Exploration of the Effects of Protective Person–Environment Factors Between Functional Impairments and Stress in Individuals With Multiple Sclerosis: Mediation and Moderation Analyses

Abstract

Functional impairments can lead to stress in individuals with multiple sclerosis (MS). The study examined protective person and environment factors (i.e., positive cognitive stress appraisal, core self-evaluations [CSE], resilience, hope, spirituality, social support, and environmental supports) as both mediators and moderators of this association to guide understanding of the experience of stress in this population. The sample consisted of 373 participants with MS. In simple mediation analyses, positive cognitive stress appraisal, CSE, resilience, hope, social support, and environmental supports served as a partial mediator between functional impairments and stress. In a parallel mediation analysis, significant unique indirect effects were observed for two of the seven hypothesized mediator variables (CSE and environmental supports). Separate moderator tests provided support for the CSE variable as a protective factor. The positive association between functional impairments and stress was weaker for persons reporting high CSE compared with those reporting low CSE. The findings provide implications for rehabilitation counseling practices by promoting CSE and environmental supports in improving rehabilitation and psychosocial outcomes for individuals with MS.

Keywords

functional impairments protective factors stress multiple sclerosis

Introduction

Stress can lead to changes in the autonomic nervous and immune systems, and prolonged stress can result in further health and mental health complications (Dutcher & Creswell, 2018). Compared with people without disabilities, people with disabilities are more likely to experience greater stress because they are more likely to encounter disease-related and psychosocial challenges (Dougall & Baum, 2011). Stress can pose considerable health implications, such as impeding the disease recovery process, increasing disease recurrence rates, and experiencing challenges in the adjustment to disabilities (Dougall & Baum, 2011). In addition to physical and mental health stressors, people with disabilities may be more vulnerable to stress as they may have limited coping resources and skills (Hughes et al., 2006).

Multiple sclerosis (MS) is a neurological disorder that affects almost 1 million individuals in the United States (National Multiple Sclerosis Society [NMSS], 2020). People with MS experience a wide range of symptoms (e.g., fatigue, vision problems, gait difficulties, cognitive changes) that are often unpredictable (Chalk, 2007). Besides managing MS-related symptoms, people with MS face other difficulties such as treatment complexity, financial strains, unemployment, relationship problems, and disease onset in young adulthood (Artemiadis et al., 2012). These challenges can contribute to elevated levels of stress. While stress is common in people with MS, previous research has demonstrated that persons with MS who have adaptive coping styles are more likely to experience reduced stress, depression, anxiety, and higher quality of life than those using maladaptive coping styles (Grech et al., 2018). This suggested the importance of exploring protective factors that can reduce the vulnerability of stress and foster health and well-being in individuals with MS.

Many stress management interventions have been developed following the Lazarus and Folkman’s stress, appraisal, and coping theory to help people implement cognitive and behavioral strategies to cope with stress (J. L. Brown & Vanable, 2008; Sanaeinasab et al., 2017). To our knowledge, there are relatively limited studies on positive psychology-based stress management interventions in MS. Positive psychology has been suggested to complement traditional health theories by the identification and cultivation of individual’s strengths, which can further promote health and well-being (Park et al., 2016). Therefore, this study aimed to integrate Lazarus and Folkman’s stress, appraisal, and coping theory with positive psychology to help researchers and practitioners gain a better understanding of how positive psychology variables can serve as protective factors to mitigate the negative effects of functional impairments on stress in MS.

Theoretical Frameworks

Lazarus and Folkman’s (1984) stress, appraisal, and coping theory

Stress occurs when an individual has limited resources to meet the contextual demands and is described as the product of the person–environment (P-E) interaction (Lazarus & Folkman, 1984). The theory posits that there are two processes (i.e., appraisal and coping) when individuals respond to stress. Appraisal is one’s evaluation of stressors, whereas coping is one’s efforts in managing stressors using their resources (Lazarus & Folkman, 1984). The P-E relationship is affected by an individual’s appraisal of stress and coping styles, which can impact people’s psychosocial adjustment to disabilities (Briones-Buixassa et al., 2017).

Positive psychology

Rather than focusing on illness and pathology, positive psychology fosters the importance of building positive qualities and constructing positive life experiences (Seligman & Csikszentmihalyi, 2000). Many constructs (e.g., resilience, hope) fall within the positive psychology paradigm that contributes to the scientific understanding of what constitutes a good life (Wehmeyer, 2013). Health and well-being are conceptualized as an optimal state of functioning that is more than the mere absence of illness (Seligman, 2011). Individuals have the tendencies to pursue growth and fulfillment through bolstering their strengths and assets (Rashid & Seligman, 2018), which can provide a more holistic understanding in individuals with disabilities’ human functioning and potentials (Chou et al., 2013).

Functional Impairments

Functional impairment is conceptualized as an individual’s reduced functions, including impairment, activity limitation, and limited social participation (Ustun & Kennedy, 2009). People’s daily functioning and social participation limitations can influence roles changes in personal and professional lives, contributing to increased stress levels (Bierman, 2012; Holper et al., 2010). Building protective factors and promoting the use of adaptive coping strategies can help individuals with disabilities better manage functional impairments and stress (Livneh & Martz, 2014). Increased functional impairments in MS have been found to be associated with greater use of avoidant strategies and worse stress management (Briones-Buixassa et al., 2017; Sung et al., 2013).

Protective Factors

Maintaining and building protective factors can promote positive growth and buffer against stressors in people with disabilities (Wehmeyer, 2013). Prior research has demonstrated positive person and environment factors, such as purpose in life and social support, are associated with psychosocial adjustment to MS (Farber et al., 2015). However, there is comparably limited research examining the role of multiple protective factors in explaining the underlying mechanisms between functional impairments and stress in the MS populations.

Rehabilitation counseling researchers have long recognized the need to consider P-E contextual factors in the development of effective rehabilitation counseling practices (F. Chan et al., 2009, 2019; Wright, 1983). As indicated by F. Chan et al. (2019), the World Health Organization (WHO, 2001) International Classification of Functioning, Disability and Health (ICF) has clearly underscored the importance of P-E factors and how these contextual factors interact with functioning and disability to influence community participation, health-related quality of life, and subjective well-being of individuals with disabilities. Positive trait factors that have been frequently used to predict stress, community participation, and life satisfaction include positive cognitive stress appraisal (Dreer et al., 2008), resilience (Catalano et al., 2011; Fujikawa et al., 2013; Moser et al., 2020), hope (Y. C. Chan et al., 2013; Smedema et al., 2014), core self-evaluations (CSE; Smedema et al., 2014; Smedema, Chan, et al., 2015; Smedema, Pfaller, et al., 2015), spirituality (Johnson et al., 2017), social support (Iwanaga et al., in press; Sanchez et al., 2016; Wilson et al., 2013), and environmental supports (Lee et al., 2018). It is plausible that these documented positive P-E contextual factors can also serve as protective factors against functional impairments and stress. In the present study, we tested the hypothesis that these positive P-E factors can buffer the negative effect of functional impairments on stress.

Positive cognitive stress appraisal

Positive cognitive stress appraisal is described as one’s cognitive interpretations of stress through appraising and reconstructing stress as meaningful (Garland et al., 2011). Cognitive appraisals can influence one’s reactions to chronic health conditions, perceived functional disability, and stress (Dreer et al., 2008). For instance, positive cognitive styles can foster positive psychological processes, resulting in reduced stress (Garland et al., 2011). In people with MS, positive cognitive appraisal styles have been found to be associated with positive psychological adjustment (Chalk, 2007).

