from the recent literature

Researchers

Stress appraisal:

Perceived stress

 A valid indicator of anxiety that remains

after the threat and the available resources

have been appraised

Bovier et al.

2004

Stawaski et al.

2008

Stress

management:

Problem

management

 Cognitive problem-solving is an effective

coping strategy when stressful situations are

amenable to change

 Good problem-solving skills buffer both

episodic or chronic stress

 Using problem-solving coping in situations

not under the individual’s control leads to

poorer quality of life outcomes

 Problem-focused strategies were associated

with positive critical thinking and the

motivation to overcome challenges to goal

attainment

Appelhans &

Schmeck.

(2002)

Mohammad et

al. (2013)

Hesselink et al.

(2004)

Stress

management:

Emotional

regulation

 Emotional coping strategies were used to

lower the level of stress, to facilitate the use

of problem management strategies

especially in high stress situations to

eliminate the source of stress.

 When stress levels are low, emotional

coping is not a necessary antecedent to

effective problem-solving coping activities.

 Anger, avoidance and other negative

emotional strategies do not lower stress and

are associated with lower levels of well

being

Bell et al. (2009)

Cresswell et al.

(2013)

Elfering et al.

(2005)

Grover et al.

(2009)

Mohmmad et al.

(2013)

Appelhans &

Schmeck (2002)

Hesselink et al.

(2004)

(table continues)

Key component of

the transactional

model of stress

and coping

Major findings from the recent literature

Researchers

Stress

management:

Meaning-based

coping

 Meaning-based coping strategies produce a

sense of calm in the early stages of a

catastrophic or life threatening situation that

may be antecedent to problem-focused or

emotion-focused responses. This benefit

fades overtime

 Meaning-based coping strategies are

effective in situations that cannot be altered

by problem management, however, their

effectiveness may be limited when a

problem-focused solution fails to produce

the desired results

Carver et al.,

(1993)

Glanz et al.,

(2008)

Guo et al.

(2013)

Hashim et al.

(2012)

Rinaldis et al.

(2012)

Outcomes of

coping:

Moderators –

Social support

 Social support bolsters cognitive, emotional,

and meaning-based strategies

 Social support moderates the relationship

between perceived stress and well-being

 Social support offers greater stress relief

when accompanied by effective strategies to

confront and deal with the stress, and a lack

of social support contributes to the delirious

effects of ineffective coping strategies

Chao et al.

(2011)

Chao et al.

(2011)

Classen et al.

(2001)

Delongis et al.

(2005)

Outcomes of

coping:

Moderators -

Dispositional

coping

 Coping style inclines the individual to rely

on dispositional compatible coping

behaviors by biasing selection among

competing behavioral options within coping

effort categories

 Emotion oriented coping style was found

more frequently among adults who

experienced severe physical or emotional

stress during childhood

 Dispositional coping was evaluated as a

generic response style to hypothetical

stressors

Lazarus (1993)

Punamaki et al.

(2008)

Sasakai and

Yamasakai

(2007)

Shikai et al.

(2008)

Steinhardt &

Dolbier (2008)

 Both dispositional and situational

approaches can be shaped by experience

and a resilient predisposition can be learned

 Specific coping skills are more appropriate

to supporting higher levels of general health

than pre-dispositional style

Steinhardt &

Dolbier (2008)

Stress and Young Adults

Young adult college students are among the most consistently-stressed segment

of the young adult population (Dusselier, Dunn, Wang, Shelley, & Whalen, 2005).

Traditional young adult college students experience stress based on separation from their

parental family, changed living conditions, academic workload, romantic entanglements,

and concerns about future employment opportunities (Dusselier et al., 2005).

Nontraditional young adult students potentially have additional stressors including

balancing employment with college classes, raising a family, and bearing the financial

responsibilities associated with these additional demands. Young adult college students,

like all young adults, must face these stresses while their brain is still maturing (Rebbeck,

Weber, Spangler, & Zeigler-Johnson, 2013). The lack of a well-developed cognitive

executive function leaves young adults vulnerable to impulsivity and maladaptive coping

choices, including anger, avoidance, blame-shifting, smoking, drinking, and time

management issues that lead to skipped meals, sleep deprivation, and lack of exercise

(Nelson, 2008; Ohayon, 2007).

Younger adults are considered emerging adults, a transitional stage between late

adolescence and adulthood (Arnett, 2004). Evidence suggests that this transition stage is

stress-provoking, because failure to accomplish developmental tasks may impact the

transition to a fully-adult lifestyle, and thereby thwart personal goals (Newman &

Newman, 2008). Epidemiologists have reported high rates of major depressive disorders

in younger adults than in the general population or among older students (Blanco et al.,

2008; Kessler et al., 2003). Living arrangements, occupational activities, and the social

environment may further influence depressive disorders in younger adults. (Kessler et al.,

2003; Ohayon, 2007).

Perceall and Keim (2007) conducted a study to understand how college students

cope with stress. They gathered data from 212 students enrolled in southern Illinois

community colleges. Of the students surveyed, 75% perceived their stress level as high,

and female students reported higher stress levels than males. The researchers found that

the most-common activities used to cope with stress were talking to family and friends,

engaging in leisure activities, and exercise. The maladaptive practices reported were

alcohol consumption, smoking, and drug use. The students who reported less social

support from family and friends also reported higher amounts of alcohol abuse (Pierceall

& Keim, 2007).

