RESEARCH REPORT

Psychosodal Adjustment AmongCentral American Immigrants withDisabilities: An Exploratory Study

S. LISBETH JARAMA

HEIDI REYST

MARILYN RODRIGUEZ

FAYE Z. BELCRAVE

MARIA CECILIA ZEA

George Washington University

This is an exploratory study thai investigated factors influencing the psychoso-

cml adjustment of Central American immigrants with disabilities. The rela-

tionships between stress, and perception of disability seventy and (a) depression

and (b) anxiety were assessed. Furthermore, this study investigated whether so-

cial support moderated the impact of stress and severity of disability on depres-

sion and anxiety. Stress, severity of disability, and social support explained a

high percentage (54 %) of the variance in depression. High levels of stress, in-

creased perceptions of severity of disability, and low social support were associ-

ated with increased depression. The interactions between support and stress

and between support and disability severity did not significantly add to the

original model which predicted depression. Main effects were found for stress,

disability severity, and the interaction between support and disability seventy.

Stress and social support significantly accounted for 31 % of the variance in

anxiety. Increased stress and decreased social support were associated with

greater levels of anxiety. The interaction between support and stress did not sig-

nificantly predict anxiety. Implications of the study in terms of future research

and intervention programs targeting mental health outcomes for Latino immi-

grants with disabilities are discussed. © 1998John Wiley & Sons, Inc.

• stress • social support • severity of disability * Latino immigrants

• This research was supported in part by the Department of Education in a grant (USDE no.

H133G20117) toFaye Z. Belgrave, Principal Investigator.

Reprint requests should be directed to Maria Cecilia Zm, Ph.D., Department of Psychology,

George Washington University, Washington, DC 20052.

Cultural Diversity and Mental Health, Vol. 4, No. 2,115-125 (1998)

© 1998 by John Wiley & Sons, Inc. CCC 1077-341X/98/020115-11

116 J A R A M A E T A

Latino immigrants with disabilities face two

stressors: having a disability and adjusting to

a new culture. High levels of stress have been

associated with negative mental health out-

comes such as depression and anxiety (Turn-

er & McLean, 1989; Weinberger, Tierney,

Booher, & Heiner, 1990). Although there

may be increased stress, poorer mental

health functioning is not inevitable. Social

support may buffer the deleterious effect of

stress. The indirect and direct impact of so-

cial support among persons with disabilities

on outcomes such as depression and anxiety

has been well documented (e.g., Elliot, Her-

rick, Patti, & Witty, 1991; Kelley & Lambert,

1992; Littlefield, Rodin, & Murray, 1990;

Turner & Wood, 1985). This study examined

the relationship between stress, disability

severity, and mental health (i.e., depression

and anxiety) among Latino immigrants with

disabilities. The study also examined the role

of social support in that relationship.

Lazarus and Folkman (1984) defined

stress as external or internal demands that

create a strain on the individual. For Latino

immigrants with disabilities, both disability

status and immigrant status can contribute to

stress and persistent strains. Disability refers

to "any restriction or lack (resulting from im-

pairment) of ability to perform an activity in

the manner or within the range considered

normal for a human being" (World Health

Organization, 1980).

Disability may be a source of ongoing

strain if it renders daily activities difficult and

contributes to the experience of additional

negative life events. As such, persons with dis-

abilities are likely to be at increased risk of

stress. Turner and McLean (1989) state that

"presumably, the elevated difficulty in per-

forming social and occupational roles that

tends to be experienced by disabled individ-

uals constitutes a significant source of en-

during stress that challenges adaptive capac-

ities." Situations in which an individual

perceives that he or she has little or no con-

trol may be stressful (Thompson & Spaca-

pan, 1991). Because of challenges in role

functioning, having a disability may decrease

perceptions of control and create additional

stress.

Being an immigrant and being of a mi-

nority status can be a significant source of

stress in and of itself (Salgado de Snyder, Cer-

vantes, & Padilla, 1990). Latino immigrants

may be at risk of lowered perceptions of con-

trol and high levels of stress resulting from

their immigrant status. Differences in cul-

ture, values, and societal norms of the adopt-

ed country may contribute to feelings of con-

fusion and loss and may make meeting basic

survival needs difficult (Lequerica, 1993).

Salgado de Snyder et al. (1990) found that

female immigrants reported experiencing

high levels of stress because of cultural and

family conflicts.