Core self-evaluations

CSE is conceptualized as people’s perception about how worthy and capable they are, and consists of four positive human traits, including self-esteem, generalized self-efficacy, internal locus of control, and emotional stability (Judge et al., 1998). Previous research discussed that bolstering CSE can lead to positive health outcomes and well-being in people with disabilities (Smedema & Tansey, 2015). Individuals with higher levels of CSE tend to experience fewer stressors and positively appraise their ability to cope compared with those with lower levels of CSE (Kammeyer-Mueller et al., 2009). CSE was found to moderate the relationship between perceived stress and depression in people with spinal cord injuries (DeAngelis et al., 2016). In a recent study, CSE was found to be a partial mediator between stress and quality of life in individuals with MS (Lee et al., 2020).

Resilience

Resilience refers to people’s ability to bounce back from stressful events (Rutter, 1987). Individuals with higher levels of resilience are more likely to use resources to cope (Tan-Kristanto & Kiropoulos, 2015). Resilience has also been demonstrated to be a moderator between stress and health (Gloria & Steinhardt, 2016). Specific to MS, increasing resilience has been demonstrated to lead to improvements in stress, mental health, and well-being in people with MS (Alschuler et al., 2018; Pakenham et al., 2018).

Hope

Hope is described as the cognitive-motivational processes to achieve goals and has been identified as a protective factor for stress (Lazarus, 1999; Snyder et al., 1991). People with disabilities with higher levels of hope tend to experience positive emotional processes in face of adversity, and experience reduced stress (Hirsch & Sirois, 2016; Lopez & Snyder, 2011). Hope was found to be a moderator between functional impairment and depressive symptoms in a sample of older adults with functional impairments (Hirsch et al., 2011). In people with MS, hope is discussed as a coping resource in mitigating the effects of stress on psychosocial adjustment to MS (Madan & Pakenham, 2014).

Spirituality

Spirituality refers to the search for meaning of life and higher power and can provide meaning and resources as one copes with challenges (Wehmeyer, 2013). Spirituality has been found to be associated with recovery as it can facilitate meaning-seeking and help people utilize coping strategies to face their chronic health conditions (Tuck et al., 2006). Spirituality was also found to be a moderator between stress and physical symptoms in college students (Kim & Seidlitz, 2002). In people with MS, higher levels of spirituality were found to be associated with reduced progression risk (D’hooghe et al., 2013).

Social support

Social support includes the sources of support and the support received and moderates the impact of stress on health (Dumont & Provost, 1999). Social support has been found to be associated with health outcomes and stress (Sanchez et al., 2016). When facing disability, helping people with disabilities develop and increase supportive relationships is important as this can promote their coping abilities (Rommer et al., 2017). Social support served as a moderator between posttraumatic stress disorder (PTSD) and depression symptom severity in veterans with PTSD (Painter et al., 2016). In people with MS, social support was associated with perceived health status (Krokavcova et al., 2008).

Environmental supports

The term environmental supports refers to the factors contributing to people’s social participation and functions (Hammel et al., 2015). In people with disabilities, environmental supports were found to be related to lower adaption difficulties and better self-management of health (Hsu & Tung, 2010). Environmental supports, including community living supports, rehabilitation, social and support services, and health and mental health services, were found to be associated with community participation in individuals with MS (Lee et al., 2018).

Stress

Although stress can present challenges in numerous domains, people with disabilities who can focus on growth and make positive life changes can more effectively deal with stress (Iwasaki & Mactavish, 2005). Stress can promote inflammation activities in MS, and can trigger MS onset and relapse (Artemiadis et al., 2011; R. F. Brown et al., 2006). Compared with those without MS, people with MS were more likely to endorse a life adversity in the year before their MS onset (Grant et al., 1989). Stressful life events were found to be associated with increased MS exacerbations (Buljevac et al., 2003). Although stress can make an impact on MS onset and disease course, Grech et al. (2018) found that those who utilize adaptive coping strategies were more likely to experience reduced stress than those who use maladaptive coping. This suggests that there are individual variations in responding to stress and highlights the importance in identifying and bolstering effective protective factors that can buffer the negative effects of functional impairments on stress in people with MS.

Purpose of the Study

Although prior research has examined protective factors individually, the functional impairment–stress relationship that can be explained by multiple protective factors remains unclear. Given that protective factors (i.e., positive cognitive stress appraisal, CSE, resilience, hope, spirituality, social support, and environment supports) are modifiable through interventions (Alschuler et al., 2018; Bigatti et al., 2012; Bombardier et al., 2008; Hollingsworth & Gray, 2010; Madan & Pakenham, 2014; Smedema & Tansey, 2015; Williams et al., 2004), exploring the roles of protective factors can further inform MS care and interventions. The research questions included the following:

Research Question 1 (RQ1): What are the relationships between functional impairments, protective factors, and stress?

Research Question 2 (RQ2): Does each protective factor mediate the relationship between functional impairments and stress?

Research Question 3 (RQ3): Do all protective factors together mediate the relationship between functional impairments and stress?

Research Question 4 (RQ4): Does each protective factor moderate the relationship between functional impairments and stress?

Method

Procedures

The Institutional Review Board was approved by the University of Wisconsin-Madison Education and Social/Behavioral Science. Participants were recruited from the National Multiple Sclerosis Society (NMSS). The study invitation was sent via emails to NMSS members and was also advertised on the NMSS website. The inclusion criteria to participate in the study were participants who were at least 18 years of age and had a diagnosis of MS. The survey included informed consent and study information. Participants had to indicate whether they agreed to participate in the study before responding to the survey. After completing the survey, participants were directed to another link and had the opportunity to provide their names and emails to receive a gift card. The first 250 participants who participated in the study received compensation in the form of a gift card as indicated in the consent form. Participants’ names and emails were separated from their survey responses.

Participants

There were 446 participants who initiated the survey. Seventy-three of them did not complete the full survey, which resulted in a final sample of 373 participants who completed the full survey. The average age of participants was 48.77 years old (SD = 11.73), ranging from 21 to 77 years. Most participants identified as female (81.0%) and Caucasian (90.6%). Many participants (61.9%) indicated being married. About 63.2% of participants have at least a bachelor’s degree and 45.6% were full-time employed. Most participants (77.5%) indicated having relapsing-remitting MS. The average MS duration was 12.26 years (SD = 9.28), ranging from 0.2 to 47 years. Descriptive statistics are presented in Table 1.

Table 1.

Descriptive Statistics of Study Sample.

Variable	n (%)	M (SD)
Age		48.77 (11.73)
Gender
Female	302 (81.0)
Male	71 (19.0)
Race/ethnicity
Caucasian	338 (90.6)
African American	14 (3.8)
Asian American/Pacific Islander	4 (1.1)
Native American/American Indian	2 (0.5)
Other	15 (4.0)
Marital status
Single	63 (16.9)
Married	231 (61.9)
Cohabitating	20 (5.4)
Widowed	6 (1.6)
Separated	5 (1.3)
Divorced	48 (12.9)
Education level
Less than high school graduation	1 (0.3)
High school diploma or equivalency	33 (8.8)
Some college	64 (17.2)
Associate degree	39 (10.5)
Bachelor’s degree and above	236 (63.2)
Employment status
Full-time	170 (45.6)
Part-time	33 (8.8)
Unemployed	49 (13.1)
Retired	72 (19.3)
Student	4 (1.1)
Looking for work	5 (1.3)
Other	40 (10.7)
MS subtype
Relapsing-remitting	289 (77.5)
Primary progressive	32 (8.6)
Secondary progressive	43 (11.5)
Other	9 (2.4)
MS duration (years)		12.26 (9.28)

Note. N = 373.