Welle and Graf (2011) identified effective lifestyle habits and coping strategies

for stress tolerance among college students. The researchers collected data via a survey of

459 students. The survey included an inventory of stressors, stress related symptoms, and

coping strategies. The researchers found that having a sense of control over life, feeling

supported, being satisfied with the environment, having adequate social interaction, and

effectively handling academic demands were associated with high stress tolerance (Welle

& Graf, 2011). The researchers also found that stress tolerance varied along racial lines,

with White students demonstrating a higher correlation between lifestyle-related factors

and high stress tolerance than did Black students. The results also varied by gender, with

males reporting more coping behaviors than females (Welle & Graf, 2011). The

researchers concluded that students of different racial and gender groups cope differently,

and that stress management among college students must account for different sub-

populations.

Mahmoud, Staten, Hall and Lennie (2012) surveyed 508 fulltime undergraduate

students to understand the relationships among students’ depression, anxiety, stress,

demographics, life satisfaction, and coping styles. The researchers used the Brief COPE

Inventory and an adapted version of the Brief Students Multidimensional Life

Satisfaction Scale to measure life satisfaction. They also used the Depression, Anxiety,

and Stress Scale-21 (DASS-21). The authors found that maladaptive coping was the main

predictor of depression anxiety and stress (Mahmoud, Staten, Hall, & Lennie, 2012). The

researchers concluded that reducing maladaptive coping behaviors may have the greatest

positive impact on reducing depression anxiety and stress in the young adult population.

LaBrie, Ehret, Hummer, & Prenovost (2012) conducted a study to evaluate the

relationship between the motives behind drinking behavior and alcohol-related outcomes

among college students. An online survey of 253 college students assessed student

alcohol consumption, alcohol-related consequences, positive and negative college

adjustments, and drinking motivation. Findings demonstrated that the relationship

between the motive of drinking to cope and alcohol consequence (negative alcohol-

related problem) is mediated by negative college adjustment. Positive college adjustment

is not directly related to alcohol related outcomes. A gender difference was also

observed, as coping motives were directly predictive of negative alcohol related

consequences among females but not males. The researchers concluded that reducing

negative college adjustment-related stress is a potentially important strategy to decrease

alcohol-related risk among college students (LaBrie et al., 2012).

Mahmoud et al. (2012) studied the relationship of mental health factors to life

satisfaction and coping strategies among young adult college students. The researchers

surveyed a total of 1.700 fulltime undergraduate students using the Depression Anxiety

Stress scale, the Brief COPE inventory, and the Brief Students Multidimensional Life

Satisfaction scale. Researchers found that students who used maladaptive coping

strategies reported higher levels of depression and anxiety. Students with greater life

dissatisfaction also reported higher levels of depression. Students who used maladaptive

coping reported higher levels of depression and anxiety. Students with greater

dissatisfaction with life indicated higher levels of depression, anxiety, and stress.

Students with lower GPA were more depressed and female students were more anxious

and stressed than male students. These study results demonstrated that maladaptive

coping, life satisfaction, gender, and GPA are significant predictors of stress (Mahmoud

et al., 2012).

Younger adults perceive time constraints on healthy dietary behaviors, which may

contribute to stress. Pelletier and Laska (2012) conducted a study to identify the

association between perceived time constraints for healthy eating and responsibility for

work, school, and family among young adults. This cross-sectional survey evaluated 598

students enrolled in community college and 603 students from a public university. The

researchers used perceived time constraints; work, school, and family responsibilities;

and socioeconomic demographic characteristics as the variables for this study. Women of

lower socioeconomic status perceived more time constraints and were less likely to have

healthy balance than women of higher socioeconomic status. Women in a committed

relationship had higher time constraints in general. Heavy course load and working long

hours were important predictors of time constraints among men while living situation

(living at home) and being in a relationship were more predictive of time constraints for

women (Pelletier & Laska, 2012).

Emotion dysregulation and impulsivity have been independently considered as

risk factors for addictive behavior (Granö, Virtanen, Vahtera, Elovainio, & Kivimäki,

2004). Schreiber, Grant, and Odlaug (2012) conducted a study to evaluate the

relationship between emotional dysregulation and impulsivity among younger adults. The

researchers used the emotion dysregulation scale, MINI international neuropsychiatric

interview, self-reported assessments (Eysenck Impulsivity Questionnaire, Barrat

Impulsivity Scale, Tridimensional Personality Inventory and Pauda Inventory) and

cognitive assessments as measures in this study of 194 participants. High emotional

dysregulation was associated with higher measures of impulsivity and increased risk of

engaging in harmful behaviors, and a reduced ability to reason clearly relative to

behavioral risk and potential negative outcomes. The researchers concluded that

emotional regulation is an important factor to consider in addiction risk (Schreiber et al.,

2012).

Daily stress and fatigue affect learning and cognitive function in younger adults

(Beckner, Tucker, Delville, & Mohr, 2006). Palmer (2013) evaluated the association

between fatigue and stress on learning and cognitive functions among 60 college

students. Fatigue was measured using saliva samples and the Iowa Fatigue scale. Stress

was measured using the Perceived Stress Scale. Cognitive functioning was measured

using neurocognitive executive functioning tests. Working memory was also tested using

a standardized scale. The study results showed that physiological fatigue and stress were

both predictive of learning challenges and poor cognitive performance among college

students (Palmer, 2013).