Padilla, Cervantes, Maldonado, and Gar-

cia (1988) report that among Latinos who

immigrate, language barriers, lowered eco-

nomic status, lack of education and work

skills, and discrimination are significant stres-

sors. Not speaking English and unemploy-

ment were reported as the first and second

most significant stressors by Padilla et al.

(1988). Reentering the work force or enter-

ing the work force for the first time is stress-

ful for any population, including Latinos.

Undocumented immigrant status can also be

a significant source of stress. Mexican and

Central American immigrants reported lhat

immigrant status is the third most difficult

factor in their experience immigrating to the

United States (Padilla et al., 1988).

Among immigrants, having a disabling

condition may increase the burden associat-

ed with migrating to a new country. Special

accommodations may be necessary, and spe-

cialized services from several individuals

and/or agencies may be needed. However,

the experience of coordination with agen-

cies to receive appropriate treatment and ser-

vices may be a new experience for the Latino

immigrant. Along with adapting to a differ-

ent cultural environment, the individual

must also modify that environment to ac-

commodate his or her special needs. The use

of special services for Latinos with disabilities

becomes very difficult because of the inabil-

P S Y C H O S O C I A L A D J U S T M E N T T O D I S A B I L I T Y 117

ity to easily communicate in English, the per-

ception of loss of control, and legal status.

Depression and Anxiety Among Personswith Disabilities

Chronic stress arising from disability status is

positively related to depression among peo-ple with disabilities (Turner & Beiser, 1990).

Turner and Beiser (1990) compared people

with disabilities to people without disabilities

and found that 37% of those with a disability

have a clinically significant level of depressive

symptoms, compared with 12% of those with-

out disabilities. Turner and Wood (1985)

found similar results in a study of adults with

physical disabilities; 34% of subjects with dis-

abilities reported depression. This is nearly

twice the rate found in the general popula-tion. These results suggest that having a dis-

ability increases the probability of becoming

depressed.

Anxiety, another form of distress, has

been linked to high levels of stress (Turner 8c

McLean, 1989). Although anxiety has been

studied with less frequency than depression,

the rates of problematic anxiety levels aresimilar to those of depression with respect to

stress levels. In a study comparing individuals

with disabilities to individuals without dis-

abilities, it was found that 45% of individuals

with a disability exceeded the cutoff score

for problematic levels of anxiety (Turner &McLean, 1989). In contrast, among individu-

als who do not have a disability, 18% had

high levels of anxiety.

A significant correlation between anxiety

and the individual's self-rated impact of ill-

ness and anxiety and the physician's rating ofdisability was found by Kuch and colleagues

(1993). Barrett and colleagues (1988) have

suggested that "high anxiety levels may be as-sociated with concerns about body deterio-ration or mortality." Although not very much

is known about the relationship between dis-

ability and anxiety, there is evidence that ahigher incidence of anxiety does exist amongpersons with disabilities. The literature has

demonstrated that individuals with disabili-

ties are significantly more anxious than the

general population.

The relationship between disability sever-ity and stress is not unequivocal. Some re-

search supports the fact that persons who per-

ceive their disability as severe are likely to

experience increased levels of distress andpoorer mental health outcomes (Jarama,

1996; Kimmel et al., 1995). However, findings

from other studies have not provided sup-port for a relationship between disability

severity and unfavorable outcomes (Eber-

hardt, Larsson, & Nived, 1993; Huber, Ram-

mohan, Bornstein, & Christy, 1993). Thus,

the relationship between level of disability

severity and menial health outcomes is not

conclusive and will be investigated in this

study.

In summary, the literature suggests thathaving a disability can be a stressor that can

lead to unfavorable mental health outcomes.Stressors among Latino immigrants may be

magnified because of minority and ethnic

status. Latino immigrants with disabilities are

therefore at high risk of poor mental health

outcomes such as depression and anxiety.

One factor believed to moderate stress is so-

cial support. There has been limited research

on social support as a moderator of stress for

Latino immigrants with disabilities. This is

the focus of the current study.