Measures

Functional impairments

The World Health Organization Disability Assessment Schedule 2.0 (Ustun et al., 2010; WHO, 2001) is a 12 item measure that was used to assess functional impairments (e.g., “In the past 30 days, how much difficulty did you have in taking care of your household responsibilities?”). Each item is rated on a 5-point Likert-type scale ranging from 1 (none) to 5 (extreme or cannot do). Higher scores represent more severe levels of functional impairments. The internal consistency reliability estimate (Cronbach’s α) was computed to be .92 in this study.

Positive cognitive stress appraisal

The Stress Appraisal Measure (Roesch & Rowley, 2005) is a 19-item measure that assesses cognitive appraisal of stress, including Challenge, Threat, Centrality, and Resources. In this study, seven items that were categorized under the Challenge domain were used to assess positive cognitive stress appraisal (e.g., “I can positively attack stressors.”). Each item is rated on a 5-point Likert-type scale ranging from 0 (not at all) to 4 (a great amount). Higher scores represent higher levels of positive cognitive stress appraisal. The Cronbach’s alpha was computed to be .91 in this study.

Core self-evaluations

The Core Self-Evaluations Scale (Judge et al., 2003) is a 12-item measure that was used to assess CSE (e.g., “When I try, I generally succeed.”). Each item is rated on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores represent higher levels of CSE. The Cronbach’s alpha was computed to be .90 in this study.

Resilience

The Brief Resilience Scale (Smith et al., 2008) is a 6-item measure that was used to assess resilience (e.g., “It does not take me long to recover from a stressful event.”). Each item is rated on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores represent higher levels of resilience. The Cronbach’s alpha was computed to be .90 in this study.

Hope

The Trait Hope Scale (Snyder et al., 1991) is a 12-item measure with 4 filler items. Eight items were used to assess hope (e.g., “I’ve been pretty successful in life.”). Each item is rated on a 4-point Likert-type scale ranging from 1 (definitely false) to 4 (definitely true). Higher scores represent higher levels of hope. The Cronbach’s alpha was computed to be .89 in this study.

Spirituality

The Spiritual Perspective Scale (Reed, 1987) is a 10-item measure that was used to assess spirituality (e.g., “Forgiveness is an important part of my spirituality.”). Each item is rated on a 6-point Likert-type scale ranging from 1 (not at all/strongly disagree) to 6 (about once a day/strongly agree). Higher scores represent higher levels of spirituality. The Cronbach’s alpha was computed to be .96 in this study.

Social support

The Multidimensional Scale of Perceived Social Support (Zimet et al., 1988) is a 12-item measure that was used to assess social support (e.g., “I get the emotional help and support I need from my family.”). Each item is rated on a 7-point Likert-type scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). Higher scores represent higher levels of social support. The Cronbach’s alpha was computed to be .94 in this study.

Environmental supports

The Multiple Sclerosis Environmental Supports Scale (F. Chan & Pfaller, 2016) is a 17-item measure that was used to assess environmental supports (e.g., “I have access to good quality health care.”). Each item is rated on a 5-point Likert-type scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores represent higher levels of environmental supports. The Cronbach’s alpha was computed to be .86 in this study.

Stress

The Brief Disability Related Stress Scale (Lee & Chan, 2020) is a 10-item measure that was used to assess disability-related stress (e.g., “societal attitudes toward your disability.”). Each item is rated on a 5-point Likert-type scale ranging from 1 (not at all stressful) to 5 (extremely stressful). Higher scores represent higher levels of stress. The Cronbach’s alpha was computed to be .86 in this study.

Data Analysis

Data analyses were performed using the R statistical analysis software (RStudio Team, 2020) with mediation package (Tingley et al., 2014) and the Statistical Package for Social Sciences (SPSS) for Mac. Cook’s distance was computed to be 4/(373 − 8 − 1) = 0.010989 following the general rule of thumb (Chatterjee & Hadi, 1986), in which 24 cases were identified as outliers. Therefore, 349 participants have included in regression analyses. Missing data analysis revealed no variable had more than 1% missing data. In this study, expectation-maximization was used to impute missing values.

Correlation analysis and multiple regression analysis were carried out to examine whether the protective factors mediate/moderate the relationship between functional impairments and stress. Mediation analysis was performed following Baron and Kenny’s (1986) approach with the three steps: (a) regressed the mediator on the independent variable (X); (b) regressed the dependent variable (Y) on X; and (c) regressed Y on X and M. The bootstrapping test (Tingley et al., 2014) with 5,000 bootstrap samples was used. Moderation analysis was performed following Aiken and West’s (1991) approach, in which X and a third variable (Z) were first centered and the product of X and Z were then computed. The final step of the moderation analysis was to regress Y onto X, Z, and XZ.

Results

Correlation Analysis

Functional impairments were positively associated with stress and inversely associated with positive cognitive stress appraisal, CSE, resilience, hope, social support, and environmental supports. In addition, stress was negatively associated with positive cognitive stress appraisal, CSE, resilience, hope, social support, and environmental supports. Correlation analysis results are presented in Table 2.

Table 2.

Correlations, Means, and Standard Deviations for Functional Impairments, Protective Factors, and Stress.

Variable	1	2	3	4	5	6	7	8	9
1. Functional impairments	1
2. Positive cognitive stress appraisal	−.45***	1
3. CSE	−.59***	.71***	1
4. Resilience	−.49***	.74***	.77***	1
5. Hope	−.47***	.70***	.71***	.68***	1
6. Spirituality	.03	.11*	.05	.05	.10	1
7. Social support	−.36***	.33***	.43***	.37***	.41***	.13*	1
8. Environmental supports	−.41***	.30***	.39***	.30***	.32***	.04	.45***	1
9. Stress	.79***	−.54***	−.72***	−.59***	−.55***	.01	−.44***	−.55***	1
M (SD)	2.21 (0.79)	2.24 (0.88)	3.13 (0.74)	3.17 (0.84)	2.97 (0.50)	3.73 (1.54)	5.36 (1.29)	4.18 (0.62)	2.39 (0.78)

Note. N = 349. CSE = core self-evaluations.

p < .05. **p < .01. ***p < .001.

Mediation Analysis

When protective factors were individually tested to examine its mediating role between functional impairments and stress, simple mediation results demonstrated that positive cognitive stress appraisal, CSE, resilience, hope, social support, and environmental supports served as a partial mediator between functional impairments and stress. Conversely, spirituality was not found to be a mediator. Simple mediation analysis results (e.g., effect size) are presented in Table 3.

Table 3.

Summary of Simple Mediation Analysis Results.

