Self-care Problems and Management Strategies Experienced by Rural Patient/Caregiver Dyads Living With Heart Failure: A Qualitative Study.

BACKGROUND: Rural patients with heart failure (HF) have higher mortality and hospitalization rates compared with their urban counterparts. Although research supports the inclusion of informal caregivers in daily self-care activities, data are limited regarding the problems encountered by rural patient/caregiver dyads living with HF in managing HF in the home and how these problems are managed. OBJECTIVE: The aim of this study was to identify and describe HF self-care problems experienced by rural dyads in the home and how these problems are managed. METHODS: Using a descriptive qualitative design, data were collected from rural patient/caregiver dyads living with HF via individual, semistructured, telephone interviews and analyzed using schematic content analysis. Interviews and data analysis occurred concurrently until data saturation was reached. RESULTS: Thematic data saturation was obtained with 11 dyads. On average, patients were 65.3 (±13.9) years old, and caregivers were 62 (±12.37) years old. Four themes illustrating dyadic HF self-care problems and management strategies emerged: (1) HF self-care components, namely, maintenance, symptom monitoring, and management (diet, exercise, activities, strategies); (2) environment (rural barriers, COVID-19); (3) caregiver contributors (confidence, role); and (4) dyadic contributors (dyadic relationship). Dyads described various self-care problems, with the type of relationship and presence of mutuality influencing the problem-solving process and development of management strategies. CONCLUSIONS: The identified themes emphasize the self-care problems experienced by rural dyads living with HF and the contributions of both dyad members to effectively manage these challenges. Findings support the need for culturally sensitive, tailored interventions targeting self-care in rural dyads living with HF.

Latent profile analysis of stress and resilience among rural women: A cross-sectional study.

Stress is a cardiovascular disease risk factor, and resilience may serve as a buffer for stress. Little is known about stress and resilience among rural women. OBJECTIVE: The purposes of this study were to identify profiles of rural women based upon indicators of psychosocial and environmental stress and to examine the relationships between the identified profiles and resilience. DESIGN AND SAMPLE: A cross-sectional, descriptive design was used to explore stress, social support, and resilience among a representative sample of women (n = 354). MEASURES: Data were collected to measure perceived stress, social support, chronic stress, and resilience. RESULTS: A latent profile analysis identified three profiles (59.9% Low Stress, 25.4% Moderate Stress, and 14.7% High Stress). Women in the High Stress profile were less likely to afford necessities and have attended college and more likely to be employed. Women in the Low Stress profile had the highest scores for all five resilience subscales. CONCLUSION: The current study demonstrates the social and environmental impact of stress and how this stress can manifest differently for different women. Underserved women may benefit from strategies that reduce stress and improve social support and resilience. Future research is needed for advancing health equity in rural populations.

Social determinants of health related to stay-at-home order adherence and social distancing attitudes among a diverse Deep South population.

OBJECTIVE: To describe COVID-19 related symptoms and medical care experienced in the first six months of the pandemic as well as stay-at-home order adherence, and attitudes related to COVID-19 risk and social distancing among a diverse sample of adults in the Deep South. METHODS: Survey data were collected from 411 Louisiana and Mississippi residents for three weeks in June 2020 through social media. RESULTS: Over half (52.5%) of participants who experienced COVID-19 related symptoms (with 41.5% experiencing at least one symptom) did not feel the severity of symptoms warranted seeking medical care. 91.6% of the Deep South adults visited certain places or did activities where visiting or gathering with other people was involved during stay-at-home mandates. Religiosity/spirituality, age, education, number of children in the home, attitudes related to COVID-19 risk of complications and social distancing were related to the greater/lesser likelihood of stay-at-home order adherence. CONCLUSIONS: Various cultural and contextual factors were related to stay-at-home order adherence. Understanding how social values, life stage, socioeconomic, and geographic factors influence stay-at-home order adherence would lead to more effective policy design to improve population adherence.

Psychosocial predictors of adverse outcomes in rural heart failure caregivers.