Ohayon and Roberts (2014) conducted a two-sample investigation of 19,136

subjects from the general population and 2,196 students living on a university campus to

compare major depressive disorder in young adults living in a community versus those

living on a university campus. The researchers conducted telephone interviews using a

standardized questionnaire. Analysis showed that stress and social isolation were

predictive of depression among younger adults. The prevalence of depressed mood and

depressive disorders were similar between community and campus students group. This

study also noted the importance of prevention, early identification, and mental healthcare

access for young people (Ohayon & Roberts, 2014).

Complementary and Alternative Medicine

According to the National Center for Complementary and Alternative Medicine

(NCCAM), nearly 40% of Americans use healthcare approaches which deviate from

conventional medicine (NCCAM, 2013). These types of treatments and practices have

been labeled complementary when used in combination with conventional medicine, and

alternative when used in place of conventional medicine. Together, these practices are

referred to as CAM. Most of the people practicing CAM use it in conjunction with

traditional treatments. When woven into the fabric of Western medicine, CAM is called

integrative medicine (NCCAM, 2013).

Table 3

Key Findings from This Theoretical Literature Review

Key component of

the stress and

younger adults

Major findings from the recent literature

Researchers

Coping used for

stress management

among younger

adults

 Most common coping practices

among the younger adults are

talking to family and friends,

engaging leisure activities and

participating in exercise.

 Maladaptive practices are

alcohol consumption, smoking,

and drug use

Perceall & Keim,

2007

Stress tolerance

 Having sense of control over

one’s life, feeling well

supported, satisfaction with

one’s environment, having

adequate social interactions,

effective handling of academic

demands associated with high

stress tolerance

 Stress tolerance varies with race

and gender

Well & Graf, 2011

(table continues)

Key components of

the stress and

younger adults

Major findings from the recent literature

Researchers

Predictor for the

stress

 Maladaptive coping was the

main predictor of depression

anxiety and stress

 Students used maladaptive

coping reported higher levels of

depression and anxiety

Mahmoud, Staten,

Hall & Lennie, 2012

Alcohol

consumption

 Negative college adjustments

associated with alcohol

consumptions and alcohol-

related consequence

LaBrie, Ehret,

Hummer, &

Prenovost, 2012

Time constraints

 Women with lower

Socioeconomic status perceived

more time constraints and less

likely to have healthy balance in

life

 Women with relationship had

higher time constraints

 Heavy course load and working

long hrs. are predictors of time

constraints among men

 Living at home and being in

relationship were more

predictors of time constraints for

women

Pelletier & Laska,

2012

Emotional regulation

 High emotional dysregulation

was associated with higher

measures of impulsivity and

increased risk of engaging in

harmful behaviors

 Emotional regulation is

associated with addiction risk

Schreiber et al.,

2012

Learning challenges

and cognitive

performance

 Physiological fatigue and stress

were predictive of learning

challenges and poor cognitive

performance among college

students

Palmer, 2013

Predictor for

depression

 Stress and social isolation were

predictive of depression among

younger adults.

Ohayon & Roberts,

2014

Integrative medicine is a growing health trend, and research into the efficacy of

CAM practices is a promising emerging field (White House Commission on

Complementary and Alternative Medicine Policy, 2002). Lifestyle-related illnesses are

the leading cause of death in the United States, and holistic approaches to health are

rapidly gaining popularity. The boundaries between CAM and mainstream medicine are

often blurred, with mainstream doctors often recommending non-traditional practices in a

clinical setting (WHC, 2002). CAM is defined as a group of diverse medical and

healthcare systems, practices, and products not present in the conventional dominant

healthcare system of a particular society or culture. (Giordano, Boatwright, Stapleton, &

Huff, 2002; NCCAM, 2008b). According to NCCAM, CAM treatment approaches are

classified in to five main groups or domains (NCCAM, 2013).

The first category is that of alternative therapeutic systems informed by practice

and theory. This category includes naturopathic, homeopathic, Ayurvedic, and Chinese

medicine. Naturopathic medicine is a Western medical system based on diet and lifestyle

change combined with other CAM modalities such as massage, herbs, and joint

manipulation to support the individual's ability to heal without the application of

conventional medicine (NCCAM, 2013). Homeopathic medicine is a holistic system

originating in Europe that seeks to stimulate the body’s innate healing capacity by giving

small doses of highly-diluted substances that, in large quantities, would aggravate the

symptoms (an approach based on “like cures like”).

Ayurveda is a holistic medical system that originated in India which integrates

mind, body, and spirit to prevent and treat disease. Ayurvedic therapies employ the use of

herbs, massage, and yoga (NCCAM, 2013). Chinese medicine is also a mind-body-spirit

medicine similar to Ayurveda. Chinese medicine (as well as other Eastern medicine

systems) seeks to determine the underlying or root cause of the issue and act on the

energy that creates disease. In this sense, a root problem on the spiritual plane may cause

a physical manifestation or suffering. By treating the spirit, oftentimes the physical

complaint disappears (Cushman & Hoffman, 2004).