Mediator	Step 1: Effect of functional impairments on mediator (Path a)β [95% CI]	Step 3: Direct effect of mediator on stress (Path b)β [95% CI]	Direct effect of functional impairments on stress (Path cʹ)β [95% CI]	Indirect effects (Paths ab)[95% CI]	R² (%)
Positive cognitive stress appraisal	−.45 [−.55, −.35]	−.23 [−.30, −.16]	.69 [.61, .77]	.10 [.07, .14]	67.21
CSE	−.59 [−.69, −.50]	−.39 [−.46, −.31]	.57 [.49, .65]	.23 [.18, .28]	72.65
Resilience	−.49 [−.58, −.39]	−.26 [−.33, −.19]	.67 [.58, .75]	.13 [.09, .17]	68.29
Hope	−.47 [−.57, −.37]	−.23 [−.30, −.16]	.69 [.60, .77]	.11 [.07, .15]	67.05
Spirituality	.04^a [−.07, .14]	−.02^a [−.08, .05]	.79 [.71, .88]	−.001^a [−.006, .004]	63.00
Social support	−.36 [−.46, −.26]	−.18 [−.25, −.11]	.73 [.64, .82]	.06 [.04, .10]	65.74
Environmental supports	−.41 [−.51, −.31]	−.27 [−.34, −.20]	.68 [.60, .77]	.11 [.07, .15]	69.00

Note. N = 349. Step 2: Total effect of functional impairments on stress (β = .79; R² = 62.98%; 95% CI [.71, .88]; Path c). CSE = core self-evaluations.

No significance.

When all protective factors were examined simultaneously, parallel mediation results revealed only CSE and environmental supports partially mediated the relationship between functional impairments and stress. Following Baron and Kenny’s approach, functional impairments were associated with positive cognitive stress appraisal (β = −.45), CSE (β = −.59), resilience (β = −.49), hope (β = −.47), social support (β = −.36), and environmental supports (β = −.41), but was not associated with spirituality (β = .04). Subsequently, functional impairments were associated with stress (β = .79). After controlling for functional impairments, only two mediators (CSE [β = −.31] and environmental supports [β = −.20]) were associated with stress. After the inclusion of mediators, the standardized beta coefficient for the direct effect between functional impairments and stress was reduced to .50. However, this relationship remained significant, which suggests that CSE and environmental supports served as partial mediators between functional impairments and stress. The bootstrapping test with 5,000 bootstrapping samples demonstrated that only the indirect paths for CSE (ab = .17; 95% CI [.11, .23]) and environmental supports (ab = .08; 95% CI [.05, .11]) were significant. Parallel mediation analysis results are presented in Table 4 and Figure 1.

Table 4.

Summary of Parallel Mediation Analysis Results.

Mediator	Step 1: Effect of functional impairments on mediators (Path a) β [95% CI]	Step 3: Direct effect of mediators on stress (Path b)β [95% CI]	Indirect effects (Paths ab)[95% CI]
Positive cognitive stress appraisal	−.45 [−.55, −.35]	−.009 [−.09, .08]	.004 [−.03, .04]
CSE	−.59 [−.69, −.50]	−.31 [−.41, −.21]	.17 [.11, .23]
Resilience	−.49 [−.58, −.39]	−.04 [−.13, .05]	.02 [−.02, .06]
Hope	−.47 [−.57, −.37]	.01 [−.08, .09]	−.003 [−.04, .03]
Spirituality	.04 [−.07, .14]	.03 [−.03, .08]	.001 [−.003, .01]
Social support	−.36 [−.46, −.26]	−.03 [−.09, .03]	.01 [−.01, .03]
Environmental supports	−.41 [−.51, −.31]	−.20 [−.27, −.14]	.08 [.05, .11]

Note. N = 349. Step 2: Total effect of functional impairments on stress (β = .79; R² = 62.98%; 95% CI [.71, .88]; path c). Direct effect of functional impairments on stress (β = .50; R² = 76.34%; 95% CI [.42, .58]; path cʹ). CSE = core self-evaluations.

Figure 1.

Path coefficients for parallel mediation analysis on stress (N = 349).

Moderation Analysis

Among all protective factors, only CSE was found to be a moderator between functional impairments and stress. The main effects for functional impairments (B = .52, p < .001) and CSE (B = −.40, p < .001) were significant, indicating that higher functional impairments were associated with higher stress levels, and lower CSE levels were associated with higher stress levels. The interaction term (B = −.09, p < .01) was significant, suggesting that the effect of functional impairments on stress was influenced by CSE. Moderation results suggested that effect of functional impairments on stress had a stronger effect for people reporting low CSE (slope = .58) compared with those reporting high CSE (slope = .45). The slope was .52 for those reporting medium levels of CSE. High CSE refers to mean plus 1 SD. Medium CSE refers to mean. Low CSE refers to mean minus 1 SD. Moderation results are presented in the Supplemental Material file.

Discussion

The first aim of the study sought to investigate the relationships among functional impairments, protective factors, and stress. These findings echoed previous research findings (e.g., Chalk, 2007; Hsu & Tung, 2010) that functional impairments were positively associated with stress, and was negatively associated with positive cognitive stress appraisal, CSE, resilience, hope, social support, and environmental supports. In addition, consistent with prior research (e.g., Hirsch & Sirois, 2016; Sanchez et al., 2016), this study found that stress was inversely related to positive cognitive stress appraisal, CSE, resilience, hope, social support, and environmental supports. Conversely, spirituality was not found to be associated with functional impairments and stress, which was contrary to previous studies (Johnson et al., 2017).

The second aim of the study was to investigate whether each of the protective factors mediates the relationship between functional impairments and stress. Findings of this study demonstrated that when each protective factor was individually tested, positive cognitive stress appraisal, CSE, resilience, hope, social support, and environmental supports, partially mediated the relationship between functional impairments and stress. These findings are relevant to previous research findings. For instance, the promotion of positive cognitive stress appraisal can empower clients to reinterpret stressful life events in a positive mind-set and facilitate a meaningful life (Garland et al., 2011). Individuals with higher levels of CSE tend to utilize effective coping strategies and experience less stress (Kammeyer-Mueller et al., 2009). Resilience facilitates positive emotions and plays a critical role in bouncing back from stress (Ong et al., 2006). Hope has been discussed as a protective resource for coping with stress (Madan & Pakenham, 2014). Social support has also been suggested to protect people from the adverse effects of illness and stress (Williams et al., 2004). Increased environmental supports were related to fewer difficulties with psychosocial adjustment to disabilities and reduced levels of stress (Hsu & Tung, 2010). Although previous research identified spirituality as a protective factor for stress (Kim & Seidlitz, 2002), the current study did not find spirituality as a mediator between functional impairments and stress.

The third aim of the study was to examine whether all protective factors mediate the functional impairments–stress relationship. Results indicated only CSE and environmental supports partially mediated the relationship between functional impairments and stress, suggesting the synergistic effects of CSE and environmental supports in buffering the negative effect of functional impairments on stress. These findings are relevant to prior research on the importance of including positive person and environment factors in enhancing participation and satisfaction in individuals with MS (Farber et al., 2015).

Finally, the study aimed to explore the moderating role of each protective factor between functional impairments and stress. In this study, CSE was the only factor that moderated the relationship between functional impairments and stress, which is consistent with previous research that suggested the stress-buffering role of CSE in the workplace (Rey et al., 2016). It can be explained that the interaction effect of functional impairments and CSE on stress was observed because CSE is a higher order positive psychology construct that comprises self-esteem, self-efficacy, internal locus of control, and emotional stability. This finding suggests that CSE differentially influenced stress outcomes where those with high levels of CSE may more effectively cope with stress caused by functional impairments compared with those with low levels of CSE.

Implications for Practice

This study found that the synergistic roles of CSE and environmental supports buffer the adverse consequences of functional impairments on stress in a sample of people with MS. Findings provided preliminary evidence for the need for rehabilitation counselors to help clients enhance their CSE and promote environmental supports. When CSE and environmental supports are improved, clients with MS may more effectively manage their experience of stress.