Social Support

Despite the numerous barriers for persons

with disabilities, many persons with disabili-

ties are able to maintain a well-adjusted life at

home, at work, and in the community. A fac-

tor that contributes to successful outcomes

among persons with disabilities is social sup-

port (Heller & Swindle, 1983). Social support

includes emotional closeness (intimacy), tan-gible support (material support), appraisal

support (information and advice), esteem

support (feedback that the individual is val-ued by others), and group-belonging support(companionship) (King, Reis, Porter, &

118 J A R A M A E T A L .

Norsen, 1993). These types of support are ex-

pected to buffer the relationship between

stressors and mental health outcomes. Indi-

viduals with high levels of social support are

likely to experience less stress and have bet-

ter mental health outcomes.

Turner and Noh (1988) examined fac-

tors that may buffer the link between stress

and depression in adults with disabilities.

They found that social support and mastery-

were negatively associated with depression,

such that higher feelings of social support

and mastery were associated with lowered

feelings of depression and lowered risk of de-

pressive symptoms.

The nature of the Latino culture, in

which collectivist attitudes arc more preva-

lent than individualistic attitudes, suggests

that social support may be highly beneficial.

In fact, the literature on social support indi-

cates that Latinos use social support and that

this is an important factor in their psycho-

logical and physical well-being (Griffith,

1984; Padilla, Cervantes, Maldonado, & Gar-

cia, 1988; Starrett, Mindel, & Wright, 1983).

Furthermore, social support networks can be

of special value to immigrants, who may not

be acculturated to American culture.

In summary, immigrants who have a dis-

abling condition are at risk of depression and

anxiety from increased slrcssors. The litera-

ture indicates that social support may mod-

erate the relationship between stress and

depression and anxiety. In this study, we ex-

amine how social support, stress, and severi-

ty of disability impact depression and anxiety.

Although models of social support and stress

have been well researched in the literature,

we are interested in the application to Latino

immigrants with disabilities. The following

relationships were hypothesized:

1. Stress and perceived disability severity

will positively correlate with the de-

pendent measures of depression and

anxiety.

2. The impact of stress and of perceived

disability severity on depression and

anxiety will be moderated by social

support.

Methods

Participants

A nonrandom sample of 64 Latinos who were

clients in the Rehabilitation Service Admin-

istration (RSA) in Washington D.C. partici-

pated in the study. There were 27 men and

37 women participants. Most of them origi-

nated from Central America (72%), but

there were a few Dominican (10%) and

South American (17%) participants. Partici-

pants had a variety of disabling conditions

that included physical, chronic illness, neu-

rologic, sensory, emotional, substance abuse,

and cognitive disabilities (Table 1). Sixteen

participants reported not having any disabil-

ity; these participants may have assumed that

a disability meant a visible disability. Howev-

er, one criterion for being clients of RSA is

the presence of a disability.

Procedures

Participants were recruited as part of a larg-

er study that assessed the impact of an inter-

vention program aimed at improving mental

health and employment outcomes among

persons with disabilities. Project staff collab-

orated with the administrators and coun-

selors at RSA to recruit participants. A crite-

rion for participation was that clients be in

job-ready or training status. Clients who met

the study criteria were contacted by their

counselors who provided information about

the study. If clients indicated interest and

were motivated to participate, they were re-

ferred to project staff. The project staff con-

tacted each referral, explained the purpose

of the program, and asked for their partici-pation.

Informed consents were obtained before

data collection. Participants were assured

that their responses would remain coiifiden-

P S Y C H O S O C I A L A D J U S T M E N T T O D I S A B I L I T Y 119

TABLE 1. Descriptive Statistics of Sample

Demographic Characteristics

N %

Age Range: 18-67

Average Age: 32.6

Gender

Women

Men

Education

<12th grade

>12th grade

Marital Status

Single

Married

Divorced

Separated

Living with someone

Type of disability

Physical

Chronic illness

Neurologic

Emotional

Substance abuse

Cognitive

"'None"

37

27

54

9

34

19

1

5

5

20

3

27

1

1

16

57.8

42.2

85.7

14.3

53.1

29.7

1.6

7.8

7.8

40.0

6.0

4.0

14.0

2.0

2.0

32.0

tial and that there would not be negative con-

sequences if they declined to participate. All

measures and informed consents were in

Spanish. At least two persons were available

during date collection to assist participants

with completion of questionnaires if there

were literacy problems. Participants received

a stipend for their participation and tokens

for transportation.

Measures

A comprehensive questionnaire containing

several measures was administered to partic-

ipants. Measures relevant to this study are de-

scribed in the following sections.