The second domain encompasses the mind-body systems of interventions that

have the capacity to affect body function. Such practices include: hypnosis, guided

imagery, mental healing, yoga, and meditation. Meditation includes many different

practices and disciplines, including mindfulness meditation and transcendental

meditation. Meditation is a mind practice in which individuals focus their attention and

become more in touch with their body and mind interconnectivity (NCCAM, 2013).

Yoga can be practiced in many different styles and is used to promote health. Most

practices combine movement, breathing techniques, and meditation (NCCAM, 2013).

Prayer medicine varies greatly among religions and individuals, but may include an

individual prayer for the self, or asking another to pray on their behalf (Ayers &

Kronenfeld, 2010).

The third domain encompasses biological systems, such as herbs and dietary

supplements. Manipulative body-based interventions such as osteopathic, chiropractic,

and massage also fall under this category. The chiropractic professions focus on the

relationship between the spine and body structure functioning. This practice is based on

the theory that manipulation of the spine and other parts of the body will help to improve

and support the body’s natural ability to heal (NCCAM, 2013)

Herbal medicine is considered one of the oldest healing practices; it can be found

in almost every tribe and culture. Materia medica and documentation of the healing

properties of plant substances have been recorded in ancient China, Babylon, Egypt,

India, and later Greece, Rome, and the Arabian Empire (Griggs & Van der Zee, 1997).

Known as botanical healing or herbalism in America, this method is the practice of

collecting, preparing, and using herbs. Western herbalists also incorporate the use of

pulse diagnosis, as well as examining and skin, tongue, facial markings, voice, speech,

and body movements (Cushman & Hoffman, 2004).

The last of the domains includes the energy therapies and bio-electromagnetic and

bio-field therapies such as pulse fields and therapeutic touch. Reiki is an ancient form of

therapy in which touch from the hands is believed to transmit healing energy (Cushman

& Hoffman, 2004). The Reiki practitioner acts as a conduit for life force energy to

remove energy blockages or transmit new energy to the receiver or patient. This practice

is popular as a complementary modality, as it can be used for any condition (Cushman &

Hoffman, 2004).

Although researchers have shown specific modalities to be effective in certain

conditions, most of the domains are used widely for a variety of health concerns and to

promote general wellbeing, including stress reduction. More research is needed to

specifically understand the benefits of each practice and its best applications in the

medical field (NCCAM, 2013). Table 4 summarizes the CAM domains and the therapies

associated with those domains.

Table 4

Major CAM Domains with Examples

Major Domain of

CAM

Examples

Alternative healthcare

systems

Ayurvedic medicine

Chiropractic

Homeopathic medicine

Native American medicine (e.g., sweat lodge, medicine

wheel)

Naturopathic medicine

Traditional Chinese medicine (e.g., acupuncture, Chinese

herbal medicine)

Mind-body

interventions

Meditation

Hypnosis

Guided imagery

Music therapy

Prayer and mental healing

Biological-based

therapies

Herbal therapies

Special diets (e.g. macrobiotics, extremely low-fat or high-

carbohydrate diets)

Orthomolecular medicine (e.g., megavitamin therapy)

Individual biological therapies (e.g., shark cartilage, bee

pollen)

Therapeutic massage

and somatic

movement therapies

Massage

Body work therapies

Energy therapies

Qigong

Reiki

Therapeutic touch

Bioelectromagnetics

Magnet therapy

CAM Use

Kessler et al. (2001) conducted a survey of 2,055 participants to identify the

current use, lifetime use, and age at first use of 20 CAM therapies in the United States.

The researchers also examined the use of CAM therapies to treat anxiety and depression.

The researchers reported that a total of 9.4% of the respondents had suffered from anxiety

attacks in the past 12 months, and 7.2% reported severe depression. A total of 56.7% of

those with anxiety, and 53.6% of those with depression, reported using some form of

CAM to treat these conditions. The NCCAM and National Center for Health Statistics

conducted a survey to identify Americans’ use of CAM (NCCAM, 2008a). Results of

data from 23,393 adults aged 18 year or older and 9,417 children in the United States

showed that approximately 38% adults and 12% of children had used some form of CAM

in the last 30 days.

CAM as a stress management technique. The effectiveness of CAM techniques

in reducing stress has been an important area of research (Collinge, Wentworth, & Sabo,

2005). CAM holds significant potential for enhancing the management of stress, mental

disorders, and other traumatic diseases (Pemberton & Turpin, 2008). CAM methods such

as yoga, meditation, exercise, energy-based therapies, and body-centered psychotherapies

are used to treat symptoms of anxiety, stress, and stress-related disorders (Lehrer,

Woolfolk, & Sime, 2007). Some examples of CAM used to enhance coping include

prayer, mental healing, meditation, and psychotherapy, as well as inventive outlets like

dance, art, or music (Cummings, 1998). According to Collinge et al. (2005), CAM has

been shown to be safe and effective for the management for depression, anxiety, and

stress (Collinge et al., 2005).