Increasing CSE can result in positive appraisal and decreased stress (Rey et al., 2016). Rehabilitation counselors can promote the development of CSE levels in clients with MS by implementing strategies for self-esteem, self-efficacy, internal locus of control, and emotional stability. For instance, self-esteem interventions can help people develop a positive self-concept, and self-efficacy interventions can focus on observational learning, modeling, and reframing of MS (Mikula et al., 2018; Wilski & Tasiemski, 2016). When working with clients with MS, counselors can encourage clients to think about the controllable and to actively participate in treatments, which can further build a greater sense of control (Wilski et al., 2019). For emotional stability, counselors can incorporate MS-specific cognitive-behavioral treatments to better address clients’ needs and goals (Chalk, 2007).

Rehabilitation counselors can enhance environmental supports by connecting clients with MS to health and mental health services, rehabilitation and social service provisions, and community living resources. Many individuals with MS perceive unmet health and mental health care needs due to functional, financial, and transportation barriers (Kinyanjui et al., 2018). Improving access to rehabilitation and social services resources would be important for MS care (Roddam et al., 2019). Counselors can also work to connect individuals with MS to their community support systems (Wilkinson et al., 2019). For instance, rehabilitation counselors can encourage clients to join local MS support groups to connect with others with MS and discuss their experiences living with MS.

Strategies to increase positive cognitive stress appraisal, resilience, hope, and social support may be useful in stress management interventions. For example, counselors can encourage clients to promote their positive cognitive stress appraisal by reframing the stressful life events as growth and meaningful opportunities (Garland et al., 2011). Resilience interventions (e.g., Acceptance and Commitment Therapy-based group resilience training program) can be implemented to help clients connect to their values, accept their thoughts and feelings, and improve their psychosocial outcomes (Pakenham et al., 2018). Goal identification and attainment exercise can be incorporated into treatment to promote hopeful thinking (Hirsch & Sirois, 2016), where rehabilitation counselors can work with clients with MS in setting personally meaningful vocational/rehabilitation goals, brainstorming strategies and facilitating efforts in goal achievement. Counselors can encourage clients to strengthen their social networks, explore social interaction opportunities, and improve communication and relationship quality (Williams et al., 2004). In the rehabilitation counseling process, rehabilitation counselors can assess clients with MS positive person and environment resources to better understand their needs, so an individualized plan can be developed to facilitate client’s goal attainment. Furthermore, rehabilitation counselors can facilitate the cultivation of positive cognitive stress appraisal, resilience, hope, and social support, which can help clients with MS better cope with their functional challenges and stressors, resulting in successful vocational, psychosocial, and rehabilitation outcomes.

Study Limitations

There are several limitations to be considered when interpreting this study’s findings. First, this was an online survey study, and as such participants who have technical difficulties or experience physical limitations may have been excluded. Second, the participants were recruited from the NMSS, which may suggest these individuals were more connected to resources. Third, more than half of the participants indicated at least having a bachelor’s degree. Fourth, most participants indicated having relapsing-remitting MS and participants reported an average of mild functional impairments scores, suggesting these participants may have a lower functional impairment. All of these characteristics may limit the generalizability of this study’s findings to the broader population of people with MS.

Given that this was an online survey study, there may have been social desirability or response biases. Participants may perceive their functional impairments, protective factors, and stress differently. For instance, spirituality was not found to be a mediator nor a moderator in the functional impairments-stress relationship. Although prior research suggested that spirituality plays a role in coping with disabilities (Johnson et al., 2017), some people with disabilities may feel stressed and isolated when they are unable to participate in their spiritual or faith communities (Kaye & Raghavan, 2002). In addition, those with MS who have more positive adjustment to their condition may be more likely to access spiritual resources (McNulty et al., 2003). As spirituality is an abstract concept, participants may have interpreted spirituality in their own ways (e.g., spiritual practices, relationships with higher power, spiritual connections) and some may have limited access to spiritual resources and communities depending on their functional capacity. Since this study was preliminary and exploratory in nature, further studies with larger sample sizes and longitudinal studies would be needed to substantiate this study’s findings.

Conclusion

This study provided preliminary support for the role of a positive person and environment factors between the functional impairments and stress relationship among individuals with MS. Simple mediation results demonstrated that positive cognitive stress appraisal, CSE, resilience, hope, social support, and environmental supports individually mediated the relationship between functional impairments and stress. Parallel mediation results indicated that CSE and environmental supports synergistically mediated the relationship between functional impairments and stress. In addition, moderation analysis showed that only CSE served as a moderator between functional impairments and stress. Findings of this study suggested the importance of incorporating positive person and environment factors in the rehabilitation process because this may help people with MS better cope with their functional challenges and stressors, leading to a flourishing life.

Supplemental Material

sj-docx-1-rcb-10.1177_00343552211025534 – Supplemental material for Exploration of the Effects of Protective Person–Environment Factors Between Functional Impairments and Stress in Individuals With Multiple Sclerosis: Mediation and Moderation Analyses

Supplemental material, sj-docx-1-rcb-10.1177_00343552211025534 for Exploration of the Effects of Protective Person–Environment Factors Between Functional Impairments and Stress in Individuals With Multiple Sclerosis: Mediation and Moderation Analyses by Beatrice Lee, Timothy N. Tansey, Fong Chan, Malachy Bishop, William T. Hoyt and Laura M. Hancock in Rehabilitation Counseling Bulletin

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this research was provided by the University of Wisconsin–Madison, Office of the Vice-Chancellor for Research and Graduate Education with funding from the Wisconsin Alumni Research Foundation.

ORCID iD

Beatrice Lee

Supplemental Material

Supplementary material for this article is available on the Rehabilitation Counseling Bulletin website at .

References

Aiken

L. S.

West

S. G.

(1991). Multiple regression: Testing and interpreting interactions. SAGE.

Alschuler

K. N.

Arewasikporn

Nelson

I. K.

Molton

I. R.

Ehde

D. M.

(2018). Promoting resilience in individuals aging with multiple sclerosis: Results from a pilot randomized controlled trial. Rehabilitation Psychology, 63(3), 338–348. https://doi.org/10.1037/rep0000223

Artemiadis

A. K.

Anagnostouli

M. C.

Alexopoulos

E. C.

(2011). Stress as a risk factor for multiple sclerosis onset or relapse: A systematic review. Neuroepidemiology, 36(2), 109–120. https://doi.org/10.1159/000323953

Artemiadis

A. K.

Vervainioti

A. A.

Alexopoulos

E. C.

Rombos

Anagnostouli

M. C.

Darviri

(2012). Stress management and multiple sclerosis: A randomized controlled trial. Archives of Clinical Neuropsychology, 27(4), 406–416. https://doi.org/10.1093/arclin/acs039

Baron

R. M.

Kenny

D. A.

(1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 5, 1173–1182.

Bierman

(2012). Functional limitations and psychological distress. Society and Mental Health, 2(1), 35–52. https://doi.org/10.1177/2156869312442884

Bigatti

S. M.

Steiner

J. L.

Makinabakan

Hernandez

A. M.

Johnston

Storniolo

A. M.

(2012). Matched and mismatched cognitive appraisals in patients with breast cancer and their partners: Implications for psychological distress. Psycho-Oncology, 21(11), 1229–1236. https://doi.org/10.1002/pon.2028

Bombardier

C. H.

Cunniffe

Wadhwani

Gibbons

L. E.

Blake

K. D.

Kraft

G. H.

(2008). The efficacy of telephone counseling for health promotion in people with multiple sclerosis: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 89(10), 1849–1856. https://doi.org/10.1016/j.apmr.2008.03.021

Briones-Buixassa

Milà

Arrufat

F. X.

Aragonès

J. M.

Bufill

Luminet

Moss-Morris

(2017). A case-control study of psychosocial factors and their relationship to impairment and functionality in multiple sclerosis. Journal of Health Psychology, 24(8), 1023–1032.