DEMOGRAPHIC INFORMATION. Demographic

information included age, sex, education,

marital status, and type of disability (Table 1).

Type of disability was assessed by asking par-

ticipants to list their primary disability.

PSYCHOSOCIAL STRESS. The Perceived Stress

Scale (PSS) (Cohen, Kamarck, & Mcrmel-

stain, 1983) was used to assess the degree to

which situations in one's life are appraised as

stressful. The PSS is a general measure of

stress perception. This 14-item scale, which

assesses the frequency of feelings and

thoughts during the preceding month, has

acceptable validity and reliability. Cron-

bach's alpha reliability for the study sample

was .66.

SEVERITY OF DISABILITY. Perception of the

severity of the disability was assessed by ask-

ing participants to rate their disability on a

scale that ranged from "1" a little to "7" very

severe.

SOCIAL SUPPORT. The Personal Resources

Questionnaires-Part I (PRQ) (Brandt & Wein-

crt, 1981, 1987) was used to measure satis-

faction with social support. Participants were

120 I A R A M A E T A L .

presented with problematic/difficult situa-

tions (i.e., finances, loneliness, unemploy-

ment, and urgent needs) and asked whom

they would go to for help for each. They were

asked whether they had needed help for any

of these situations/problems during the past

6 months and how satisfied they felt with the

help received. They responded to a Likert-

typc scale ranging from "6" very satisfied to

"1" very dissatisfied. The PRQ has been used

in a number of studies and has good psycho-

metric properties (Brandt & Weinert, 1981,

1987). Test-retest reliability in a group of 100

adults was .72. Internal consistency reliabili-

ty ranged from .85 to .93. Criteria-related va-

lidity (r = 40) was established by showing a

correlation between the social support mea-

sure and family functioning. The PRQ has

also been used with ethnic minority popula-

tions in other studies (Zea, Belgrave, Town-

send, Jarama, & Banks, 1996). Cronbach al-

pha's internal consistency for the study

sample was .68.

DEPRESSION. The short version of the Beck

Depression Inventory (BDI) (Beck & Beck, 1972)

was used to assess feelings of depression. This

shortened version includes 13 items and has

been demonstrated to be highly correlated

with the long BDI (correlation coefficients

ranging from .89 to .97). It also has high in-

ternal consistency, concurrent validity with

other measures of depression, and construct

validity with psychological, behavioral, and

attitudinal variables related to depression

(Beck, Steer, & Garbin, 1988). In this study

the reliability coefficient was .84.

ANXIETY. The State-Trait Anxiety Inventory

(STAI) (Spielberger, Gorsuch, & Lushene,

1970) was used to assess anxiety. This scale

has been used extensively in research and

clinical practice among persons with psychi-

atric and psychosomatic illnesses as well as

among normal populations. The STAI mea-

sures anxiety as a state and as a trait. In the

present research, the T-Anxiety scale was

used as it reflects stable, long-term anxiety.

The T-Anxiety scale consists of 20 items that

assess how people "generally" feel. In re-

search with working adults, students, and

military recruits, the alpha coefficients for

the T-Anxiety scale were uniformly high, with

a median coefficient of .90 (Spielberger, Gor-

such, Lushene, Vagg, &Jacobs, 1983). Cron-

bach's alpha coefficient for the T-Anxiety of

this sample was .79.

Measures were translated into standard

Spanish by one translator and then back

translated by another translator. The two

English versions were then contrasted to

identify inconsistencies. A panel of four

Spanish-speaking researchers of diverse na-

tionalities reviewed the Spanish version to

ensure that the language was standard and

avoided regionalisms.

Results

Descriptive Statistics

Demographic information on age, sex, edu-

cational level, marital status, and disability

are shown in Table 1. The mean score for de-

pression was 8.83 (SD 7.3); for anxiety, there

was an average score of 2.22 (SO .49). The

mean score of stress for this sample was 3.05

(SD .53); for severity of disability, the mean

score was 1.84 (SD 1.75); and for social sup-

port those scores were 4.4 and 1.48, respec-

tively.