CAM is used for stress management by 40% of the women in United States (Su &

Li, 2011). When vitamins and praying for health are included, the proportion of the

female population that uses CAM treatments increases to 69% (Barnes, Bloom, & Nahin,

2008). People who frequently use CAM treatments and therapies are of three types: (a)

educated people (mostly younger adults), (b) women, and (c) people who live in or near

urban areas (Barnes et al., 2008).

The use of relaxation techniques for health is widely practiced. Researchers have

supported the use of relaxation techniques for a variety of conditions including anxiety,

asthma, depression, fibromyalgia, headache, heart disease, high blood pressure, hot

flashes, insomnia, irritable bowel syndrome, nausea, nightmares, overactive bladder, and

pain (NCCAM, 2013).

Strauss and Lang (2012) conducted a review to explore the use of CAM in

addressing stress levels for patients with post-traumatic stress disorder (PTSD). The

authors found that CAM interventions such as relaxation, exercise, and meditation often

addressed mental and emotional problems that exacerbate stress. The findings suggested

that meditation techniques are associated with moderate improvements in PTSD severity

and health-related quality of life compared to individual psychotherapy.

Jacobs (2001) evaluated the clinical application of relaxation response and mind

body intervention. According to this review, mind-body intervention helps to restore

homeostasis by balancing the sympathetic and parasympathetic nervous system; this is

likely to be the reason why CAM is effective in easing the symptoms of PTSD. Jacobs

also concluded that mind-body interventions are cost effective and should be used in

conjunction with standard medical care.

A global survey of CAM use indicated that military personnel reported using

prayers, massage therapy, and relaxation techniques for stress reductions at 2.5-7 times

the rate of civilians (Goertz et al., 2013). A total of 16,146 active-duty military personnel

participated in this study. Another survey conducted among 342 North American nurses

showed that 99% of participants reported using one or more mind-body practice to reduce

stress. Prayers, breath-focused meditation, healing or therapeutic touch, yoga, and

mindfulness-based meditations are commonly-practiced CAM modalities. The reported

benefits of these modalities were spiritual well-being, serenity, calm, better mood,

compassion, and better sleep.

Yadav, Magan, Mehta, Sharma, and Mahapatra (2012) conducted a study at an

integrated health clinic to evaluate the efficacy of a yoga-based lifestyle intervention

program for the prevention and management of chronic diseases. The program used yoga

postures, breathing exercise, stress management, and group discussion as interventions

for participants who were overweight or had chronic inflammatory disease. The

researchers performed laboratory assessments of biochemical markers of stress and

inflammation at baseline and at the end of the intervention (10 days). Results from this

study showed that yoga-based lifestyle practices reduced stress markers and

inflammatory changes (Yadav et al., 2012).

Recent studies have showed that CAM use has been increasing among cancer

patients (Ernst, 2003). Several studies of cancer patients have showed the effect of

meditation and yoga on quality of life, fatigue, and sleep (Banasik, Williams, Haberman,

Blank, & Bendel, 2011; Carlson, Speca, Faris, & Patel, 2007; Carson, Carson, Porter,

Keefe, & Seewaldt, 2009). Mind-body techniques of meditation, yoga, Tai Chi,

acupuncture, manipulative technique massage, energy-based polarity therapy, and Reiki

are some of the CAM interventions commonly used by cancer patients (Chandwani et al.,

2012). Results from the review study of Chandwani et al. showed that mindfulness-based

stress reduction programs with components similar to yoga and acupuncture showed

reduction of stress levels, anxiety, fatigue, and distress associated with advanced cancer.

Li and Goldsmith (2012) conducted a review to evaluate the effectiveness of yoga

on anxiety and stress. The researchers identified a total of 35 studies assessing effects of

yoga on anxiety and stress for this review, 25 of which showed a significant decrease in

stress/anxiety symptoms among participants after starting yoga practices. The researchers

suggested that yoga as supplement to pharmacologic therapy may improve stress and

anxiety levels (Li & Goldsmith, 2012).

Penman, Cohen, Stevens and Jackson (2012) conducted a national survey of yoga

practitioners in Australia to evaluate practice of yoga. Survey respondents indicated that

they commonly practiced yoga for health and fitness as well as stress management.

Regular practice of yoga was associated with a direct healthy lifestyle effect including

vegetarianism, non-smoking, reduced alcohol consumption, increased exercise, and

reduced stress (Penman et al., 2012).

Hollifield, Sinclair-Lian, Warner, and Hammerschlag (2007) conducted a study to

evaluate the potential efficacy and acceptability of acupuncture for PTSD. The

researchers used self-reported PTSD symptoms as the outcome measure for this study.

The researchers compared acupuncture therapy to cognitive behavioral therapy. The

results showed reduction in the symptoms of PTSD at the end of the treatment, as well as

after 3-month follow up for the group that received acupuncture treatment (Hollifield et

al., 2007). This finding suggested that acupuncture may be an efficacious and acceptable

treatment option for PTSD. Hollifield (2011) also conducted a review study to evaluate

the role of acupuncture for PTSD. Hollifield explained that acupuncture has biological

effects that are relevant to PTSD pathology.

CAM as stress management intervention in young adults. Among the most

recent literature on the use of CAM as a stress management approach for young adults is

a randomized controlled study of 288 medical students conducted by de Vibe et al.