INTRODUCTION: Depressive symptoms, negative life changes, poor self-care, and higher caregiver burden are common in caregivers who assist individuals with heart failure (HF) in managing daily activities and disease-related symptoms. Previous research findings suggest social support, problem solving, and family function may influence these outcomes. However, the influence of these factors on outcomes in rural HF caregivers is unknown. The purpose of this study is twofold: (1) to examine whether social support, problem solving, and family function predicted depressive symptoms, caregiving-related life changes, self-care, and caregiver burden in rural HF caregivers; and (2) to compare differences in these variables between rural and urban caregivers. METHODS: Rural caregivers (n=114) completed an online researcher-developed sociodemographic and clinical survey and standardized (Likert-type) self-report instruments. Participants were recruited locally from south-eastern USA (using face-to-face and telephone contacts, posted flyers, newspaper advertisements, and social media), nationally (newspaper advertisements and social media sites) and internationally (using social media). Potential participants were directed to the study website to complete the online surveys. These methods recruited participants who lived in 24 states within the USA, as well as from Canada, England, Ireland, Scotland, and Wales. Demographic statistics and Mann-Whitney U-test, as well as bivariate correlations, multivariate linear modelling, and Roy's largest root, were used to analyse data, controlling for covariates. RESULTS: Rural (n=114) caregivers were primarily Caucasian (84.2%), women (58.8%), and 41.45 (±9.013) years old. Social support had significant effects on depressive symptoms (ηp2=0.384, p<0.001), self-care (ηp2=0.108, p=0.001), and life changes (ηp2=0.055, p=0.016), while problem solving showed significant effects on depressive symptoms (ηp2= 0.078, p=0.004) and caregiver burden (ηp2=0.23, p<0.001). Family function had significant effects on life changes (ηp2=0.104, p=0.001), self-care (ηp2=0.088, p=0.002), and caregiver burden (ηp2=0.116, p<0.001). Compared to urban (n=412) participants, rural caregivers experienced significantly less social support (p=0.001), worse problem-solving skills (p=0.003) and family functioning (p=0.009), and greater depressive symptoms (p≤0.01) and subjective burden (p=0.001). There were no significant differences in caregiver self-care (p=0.416) and perceived life changes (p=0.346) among rural and urban caregivers. CONCLUSION: Both social support and problem solving have significant effects on depressive symptoms in rural HF caregivers, while social support and family function influences self-care. Problem solving and family function also affect caregiver burden, while social support and family functioning influences caregiver life changes. Rural caregivers are often separated by long distances, and have transportation issues and limited access to healthcare providers and support services; therefore, innovative strategies are needed to explore the usefulness of these variables in improving caregiver outcomes.

Psychosocial Factors Related to Adverse Outcomes in Heart Failure Caregivers: A Structural Equation Modeling Analysis.

BACKGROUND: Heart failure (HF) caregivers experience increased demands and burden. Social support and problem solving may influence the effect of these variables on caregiver outcomes. OBJECTIVE: The aim of this study was to examine whether social support and problem solving mediate relationships among caregiver demands and burden, self-care, depression, and life changes in heart failure caregivers. METHODS: Using a cross-sectional, exploratory design, heart failure caregivers (n = 530) completed online questionnaires on caregiver demands and burden, social support, problem solving, depression, self-care, and life changes. Path analysis examined a hypothesized mediating role of social support and problem solving in the relationships among caregiver demands and burden and caregiver outcomes. The analysis included (1) a model-development phase (n = 329) to make data-based decisions on measurement indicators and model structure and (2) a confirmatory phase (n = 201) to provide unbiased inference on the model structure resulting from the initial phase. RESULTS: Participants were 41.39 (±10.38) years old and primarily white (78.3%) men (50.9%) caring for a spouse (44.9%). Per the magnitudes of the estimated path coefficients, social support mediated the relationship between caregiver burden and depression but did not relevantly mediate the relationship between caregiver burden and self-care or caregiver life changes. In the presence of social support as a parallel mediator, problem solving was not a relevant mediator between caregiver burden and demands and caregiver outcomes. CONCLUSIONS: Social support mediates the effects of caregiver burden on depression but has little effect on self-care or life changes. In the presence of social support, problem solving does not mediate the effects of caregiver demands and burden on caregiver outcomes.

Cardiovascular disease risk among rural residents living with diabetes and prediabetes: A cluster randomized trial.