Bivariate Correlations

Initial correlations between the independent

variables and depression indicated that de-

pression was positively related to stress (r =

.65, p < .001) and to perception of severity of

disability (r— .51, p < .001). Depression was

negatively related to satisfaction with social

support (r = —.35, p < .008). Increased

stress, high perception of the severity of dis-

ability', and decreased satisfaction with sup-

P S Y C H O S O C I A L A D J U S T M E N T T O D I S A B I L I T Y 727

port were associated with increased depres-

sion.

Correlations between the independent

variables and anxiety indicated that anxietywas positively related to stress (r — .44, p <

.008) and negatively related to satisfaction

with social support (r = .41, p < .02). Therewas no relationship between anxiety and dis-

ability severity. Increased stress and de-

creased satisfaction with support were associ-

ated with increased anxiety.Correlations between demographic vari-

ables and depression and anxiety were com-puted. There were no significant associations

between demographic variables and depres-

sion and anxiety.

Hierarchical Regression Analyses

Multivariate analyses were conducted to ex-amine whether stress, perception of severity

of disability, and satisfaction with social sup-

port predicted depression and anxiety. Sepa-

rate hierarchical multiple regressions were

performed in which stress, perception of the

severity of disability, and satisfaction with so-

cial support were entered simultaneously in

the first step. Two-way interactions betweensupport and stress and between support and

perception of the severity of disability were

examined. Two separate analyses were con-

ducted in which each interaction was entered

in the second step. Demographic variables

(i.e., gender, education) were not entered in

the model because they were not significant

at the bivariate level.

Depression

As a set, stress, perception of the severity of

disability, and social support significantly

predicted depression (Table 2). Fifty-four

percent of the proportion of variance could

be accounted for by the variables in the mod-

TABLE 2. Hierarchical Multiple Regression Analyses for the Prediction

of Depression (JV = 50) and of Anxiety (N = 35)

Step

Predictor Variables

Cumulative" R2

.54

R2 Increment df F

Depression

.54 3,49 17.97***

Stress

Severity of disability

Social support

Interactions1*

Stress x Social support

Severity of disability x Social support

Predictor Variables

Stress

Social Support

Interaction

Stress x Social Support

.54

.59

.31

.00

.05

Anxiety

.31

4,49

4,49

2,34

13.28***c

16.10**»

7.07**

.31 3,34 4.60**

aTota! percent variance accounted tor dependent variable by predictor variables.hEach interaction term was entered in a different regression equation.lvalue represents the joint contribution of the predictor variables and each interaction term.*p < .05.

**/»<.01.***£<.0001.

122 J A R A M A E T A L .

el (F= 17.97, p < .0001). The individual con-

tribution of variables when controlling for

each other showed that stress was a stronger

predictor (F= 16.37,p< .001) than percep-

tion of severity of disability (F = 6.40, p <

.01). Social support did not make a unique

contribution to the model.

The two-way interactions between sup-

port and stress and support and severity of

disability were tested in separate regression

equations. Each interaction was entered in

the second step along with the predictor vari-

ables. The models containing each interac-

tion term did not significantly add to the

original model that contained the predictor

variables. However, when each variable was

controlled for each other, there was a unique

contribution of the interaction between so-

cial support and severity of disability (F =

5.36, p < .03). Increased perception of sever-

ity of disability was related to high levels of

depression when social support was low.

Anxiety

Stress and social support were entered as a

block in the first step. Perception of severity

of disability was not entered in this step be-

cause it was not significant at the bivariatc lev-

el. Stress and social support were significant

predictors of anxiety'. The individual contri-

bution of stress and social support when con-

trolling for the other was also significant (F

= 6.56, p < .02, and F= 5.11, p .03, respec-

tively). Thirty-one percent of the proportion

of variance could be accounted for by the

variables in the model (F = 7.07, p < .003).

Although the model that included the inter-

action between support and stress was signif-

icant, the interaction did not significantly

add to the original model.

Discussion

This was an exploratory study that examined

the relationships between stress, perceived

severity of disability, social support, and de-

pression and anxiety among Central Ameri-

can immigrants with disabilities. The role of

social support in moderating the impact of

stress and severity of disability on depression

and anxiety was also explored.

Stress, severity of disability, and social

support jointly explained a large percentage

(54%) of the variance in depression. High

levels of stress, coupled with increased per-

ceptions of severity of the disability, and a

nonexistent or ineffective social support net-

work were associated with increased depres-

sion among Central American immigrants

with disabilities. Stress made the greatest

unique contribution to depression, followed

by perceptions of the severity of disability.