(2013) to examine the effectiveness of mindfulness-based stress reduction (MBSR) in

reducing stress and improving subjective well-being. The intervention group received a

7-week MBSR program in addition to their regular coursework, while the control group

continued with their standard classes. The MBSR program included physical and mental

exercises to increase the mindfulness experience; mindfulness communication and

reflection; and didactic teaching on mindfulness, stress, and stress management. Study

results showed that students experienced significant improvements in mental distress,

study stress, subjective well-being, and mindfulness after participating in this program

(de Vibe et al., 2013). Similarly, Simard and Henry (2009) conducted a study of first-year

medical students to evaluate the effect of a 16-week yoga intervention. Yoga practices

consisted of asana, pranayama, and meditations. Study results demonstrated

improvements in overall health, a reduction in perceived stress, and reduced levels of

depression (Simard & Henry, 2009).

A study conducted by Rantanasiripong, Sverduk, Prince, and Hayashino (2012)

analyzed the effectiveness of biofeedback and counseling for stress and anxiety among

college students. The results indicated that participants who received biofeedback

training and counseling had a greater reduction in anxiety symptoms than did the

participants who received counseling alone. The program used a portable, user-friendly

biofeedback program to help students learn to take control of their stress and anxiety, by

generating automated feedback about the stress levels in exhibited by their bodies

(Ratanasiripong et al., 2012). The results from this study suggested that combining

modalities may be beneficial in addressing the broad range of challenges students face.

Exercise has been shown to help alleviate stress in college students (Baghurst,

2011). In a study to determine whether different stress reduction interventions could alter

the perceived stress levels of college students, 531 students participated in a 16-week

program that focused on cognitive-behavior stress management and cardiovascular

fitness. A control group received no intervention (Baghurst, 2011). Measurements were

taken at the beginning and end of the semester. Perceived stress was measured by the

Perceived Stress Scale. Both the stress management and physical activity groups had

significantly lower levels of perceived stress at the end of the semester than the control

group (Baghurst, 2011). These findings indicated that it is helpful for students to have

some type of outlet or structure to manage stress. Although physical activity and

cognitive-behavior stress management are very different, both were effective in reducing

the students’ perceived stress versus no program or activity at all.

A study by Gard et al. (2012) examined the effects of a yoga-based intervention

on young adults’ on quality of life, perceived stress level, mindfulness, and self-

comparison. The variables were measured in 33 self-selected participants in a 4-month

residential yoga intervention. Assessment was conducted before and after the program via

questionnaire. A demographically-matched control group also completed the same

questionnaires. Program participants exhibited increased quality of life scores and

decreased levels of perceived stress both from baseline and relative to study controls. The

researchers concluded that yoga-based interventions may be of value in reducing stress

and improving quality of life in young adults. The practices may also improve coping

mechanisms in young adults (Gard et al., 2012).

A study conducted by Zhang, Ren, and Zhang (2010) observed the clinical

therapeutic effects of acupuncture plus cupping for treating insomnia in college students.

The researchers randomly divided 92 college students suffering from insomnia into a

treatment group (52 cases) and a control group (40 cases). Acupuncture plus cupping was

used to enhance brain function and reduce stress in the treatment group. Therapeutic

effects were measured by a self-rating sleeping scaling (SRSS), and evaluated after 1

month of treatment. Results showed a significant difference between the two groups. The

therapeutic effects shown in the treatment group was significantly better than that in the

control group (Zhang et al., 2010). These results suggested that acupuncture and cupping

treatments may be effective in helping college students manage stress and improve

quality of sleep.

Psychological distress such as anxiety and depression have been linked to the

development of hypertension (Rozanski, Blumenthal, Davidson, Saab, & Kubzansky,

2005). College students are more prone to psychological distress (D’Zurilla & Sheedy,

1991). A study by Nidich et al. (2009) evaluated the effectiveness of a Transcendental

Meditation (TM) program on blood pressure and psychological factors in young adults.

In this randomized controlled trial, the researchers allocated 298 university students into

the TM program or to the control group. At baseline and after 3 months, blood pressure,

psychological distress, and coping ability were assessed. The study results showed that

this mind-body intervention program decreased BP, decreased psychological distress, and

increased coping capacity (Nidich et al., 2009).

Researchers in this review of the most recent literature have provided evidence

that a range of complementary and alternative treatment options have proven beneficial

among young adults. Further to this, CAM techniques have been seen to improve both

young adults’ general well-being and specific stress-related symptomology. Although

many of these practices come from ancient traditions, they can be easily adapted and

implemented into college settings, providing students with more skill and knowledge to

better manage their stress levels.

Conceptual Model

Although researchers have examined the effectiveness of CAM as a specific stress

reduction intervention among this study’s target population, no studies currently exist that

assessed the extent to which young adults choose to use CAM interventions as

supplements to other adaptive coping mechanisms, or as substitutes for maladaptive

coping efforts. In addition, no literature has examined the extent to which young adults

adopt CAM practices under stressful circumstance when they are not specifically enrolled

in an intervention trial. Two recent studies have evaluated the adoption of stress reduction

interventions in a more natural student context.