10.

Brown

J. L.

Vanable

P. A.

(2008). Cognitive–behavioral stress management interventions for persons living with HIV: A review and critique of the literature. Annals of Behavioral Medicine, 35, 26–40. https://doi.org/10.1007/s12160-007

11.

Brown

R. F.

Tennant

C. C.

Sharrock

Hodgkinson

Dunn

S. M.

Pollard

J. D.

(2006). Relationship between stress and relapse in multiple sclerosis: Part II. Direct and Indirect Relationships. Multiple Sclerosis Journal, 12(4), 465–475. https://doi.org/10.1191/1352458506ms1296oa

12.

Buljevac

Hop

W. C. J.

Reedeker

Janssens

A. C. J. W.

Van Der Meché

F. G. A.

Van Doorn

P. A.

Hintzen

R. Q.

(2003). Self reported stressful life events and exacerbations in multiple sclerosis: Prospective study. British Medical Journal, 327(7416), 1–5.

13.

Catalano

Chan

Wilson

Chiu

C. Y.

Muller

(2011). Buffering effect of resilience on secondary mental health condition of people with spinal cord injury: A structural equation model. Rehabilitation Psychology, 56, 200–211. https://doi.org/10.1037/a0024571

14.

Chalk

H. M.

(2007). Mind over matter: Cognitive—behavioral determinants of emotional distress in multiple sclerosis patients. Psychology, Health & Medicine, 12(5), 556–566. https://doi.org/10.1080/13548500701244965

15.

Chan

Pfaller

(2016). Development of the Multiple Sclerosis Environmental Supports Scale. Rehabilitation Research and Training Center for Evidence-Based Practice in Vocational Rehabilitation.

16.

Chan

Tarvydas

Blalock

Strauser

Atkins

(2009). Unifying and elevating rehabilitation counseling through model-driven, culturally-sensitive evidence-based practice. Rehabilitation Counseling Bulletin, 52, 114–119.

17.

Chan

Yaghmaian

Chen

J. R.

Lee

Iwanaga

Tao

(2019). The world health organization international classification of functioning, disability and health as a framework for rehabilitation assessment. In Strauser

Tansey

Chan

(Eds.), Assessment in rehabilitation and mental health counseling (pp. 15–36). Springer.

18.

Chan

Y. C.

Chan

Ditchman

Phillips

Chou

C. C.

(2013). Evaluating Snyder’s hope theory as a motivational model of participation and life satisfaction for individuals with spinal cord injury: A path analysis. Rehabilitation Research, Policy, & Education, 27, 171–185.

19.

Chatterjee

Hadi

A. S.

(1986). Influential observations, high leverage points, and outliers in linear regression. Statistical Science, 1(3), 379–393.

20.

Chou

C. C.

Chan

Phillips

Chan

J. Y. C.

(2013). Introduction to positive psychology in rehabilitation. Rehabilitation Research, Policy, and Education, 27(3), 126–130.

21.

DeAngelis

J. B.

Yaghmaian

Smedema

S. M.

(2016). The role of core self-evaluations in the relationship between stress and depression in persons with spinal cord injury. Rehabilitation Research, Policy, and Education, 30(4), 353–370.

22.

D’hooghe

M. B.

Nagels

De Keyser

Haentjens

(2013). Self-reported health promotion and disability progression in multiple sclerosis. Journal of the Neurological Sciences, 325(1–2), 120–126. https://doi.org/10.1016/j.jns.2012.12.018

23.

Dougall

A. L.

Baum

(2011). Stress, health, and illness. Routledge.

24.

Dreer

L. E.

Elliott

T. R.

Berry

Fletcher

D. C.

Swanson

Christopher McNeal

(2008). Cognitive appraisals, distress and disability among persons in low vision rehabilitation. British Journal of Health Psychology, 13(3), 449–461. https://doi.org/10.1348/135910707X209835

25.

Dumont

Provost

M. A.

(1999). Resilience in adolescents: Protective role of social support, coping strategies, self-esteem, and social activities on experience of stress and depression. Journal of Youth and Adolescence, 28(3), 343–363.

26.

Dutcher

J. M.

Creswell

J. D.

(2018). The role of brain reward pathways in stress resilience and health. Neuroscience and Biobehavioral Reviews, 95, 559–567. https://doi.org/10.1016/j.neubiorev.2018.10.014

27.

Farber

R. S.

Kern

M. L.

Brusilovsky

(2015). Integrating the ICF with positive psychology: Factors predicting role participation for mothers with multiple sclerosis. Rehabilitation Psychology, 60(2), 169–178. https://doi.org/10.1037/rep0000023

28.

Fujikawa

Lee

E. J.

Chan

Catalano

Hunter

Bengtson

Rahimi

(2013). The Connor-Davidson Resilience Scale as a positive psychology measure for people with spinal cord injuries. Rehabilitation Research, Policy, & Education, 27, 213–222.

29.

Garland

E. L.

Gaylord

S. A.

Fredrickson

B. L.

(2011). Positive reappraisal mediates the stress-reductive effects of mindfulness: An upward spiral process. Mindfulness, 2(1), 59–67. https://doi.org/10.1007/s12671-011-0043-8

30.

Gloria

C. T.

Steinhardt

M. A.

(2016). Relationships among positive emotions, coping, resilience and mental health. Stress and Health, 32(2), 145–156. https://doi.org/10.1002/smi.2589

31.

Grant

Brown

G. W.

Harris

McDonald

W. I.

Patterson

Trimble

M. R.

(1989). Severely threatening events and marked life difficulties preceding onset or exacerbation of multiple sclerosis. Journal of Neurology, Neurosurgery, and Psychiatry, 52(1), 8–13.

32.

Grech

L. B.

Kiropoulos

L. A.

Kirby

K. M.

Butler

Paine

Hester

(2018). Target coping strategies for interventions aimed at maximizing psychosocial adjustment in people with multiple sclerosis. International Journal of MS Care, 20(3), 109–119. https://doi.org/10.7224/1537-2073.2017-008

33.

Hammel

Magasi

Heinemann

Gray

D. B.

Stark

Kisala

Carlozzi

N. E.

Tulsky

Garcia

S. F.

Hahn

E. A.

(2015). Environmental barriers and supports to everyday participation: A qualitative insider perspective from people with disabilities. Archive of Physical Medicine and Rehabilitation, 96(4), 578–588. https://doi.org/10.1016/j.apmr.2014.12.008

34.

Hirsch

J. K.

Sirois

F. M.

(2016). Hope and fatigue in chronic illness: The role of perceived stress. Journal of Health Psychology, 21(4), 451–456. https://doi.org/10.1177/1359105314527142

35.

Hirsch

J. K.

Sirois

F. M.

Lyness

J. M.

(2011). Functional impairment and depressive symptoms in older adults: Mitigating effects of hope. British Journal of Health Psychology, 16(4), 744–760. https://doi.org/10.1111/j.2044-8287.2010.02012.x

36.