These findings are consistent with those re-

ported in other studies, which have found

stress and disability severity to correlate sig-

nificantly with depression among persons

with disabilities (Turner & Beiser, 1990;

Turner & McLean, 1989; Turner & Wood,

1985). In addition, increased perceptions of

disability' severity resulted in depression

when satisfaction with social support was low.

A significant proportion (31%) of anxiety

experienced by Central Americans with dis-

abilities can be explained by increased stress

and decreased social support. Although pre-

liminary, these findings contribute to the

sparse literature research assessing the rela-

tionship between stress and anxiety among

persons with disabilities. Latino immigrants

with disabilities experience great levels of

anxiety because of their increased stress.

There are several stressors unique to this

population such as immigrant status, uproot-

ing from culture of origin, the language bar-

rier, and limited employment opportunities,

which contribute directly to anxiety. The

study findings are consistent with the few

studies that have found stress to be related

to anxiety among persons with disabilities

(Burlewetal., 1995; Turner & McLean, 1989).Perception of disability severity con-

tributed to depression, but not to anxiety.

Perhaps for this population, other stressors

play a more insidious role in generating anx-

iety than perception of disability severity.

Among study participants, not having ade-

quate social support contributed to in-

creased anxiety. However, the impact of

P S Y C H O S O C I A L A D J U S T M E N T T O D I S A B I L I T Y 123

stress on anxiety was not moderated by social

support. The small sample size available for

these analyses may have contributed to this

lack of effects.It is of interest that there was a finding of

a direct impact of social support on anxiety

and not on depression. This finding suggests

that the experience of anxiety may be inde-

pendent of depression for this population.

The findings underscore the role of satisfac-tion with social support on mental health

among Latino immigrants with disabilities.Social support can directly relieve the dis-

tress from anxiety or may serve a protective

function when there is depression. Social

support may significantly reduce anxiety feel-

ings regardless of the level of stress experi-

enced. Likewise, satisfaction with one's social

network may be critical to protect persons

from feeling depressed when they have high

perceptions of severity of disability.Despite the significant findings, this is an

exploratory study that has some limitations.

While we expected social support, stress, anddisability severity to precede depression and

anxiety, this may not have been the case. De-

pression and anxiety may have unfavorably

influenced participants' perceptions of sup-

port, disability severity, and stress, law sup-

port, increased perceptions of the severity of

disability, and increased stress may resultfrom a depressive and/or anxious view. An

important caveat relates to the generalizabil-

ity of the study results. The sample was takenfrom a state rehabilitation agency in Wash-

ington, DC. These individuals may have been

different from others who are not affiliated

with a state rehabilitation agency. For exam-

ple, participants may have been more moti-

vated because they were clients at this

agency; or they may have been clients be-cause they needed more services.

Another limitation of this research is the

small sample size, which limited the power of

analyses. The use of self-report measures isanother limitation.

Future research is needed to continue toaddress the relationship between stress, per-

ceived severity of disability, social supportand anxiety and depression. Using a larger

and more heterogeneous sample may con-

tribute to better generalizability of findings.

Objective measures, such as independent rat-

ings of disability severity by rehabilitationprofessionals, could be used to complement

the more subjective self-reported perception

of disability severity. Perhaps focusing on onespecific disability instead of disabilities in

general would also yield different results. An-

other interesting research possibility would

be to assess the relationship between stress,

severity of disability, and social support, and

their impact on other outcomes such as

health behaviors, morbidity and mortality,and vocational outcomes. Evaluating whether

differences exist between nonimmigrant andimmigrant Latinos is also an interesting ex-

tension of the present research.

Clinical Implications

The findings provide some suggestions and

issues to address when designing interven-

tions. An effective intervention for Latino

immigrants with disabilities should consider

individual perceptions of stress and of the

severity of the disability. Strategies aimed atcognitive restructuring, improving coping

skills, and improving self-efficacy may proveeffective. For example, to change detrimen-

tal perceptions of severity of disability, learn-ing to think of one's disabling condition in

more adaptive ways through cognitive re-

structuring could be effective. Also, stressmanagement training, which teaches effec-

tive coping skills, may be helpful in reducing

stress. Finally, intervention programs mayemphasize the use and development of social

networks as effective resources to alleviate or

prevent the experience of anxiety and distress.

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