Conley, Travers, and Bryant (2013) investigated the outcomes of promoting

psychosocial adjustment and stress management in first-year college students engaged in

a psychosocial wellness seminar. The researchers collected data from 2009 to 2011 using

an 8-month prospective quasi-experimental design. Intervention and control participants

showed no differences at baseline, but the intervention group reported significantly

greater perceived improvements in stress management and psychosocial adjustment over

the course of the seminar. (Conley et al., 2013). The researchers interpreted the results as

supporting the use of educational programmatic approaches embedded in the academic

curriculum, in order to promote psychosocial adjustment and stress management in

college students and to counter the potential development of maladaptive coping

strategies.

MyStudentBody-Stress is an online stress management program intended to

enhance stress management and promote healthy behaviors. Chiauzzi et al. (2008)

implemented and evaluated this program at six U.S. colleges. Groups were randomized to

one of three conditions: the MyStudentBody-Stress program, a control health information

website, or no intervention. The researchers compared group data at baseline and again at

1, 3 and 6 months. The primary outcome measure was perceived stress within the past

month. Secondary outcome measures were the Health Promoting Lifestyle Profile II, a

52-item frequency scale measuring self-reported health-promoting behaviors such as

physical activity, nutrition, spiritual growth, interpersonal relations, and stress

management, and the College Adjustment Scales that screen for developmental and

psychological problems. Although there were no between =0group differences on the

primary outcome variables, analysis between secondary outcome variables indicated that

the MyStudentBody-Stress participants were more likely to increase weekly physical

activity, use specific stress management methods, and exhibit decreased anxiety and

family problems (Chiauzzi et al., 2008). The researchers not only found support for the

potential benefit of the MyStudentBody-Stress program, but their findings may also be

interpreted as evidence that stressed young adults are capable of adopting and practicing

stress management techniques presented through an objective and impersonal medium.

These studies provided preliminary evidence that stressed students can and will

choose effective stress management techniques that are presented within the context of

daily educational requirements, or are presented as available noncompulsory stress

reduction resources. This educational and noncompulsory context corresponds to the

circumstances under which young adults seek and obtain stress management assistance

from their healthcare providers. Healthcare providers refer clients to CAM for education,

skill building, and therapy sessions that compete for priority among the other stressors

and demands clients face and attend to in their daily lives.

I designed the current study to determine if young adults will indeed adopt CAM

techniques in a non-compulsory setting, by framing the question in terms of the

transactional model of stress and coping, accounting for factors that are known to

influence stress and coping in young adults. Based on these possible influences, the

conceptual model guiding this investigation is presented in Figure 2.

Exposure to CAM-------------------------- and Coping Behaviors--------Perceived

Stress

Figure 2. The relationship between stress and young adults’ complementary and

alternative medicine use.

Researchers have demonstrated the effectiveness of CAM techniques as stress

management tools for young adults (Baghurst, 2011; de Vibe et al., 2013; Gard et al.,

2012; Nidich et al., 2009; Ratanasiripong et al., 2012; Simard & Henry, 2009; Zhang et

al., 2010), but researchers have also demonstrated that overwhelming stress can interfere

with cognition, making it difficult to comprehend or execute novel or complex functions

(LaBrie et al., 2012; Palmer, 2013; Pelletier & Laska, 2012; Pierceall & Keim, 2007;

Schreiber et al., 2012; Welle & Graf, 2011). Individuals laboring under a heavy stress

Life Stressors

Moderator

Dispositional

Coping Style

Mediator

Social Support

Mediator

Gender

Race

SES

load may, consequently, find it difficult to learn or practice CAM modalities when they

are not participating in a structured intervention. In addition, even those CAM modalities

that are guided or delivered by CAM practitioners require a time commitment, and the

literature has demonstrated that time management is a major concern among stressed

young adults (Nelson, 2008; Ohayon, 2007).

Both of these considerations raise a concern as to whether heavily-stressed

individuals would embrace or pursue recommended CAM modalities, even if those

modalities were known to them and readily available. This concern is buttressed by a

study that found that fewer than 25% of psychology students were willing to seek

professional help, or use readily-available campus resources to treat mental distress

(Thomas, Caputi, & Wilson, 2014). Brimstone, Thistlethwaite, and Quirk (2007)

comparing the willingness of medical students to seek conventional care for physical

illness or mental distress, to the willingness of psychology students to seek such care,

found that neither group was willing to avail themselves of the resources they knew to be

beneficial from their own disciplines. Both groups preferred to self-treat by engaging

their social support system for advice and solace (Brimstone et al., 2007). These findings

are consistent with the understanding that the executive decision-making component of

the young adult is still developing (Caspi et al., 1996; Huffman, 2012; Steinberg et al.,

2010), and underscore the potential for stressed young adults to choose a coping

mechanism with which they have had long-term familiarity.

The conceptual model, then, derives from this understanding, framed within the

transactional model of stress and coping. To determine whether exposure to CAM is

salient and appealing enough to be incorporated into stressed young adults’ coping

behaviors requires a measure of the magnitude life stressors, an accounting of the

resources available to cope with those stressors, and a measure of the coping strategies

actually implemented by the target population. According to this conceptualization, life

stressors are operative throughout exposure to, and training in, CAM stress management

techniques, and have the potential to moderate the extent to which CAM techniques are

internalized (Zimmerman & Kandiah, 2012).