Hollingsworth

Gray

D. B.

(2010). Structural equation modeling of the relationships between participation in leisure activities and community environments by people with mobility impairments. Archives of Physical Medicine and Rehabilitation, 91(8), 1174–1181. https://doi.org/10.1016/j.apmr.2010.04.019

37.

Holper

Coenen

Weise

Stucki

Cieza

Kesselring

(2010). Characterization of functioning in multiple sclerosis using the ICF. Journal of Neurology, 257(1), 103–113. https://doi.org/10.1007/s00415-009-5282-4

38.

Hsu

H. C.

Tung

H. J.

(2010). What makes you good and happy? Effects of internal and external resources to adaptation and psychological well-being for the disabled elderly in Taiwan. Aging and Mental Health, 14(7), 851–860. https://doi.org/10.1080/13607861003800997

39.

Hughes

R. B.

Robinson-Whelen

Taylor

H. B.

Hall

J. W.

(2006). Stress self-management: An intervention for women with physical disabilities. Womens Health Issues, 16(6), 389–399. https://doi.org/10.1016/j.whi.2006.08.003

40.

Iwanaga

J. R.

Armstrong

Kaya

Dutta

Kundu

Chan

(in press). Assessing perceived social support among African American college students with disabilities: A confirmatory factor analysis. Journal of Postsecondary Education and Disability.

41.

Iwasaki

Mactavish

J. B.

(2005). Ubiquitous yet unique: Perspectives of people with disabilities on stress. Rehabilitation Counseling Bulletin, 48(4), 194–208.

42.

Johnson

E. T.

Kaseroff

Flowers

Sung

Iwanaga

Chan

Kriofske-Mainella

Morrison

Catalano

(2017). Psychosocial mechanisms explaining the association between spirituality and happiness in individuals with spinal cord injuries. Journal of Rehabilitation, 83(4), 34–42.

43.

Judge

T. A.

Erez

Bono

J. E.

Thoresen

C. J.

(2003). The core self-evaluations scale: Development of a measure. Personnel Psychology, 56(2), 303–331.

44.

Judge

T. A.

Locke

E. A.

Durham

C. C.

Kluger

A. N.

(1998). Dispositional effects on job and life satisfaction: The role of core evaluations. Journal of Applied Psychology, 83, 17–34.

45.

Kammeyer-Mueller

J. D.

Judge

T. A.

Scott

B. A.

(2009). The role of core self-evaluations in the coping process. Journal of Applied Psychology, 94(1), 177–195. https://doi.org/10.1037/a0013214

46.

Kaye

Raghavan

S. K.

(2002). Spirituality in disability and illness. Journal of Religion and Health, 41(3), 231–242.

47.

Kim

Seidlitz

(2002). Spirituality moderates the effect of stress on emotional and physical adjustment. Personality and Individual Differences, 32(8), 1377–1390.

48.

Kinyanjui

McDaniels

Frain

Bishop

Chiu

C.-Y.

Lee

Tiro

(2018). Healthcare and rehabilitation needs of individuals with multiple sclerosis. Contemporary Research in Disabilities and Rehabilitation, 1(1), 2–17.

49.

Krokavcova

Nagyova

van Dijk

J. P.

Rosenberger

Gavelova

Middel

Gdovinova

Groothoff

J. W.

(2008). Mastery, functional disability and perceived health status in patients with multiple sclerosis. European Journal of Neurology, 15(11), 1237–1244. https://doi.org/10.1111/j.1468-1331.2008.02304.x

50.

Lazarus

R. S.

(1999). Hope: An emotion and a vital coping resource against despair. Social Research, 66(2), 653–678.

51.

Lazarus

R. S.

Folkman

(1984). Stress, appraisal, and coping. Springer.

52.

Lee

Chan

(2020). Development and validation of the Brief Disability Related Stress Scale. Rehabilitation Research and Training Center on Evidence-Based Vocational Rehabilitation Practice.

53.

Lee

Iwanaga

Pfaller

Chan

Chiu

C. Y.

Moser

Rumrill

(2018). Psychometric validation of the Multiple Sclerosis Environmental Supports Scale: A brief report. Rehabilitation Counseling Bulletin, 61(3), 187–191.

54.

Lee

Pfaller

Iwanaga

Chen

J. R.

Chan

(2020). Core self-evaluations as a mediator of the relationship between stress and quality of life in women with multiple sclerosis. Journal of Vocational Rehabilitation, 52(2), 137–144. https://doi.org/10.3233/JVR-191066

55.

Livneh

Martz

(2014). Coping strategies and resources as predictors of psychosocial adaptation among people with spinal cord injury. Rehabilitation Psychology, 59(3), 329–339. https://doi.org/10.1037/a0036733

56.

Lopez

S. J.

Snyder

C. R.

(2011). The Oxford handbook of positive psychology. Oxford University Press.

57.

Madan

Pakenham

K. I.

(2014). The stress-buffering effects of hope on adjustment to multiple sclerosis. International Journal of Behavioral Medicine, 21(6), 877–890. https://doi.org/10.1007/s12529-013-9384-0

58.

McNulty

Livneh

Wilson

L. M.

(2003). Perceived uncertainty, spiritual well-being, and psychosocial adaptation in individuals with multiple sclerosis. Rehabilitation Psychology, 49(2), 91–99. https://doi.org/10.1037/0090-5550.49.2.91

59.

Mikula

Nagyova

Vitkova

Szilasiova

(2018). Management of multiple sclerosis: The role of coping self-efficacy and self-esteem. Psychology, Health & Medicine, 23(8), 964–969. https://doi.org/10.1080/13548506.2018.1437277

60.

Moser

Chan

Berven

N. L.

Bezyak

Iwanaga

Umucu

(2020). Resilience and life satisfaction in young adults with epilepsy: The role of person-environment contextual factors. Journal of Vocational Rehabilitation, 52(2), 157–171. https://doi.org/10.3233/JVR-191067

61.

National Multiple Sclerosis Society. (2020). MS prevalence. https://www.nationalmssociety.org/About-the-Society/MS-Prevalence

62.

Ong

A. D.

Bergeman

C. S.

Bisconti

T. L.

Wallace

K. A.

(2006). Psychological resilience, positive emotions, and successful adaptation to stress in later life. Journal of Personality and Social Psychology, 91(4), 730–749. https://doi.org/10.1037/0022-3514.91.4.730

63.

Painter

J. M.

Gray

McGinn

M. M.

Mostoufi

Hoerster

K. D.

(2016). The relationships of posttraumatic stress disorder and depression symptoms with health-related quality of life and the role of social support among veterans. Quality of Life Research, 25(10), 2657–2667. https://doi.org/10.1007/s11136-016-1295-5

64.

Pakenham

K. I.

Mawdsley

Brown

F. L.

Burton

N. W.

(2018). Pilot evaluation of a resilience training program for people with multiple sclerosis. Rehabilitation Psychology, 63(1), 29–42. https://doi.org/10.1037/rep0000167

65.

Park

Peterson

Szvarca

Vander Molen

R. J.

Kim

E. S.

Collon

(2016). Positive psychology and physical health: Research and applications. American Journal of Lifestyle Medicine, 10(3), 200–206. https://doi.org/10.1177/1559827614550277

66.

Rashid

Seligman

M. P.

(2018). Positive psychotherapy: Clinician manual. Oxford University Press.

67.