OBJECTIVE: Diabetes is a major health problem that is closely linked with cardiovascular disease (CVD), the leading cause of death in the United States. The purpose of this analysis was to determine the effect of a culturally relevant diabetes health promotion program on diabetes knowledge and self-reported self-care behaviors. DESIGN: A cluster randomized controlled trial was conducted in 12 rural church settings. Seven churches were randomized to the intervention group and five to the control group. SAMPLE: The sample included 146 African American participants diagnosed with diabetes and prediabetes. INTERVENTION: The intervention group participants (n = 75) received the diabetes health program, and those in the control group (n = 71) group received a publicly available diabetes health brochure. MEASURES: Data were collected about diabetes knowledge, self-care activities, fatalism, and social support. RESULTS: Linear mixed model was the statistical test used to analyze group differences. Compared with the control group, the intervention group showed significant changes from pretest to posttest for diabetes knowledge and behaviors associated with diet and blood glucose testing. CONCLUSION: Health promotion programs implemented by public health nurses among rural groups at increased risk for developing CVD can facilitate understanding about strategies to reduce disease risk.

Influencing cardiovascular health habits in the rural, deep south: results of a cluster randomized trial.

Cardiovascular disease (CVD) is a major cause of death among people living in the United States. Populations, especially minorities, living in the rural South are disproportionately affected by CVD and have greater CVD risk, morbidity and mortality. Culturally relevant cardiovascular health programs implemented in rural community settings can potentially reduce CVD risk and facilitate health behavior modification. The purpose of this study was to examine the effects of a cardiovascular health promotion intervention on the health habits of a group of rural African American adults. The study had a cluster randomized controlled trial design involving 12 rural churches that served as statistical clusters. From the churches (n = 6) randomized to the intervention group, 115 participants were enrolled, received the 6-week health program and completed pretest-posttest measures. The 114 participants from the control group churches (n = 6) did not receive the health program and completed the same pretest-posttest measures. The linear mixed model was used to compare group differences from pretest to posttest. The educational health intervention positively influenced select dietary and confidence factors that may contribute toward CVD risk reduction.

Promoting Heart Health Among Rural African Americans.

BACKGROUND: Cardiovascular disease is a major cause of death for people living in the United States. African Americans bear a disproportionate burden of cardiovascular disease. Interventions designed to target multiple risk factors may facilitate elimination of cardiovascular disease health disparities. OBJECTIVE: The purpose of this study was to evaluate a culturally relevant cardiovascular health promotion intervention that could potentially reduce cardiovascular disease risk among a group of rural African American adults by improving intentions, attitudes, norms, and self-efficacy to increase produce consumption, reduce dietary saturated fat intake, and increase exercise. METHODS: A cluster randomized controlled trial design was used to evaluate the effect of the "With Every Heartbeat Is Life" cardiovascular health promotion program among rural African Americans. The African American congregants of 12 rural churches located in northern Florida were randomly assigned to either an intervention group that received a culturally relevant cardiovascular health promotion intervention or a control group. Data analysis using linear mixed model was performed to compare group differences from pretest to posttest. RESULTS: The cardiovascular health promotion intervention had a positive influence on the intentions, attitudes, norms, and self-efficacy of rural African Americans to increase produce consumption and reduce dietary saturated fat. The intervention also enhanced participants' attitudes and self-efficacy regarding exercise. CONCLUSION: The culturally relevant cardiovascular health promotion program presented to cluster groups of rural African American participants had positive influences on psychosocial variables associated with engaging in cardiovascular health recommendations. Nurse-led interventions in community settings can potentially reduce cardiovascular disease risk.

Exploring the intervention effect moderators of a cardiovascular health promotion study among rural African-Americans.

OBJECTIVE: The purpose of this analysis was to examine the participant characteristics that served as intervention effect moderators of a cardiovascular health promotion intervention study. DESIGN AND SAMPLE: This exploratory study was a secondary analysis of data collected during a cluster randomized controlled trial. The participants (n = 229) of the study were African-American adults recruited from 12 rural churches that were randomized to intervention (n = 6) and control (n = 6) groups. There were 115 individual participants in the intervention group, and 114 in the control group. MEASURES: Cardiovascular health intentions, attitudes, norms, and self-efficacy for produce consumption, dietary fat intake, and exercise were measured to test the effect of the intervention. Linear mixed model was used to detect intervention effect moderators. RESULTS: Personal heart disease status was a moderator of intervention effects for intentions, norms, and self-efficacy regarding dietary fat intake and attitudes about produce consumption. Lacking a family heart disease history was a moderator for dietary fat intake self-efficacy, and age was a dietary fat norms moderator. CONCLUSIONS: Knowledge about the moderators that influenced intervention outcomes can assist public health nurses in tailoring health promotion programs for underserved populations that can be implemented in community settings.