The extent to which life stressors do, in fact, moderate CAM internalization is

also influenced by the presence or absence of other coping resources that can blunt the

impact of existing stressors. The stress literature has provided evidence that objective

stressors are less likely to cause an individual physical and emotional distress when there

are social and monetary supports available to the counter external demands (Chao, 2011;

Classen et al., 2001; DeLongis & Holtzman, 2005). Socioeconomic status is a reasonable

measure of monetary support, and social support is both self-explanatory and an

acknowledged mediator variable in the transactional model of stress and coping (Lazarus

& Folkman, 1984).

The findings in the literature reviewed for this study also demonstrated gender

and racial differences in both the manner in which stressors are experienced, and the

coping mechanisms chosen to address stress (Welle & Graf, 2011). Gender or race could,

consequently, play a role in the internalization and use of CAM stress management

techniques and have been factored into the conceptual model. Dispositional coping style

is an acknowledged mediator in the transactional model of stress and coping, as it biases

the individual to favor one type of coping behavior over other available options (Lazarus,

1993). Nothing in the literature reviewed to date has suggested that any given

dispositional coping style would influence an individual to be more or less inclined to

internalize or utilize CAM; however, this lack of information poses the question as to

whether or not dispositional coping style does have an impact remains open. This

variable has, consequently, also been included in the model.

The outcome of the interaction among stressful demands, coping resources,

coping predisposition, and exposure to CAM stress management techniques is the actual

coping behavior used to address the existing stressors. The final coping behaviors may or

may not include CAM techniques, and determining this is the main goal of this

investigation. The final outcome of the conceptual model is the level of stress felt by the

individual once coping is operationalized. The literature has offered evidence that

avoidance-oriented coping behaviors such as procrastination or substance abuse are

associated with in higher levels of perceived stress than are positive coping behaviors

such as seeking social support (Chao, 2011; Rinaldis et al., 2012). As the literature has

supported CAM as a positive stress management technique, it is reasonable to

hypothesize individuals who do operationalize their CAM training will have lower

perceived stress than individuals who engage in negative coping behaviors. No evidence

was found in the literature, however, that would allow speculation as how CAM might

contribute to perceived stress in conjunction with, or compared to, other patterns of

positive or negative coping behaviors. Examining this contribution is a second goal of

this investigation and is, therefore, represented in the model.

Summary

In this chapter, I reviewed the literature in four areas relevant to the current

investigation. The first literature set developed the research problem pertaining to young

adults’ elevated risk for incurring high levels of stress as they pursue an education and

compete to enter the workforce and establish a family. Specifically, the literature

supported the proposition that young adults in the United States could benefit from stress-

management techniques that are compatible with their still-maturing cognitive

sensibilities, but researchers have questioned the capability of young adults to actively

internalize and use novel techniques under conditions of elevated stress.

The second set of literature established the form, function, and applicability of

the transactional model of stress and coping to investigating the relevant dimensions of

the research problem. The third literature set presented information on complementary

and alternative medicine modalities as documented stress-reduction techniques with the

potential to appeal to young adults. The final literature set examined the outcomes of

stress management interventions among young adults and documented the current

knowledge gap regarding how, or if, young adults’ demanding lives interfere with their

ability to embed CAM stress management techniques into their routine coping behaviors.

I concluded the chapter with a conceptual model drawn from the literature reviewed to

guide the proposed research.

In Chapter 3, I will develop and justify the study methodology including the study

design, the study sample, the data collection instruments, the study hypotheses, and the

data analyses. Each of these elements will be presented as aligned with the conceptual

model developed in Chapter 2.

Chapter 3: Methodology

Introduction

The purpose of this quantitative study was to examine whether exposure to CAM,

stress level, dispositional working style, sociodemographic variables, and social support

impact the use of CAM modalities for stress management among young adults. This

study also looked at the difference in the levels of perceived stress among the younger

adults who do and do not use the CAM modalities for stress s management. I performed a

quantitative cross-sectional correlational study to identify whether the factors identified

in the study influence the dependent variable of the use of CAM modalities for stress

management. I used a survey methodology to gather primary data for the analysis of

potential relationships. In this chapter, I will provide a discussion and the justification of

the research design chosen for this study. I will also discuss the research methodology,

including the target population, sampling design, sample size, and recruitment

procedures. I will then provide explanations of the appropriateness, validity, and

reliability of the study measurement instruments, followed by an explanation of the study

variables and how those variables are operationalized. In the subsequent sections, I will

present the data collection procedures and data analysis plan, as well as the

appropriateness of each analysis to testing the null hypotheses in this study. Finally, I will

discuss of the potential threats to the study’s validity and how the threats were addressed

in this study, as well as ethical considerations. I will then provide a summary to

emphasize the main points of this chapter.

Research Design and Rationale

I employed a quantitative cross-sectional correlational research design using

primary data collected via validated survey instruments to identify potential relationships

between variables such as exposure to CAM, stress level, dispositional working style,

sociodemographic variables, and social support impact the use of CAM modalities for

stress management among young adults. The dependent variable in this study was the use

of CAM modalities for stress management, such as meditation, yoga, talking to friends,

special diets, seeking family support, and similar techniques. The 30 modalities

considered in this study are presented in Appendix A. Independent variables included the

participants’ exposure to CAM, stress level, dispositional working style,

sociodemographic variables, and social support.