Reed

P. G.

(1987). Spirituality and well-being in terminally ill hospitalized adults. Research in Nursing and Health, 10(5), 335–344.

68.

Rey

Extremera

Peláez-Fernández

M. A.

(2016). Linking social support to psychological distress in the unemployed: The moderating role of core self-evaluations. Social Indicators Research, 127(1), 435–445. https://doi.org/10.1007/s11205-015-0958-x

69.

Roddam

Rog

Janssen

Wilson

Cross

Olajide

Dey

(2019). Inequalities in access to health and social care among adults with multiple sclerosis: A scoping review of the literature. Multiple Sclerosis and Related Disorders, 28, 290–304. https://doi.org/10.1016/j.msard.2018.12.043

70.

Roesch

S. C.

Rowley

A. A.

(2005). Evaluating and developing a multidimensional, dispositional measure of appraisal. Journal of Personality Assessment, 85(2), 188–196. https://doi.org/10.1207/s15327752jpa8502_11

71.

Rommer

P. S.

Suhnel

Konig

Zettl

U. K.

(2017). Coping with multiple sclerosis-the role of social support. Acta Neurologica Scandinavica, 136(1), 11–16. https://doi.org/10.1111/ane.12673

72.

RStudio Team. (2020). RStudio: Integrated Development Environment for R. RStudio. http://www.rstudio.com/

73.

Rutter

(1987). Psychosocial resilience and protective mechanisms. American Journal of Orthopsychiatry, 57, 316–331.

74.

Sanaeinasab

Saffari

Hashempour

Karimi Zarchi

A. A.

Alghamdi

W. A.

Koenig

H. G.

(2017). Effect of a transactional model education program on coping effectiveness in women with multiple sclerosis. Brain and Behavior, 7(10), 1–9. https://doi.org/10.1002/brb3.810

75.

Sanchez

Rosenthal

D. A.

Tansey

T. N.

Frain

M. P.

Bezyak

J. L.

(2016). Predicting quality of life in adults with severe mental illness: Extending the International Classification of Functioning, Disability, and Health. Rehabilitation Psychology, 61(1), 19–31. https://doi.org/10.1037/rep0000059

76.

Seligman

M. E. P.

(2011). Flourish: A visionary new understanding of happiness and well-being. Free Press.

77.

Seligman

M. E. P.

Csikszentmihalyi

(2000). Positive psychology: An introduction. American Psychologist, 55(1), 5–14.

78.

Smedema

S. M.

Chan

Yaghmaian

Cardoso

Muller

Keegan

Dutta

Ebener

D. J.

(2015). The relationship of core self-evaluations and life satisfaction in individuals with disabilities: Evaluation of a mediator model. Journal of Postsecondary Education and Disability, 28(3), 341–358.

79.

Smedema

S. M.

Chan

J. Y.

Phillips

B. N.

(2014). Core self-evaluations and Snyder’s hope theory in persons with spinal cord injuries. Rehabilitation Psychology, 59(4), 399–406. https://doi.org/10.1037/rep0000015

80.

Smedema

S. M.

Pfaller

J. S.

Yaghmaian

R. A.

Weaver

Cardoso

Chan

(2015). Core self-evaluations as a mediator between functional disability and life satisfaction in college students with disabilities. Rehabilitation Research, Policy, and Education, 29, 1–9

81.

Smedema

S. M.

Tansey

T. N.

(2015). Mediators of the relationship between core self-evaluations and life satisfaction in individuals with spinal cord injuries. Rehabilitation Counseling Bulletin, 58(4), 217–226.

82.

Smith

B. W.

Dalen

Wiggins

Tooley

Christopher

Bernard

(2008). The brief resilience scale: Assessing the ability to bounce back. International Journal of Behavioral Medicine, 15(3), 194–200. https://doi.org/10.1080/10705500802222972

83.

Snyder

C. R.

Harris

Anderson

J. R.

Holleran

S. A.

Irving

L. M.

Sigmon

S. T.

Yoshinobu

Gibb

Langelle

Harney

(1991). The will and the ways: Development and validation of an individual-differences measure of hope. Journal of Personality and Social Psychology, 60(4), 570–585.

84.

Sung

Chiu

Lee

E.-J.

Bezyak

Chan

Muller

(2013). Exercise, diet, and stress management as mediators between functional disability and health-related quality of life in multiple sclerosis. Rehabilitation Counseling Bulletin, 56(2), 85–95. https://doi.org/10.1177/0034355212439899

85.

Tan-Kristanto

Kiropoulos

L. A.

(2015). Resilience, self-efficacy, coping styles and depressive and anxiety symptoms in those newly diagnosed with multiple sclerosis. Psychology, Health & Medicine, 20(6), 635–645. https://doi.org/10.1080/13548506.2014.999810

86.

Tingley

Yamamoto

Hirose

Keele

Imai

(2014). Mediation: R package for causal mediation analysis. Journal of Statistical Software, 59(5), 1–38. http://www.jstatsoft.org/v59/i05/

87.

Tuck

Alleyne

Thinganjana

(2006). Spirituality and stress management in healthy adults. Journal of Holistic Nursing, 24(4), 245–253.

88.

Ustun

Kennedy

(2009). What is “functional impairment”? Disentangling disability from clinical significance. World Psychiatry, 8(2), 82–85.

89.

Ustun

T. B.

Kostanjsek

Chatterji

Rehm

, & World Health Organization (2010). Measuring health and disability: Manual for WHO Disability Assessment Schedule WHODAS 2.0. World Health Organization.

90.

Wehmeyer

M. L.

(2013). The Oxford handbook of positive psychology and disability. Oxford University Press.

91.

Wilkinson

Bowen

Gustavsson

Hakansson

Littleton

McCormick

Thompson

Mulligan

(2019). Maintenance and development of social connection by people with long-term conditions: A qualitative study. International Journal of Environmental Research and Public Health, 16(11), Article 1875. https://doi.org/10.3390/ijerph16111875

92.

Williams

R. M.

Turner

A. P.

Hatzakis

Chu

Rodriquez

A. A.

Bowen

J. D.

Haselkorn

J. K.

(2004). Social support among veterans with multiple sclerosis. Rehabilitation Psychology, 49(2), 106–113. https://doi.org/10.1037/0090-5550.49.2.106

93.

Wilski

Brola

Tomczak

(2019). Health locus of control and mental health in patients with multiple sclerosis: Mediating effect of coping strategies. Research in Nursing and Health, 42(4), 296–305. https://doi.org/10.1002/nur.21955

94.

Wilski

Tasiemski

(2016). Illness perception, treatment beliefs, self-esteem, and self-efficacy as correlates of self-management in multiple sclerosis. Acta Neurologica Scandinavica, 133(5), 338–345. https://doi.org/10.1111/ane.12465

95.

Wilson

Catalano

Sung

Phillips

Chou

C. C.

Chan

Y. C.

Chan

(2013). Attachment, social support, and coping as psychosocial correlates of happiness in people with spinal cord injuries. Rehabilitation Research, Policy, & Education, 27, 186–205.

96.

World Health Organization. (2001). International classification of functioning, disability and health.

97.

Wright

B. A.

(1983). Physical disability: A psychosocial approach (2nd ed.). Harper and Row.

98.

Zimet

G. D.

Dahlem

N. W.

Zimet

S. G.

Farley

G. K.

(1988). The Multidimensional Scale of Perceived Social Support. Journal of Personality Assessment, 52(1), 30–41. https://doi.org/10.1207/s15327752jpa5201_2

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.03 MB