Eliminating Health Disparities through Action on the Social Determinants of Health: A Systematic Review of Home Visiting in the United States, 2005-2015.

OBJECTIVE: The purpose of this systematic literature review was to synthesize the results of transdisciplinary interventions designed with a home visit component in experimental and quasi-experimental studies having representative samples of racial and ethnic minorities. DESIGN AND SAMPLE: The design of this systematic review was adapted to include both experimental and quasi-experimental quantitative studies. MEASURES: The predetermined inclusion criteria were studies (a) having an experimental or quasi-experimental quantitative design, (b) having a home visit as a research component, (c) including a prevention research intervention strategy targeting health and/or safety issues, (d) conducted in the United States, (e) having representation (at least 30% in the total sample size) of one or more racial/ethnic minority, (f) available in full text, and (g) published in a peer-reviewed journal between January, 2005 and December, 2015. RESULTS: Thirty-nine articles were included in the review. There were 20 primary prevention, 5 secondary prevention, and 14 tertiary prevention intervention studies. CONCLUSIONS: Community and home visitation interventions by nurses can provide an effective means for mitigating social determinants of health by empowering people at risk for health disparities to avoid injury, maintain health, and prevent and manage existing disease.

Evaluation of Nursing Interventions Designed to Impact Knowledge, Behaviors, and Health Outcomes for Rural African-Americans: An Integrative Review.

OBJECTIVE: The purpose of this review is to evaluate published nursing research reports of effective health promotion strategies for preventing cardiovascular disease, cancer and stroke among rural African Americans. DESIGN AND SAMPLE: A review of the nursing literature was conducted to select intervention studies published within the past decade (2004-2014). An integrative review method was adapted to evaluate, analyze, and synthesize the nursing research articles that met the inclusion criteria. RESULTS: Data evaluation encompassed displaying the data in a literature matrix for the appraisal of research components employed in the studies. The major intervention strategies reported in the health promotion studies were reduced, displayed in tables, and synthesized. The resultant comparison of the studies can potentially guide nurse researchers in designing health promotion interventions targeting rural African Americans. DISCUSSION: Public health nurses are uniquely qualified to assist in the national goals of eliminating health disparities for population groups at risk for poor health outcomes by the development and implementation of evidence-based health promotion interventions. Assisting healthy individuals within community settings reduce risk factors for cardiovascular disease and cancer can potentially decrease mortality rates associated with these diseases and improve health equity for disadvantaged populations.

Classifying Heart Failure Caregivers as Adequately or Inadequately Resourced to Care: A Latent Class Analysis.

OBJECTIVES: To identify classes of heart failure (HF) caregivers based upon indicators of coping resources and stress, and then, to examine the relationships between the identified caregiver classes and depression, caregiver burden, and life changes. METHODS: Cross-sectional data from 530 HF caregivers were analyzed in this secondary analysis using a three-step latent class mixture model to classify caregivers based on level of resources and examine the relationship between the identified classes and depression, caregiver burden, and life changes. Using an online survey, caregivers reported on social support, problem-solving, family function, depression, caregiver burden, and life changes. RESULTS: Caregivers were 41.39 (± 10.38) years of age, 49.1% women, 78.3% white, 77.6% urban-dwelling, and 61.7% college/postgraduate educated. Three classes of caregivers (42.3% Adequately Resourced, 25.1% At Risk for Decompensation, 32.6% Inadequately Resourced) were identified. Inadequately Resourced caregivers had the lowest levels of social support, problem-solving, and family function and the highest levels of depression and caregiver burden. Caregivers At Risk for Decompensation had the best family function and reported the most positive perceptions of life changes despite low levels of social support and problem-solving. CONCLUSION: Social support, problem-solving, and family function are modifiable coping resources which may buffer stress and influence stress indicators. Caregivers with few coping resources may experience higher degrees of depression and burden, and less positive perceptions of life changes. More research is needed to examine the influence of these coping resources on caregiver adaptation to facilitate the development of targeted interventions which support caregiver mental health.

Passive recruitment reach of a lifestyle management program to address obesity in the deep south during the COVID-19 pandemic.

Obesity is a significant public health concern, especially in the Deep South and in Mississippi where prevalence is among the worst in the nation paired, with other poor health outcomes and socioeconomic conditions. Lifestyle management programs that address modifiable risk factors, such as nutrition and physical activity, can be effective mitigation strategies to halt weight accumulation patterns and ameliorate metabolic risk factors for some populations. However, there is limited evidence regarding the implementation of effective practice models to address obesity risk in underserved and underrepresented populations, such as African Americans, and people in the stage of earlier adulthood. Furthermore, there is growing evidence supporting the impact of the COVID-19 pandemic on lifestyle management programs that should be considered in these populations. The purpose of this manuscript was to describe the development and telehealth implementation of a weight management program during the COVID-19 pandemic and provide a preliminary examination of recruitment strategies and baseline characteristics for enrolled participants. Passive recruitment (social media, web, email, and other media advertisements) resulted in 157 screening initiations, and 79 of those participants met the study inclusion criteria. Further, of the 79 eligible participants, 38 completed all study enrollment requirements and presented with metabolic abnormalities. The study findings add to the emerging body of evidence for how the pandemic may have impacted lifestyle management programs and is representative of an understudied and underrepresented population.

Factors Associated with Diabetes Outcomes among Rural African Americans.

Diabetes is a major public health threat and contributory risk factor for cardiovascular disease, especially among underserved populations living in the rural, southern states. In these areas, African Americans have the highest rates of both diabetes and cardiovascular disease, but not much is known about the psychosocial factors that influence diabetes outcomes. This study examined bivariate correlations among diabetes knowledge, diabetes self-care activities, perceived diabetes self-management, diabetes fatalism, and social support. The data were collected during a cluster randomized trial involving rural African American participants living with diabetes and prediabetes in a rural, southeastern area. The findings of this analysis point to associations among social support, diabetes fatalism, diabetes self-care activities, and perceived diabetes self-management. Diabetes knowledge was not significantly correlated with any of these factors or their subscales.

Development and Evaluation of a Measure for Social Support Provided by Friends during Lifestyle Management Programs.

Obesity is a public health crisis that contributes to chronic disease prevalence, morbidity, and mortality. Nutrition and physical activity are risk factors for many chronic diseases including cancer and cardiovascular disease, the leading causes of death in the United States. Lifestyle management programs to address obesity and potential sequelae such as chronic conditions have shown efficacy, with social support an important factor in interventions. Instruments that assess social support specifically provided by friends are lacking but could be important predictors of program success. The purpose of this study was to examine the reliability and validity of the 10-item Social Support to Eat Better and Move More instrument that was developed and designed to measure support from friends that influence dietary and physical activity behaviors during lifestyle management programs. Data were collected during a cross-sectional study using purposive sampling strategies among adult residents of two southern states. Statistical analysis was conducted to examine latent factors, internal consistency, and convergent and predictive validity. These preliminary results indicated that the Social Support to Eat Better and Move More instrument had excellent internal consistency for the overall measure (α = 0.96) as well as for informational support (α = 0.97), emotional support (α = 0.96), and encouragement (α = 0.97). The tool related well to another general social support measure as well as to diet, physical activity, and health-related variables, and it can be a useful measure in lifestyle management studies.

A Structural Equation Modeling Analysis to Explore Diabetes Self-Care Factors in a Rural Sample.

Diabetes is a public health problem that requires management to avoid health sequelae. Little is known about the determinants that influence diabetes self-care activities among rural populations. The purpose of this analysis was to explore the relationships among diabetes self-care activities, diabetes knowledge, perceived diabetes self-management, diabetes fatalism, and social support among an underserved rural group in the southern United States. A diabetes health promotion program was tested during a cluster randomized trial that tested a disease risk reduction program among adults living with prediabetes and diabetes. A structural equation model was fit to test psychosocial factors that influence diabetes self-care activities using the Information-Motivation-Behavioral Skills Model of Diabetes Self-Care (IMB-DSC) to guide the study. Perceived diabetes self-management significantly predicted self-care behaviors, and there was also a correlation between perceived diabetes self-management and diabetes fatalism. Perceived diabetes self-management influenced diabetes self-care activities in this rural sample and had an association with diabetes fatalism. The findings of this study can facilitate clinical care and community programs targeting diabetes and advance health equity among underserved rural groups.

The Impact of Stereotype Threat on Memory and Cognition in Older Adults.

Cultural stereotypes that equate aging with decreased competence and increased forgetfulness have persisted for decades. Stereotype threat (ST) refers to the psychological discomfort people experience when confronted by a negative, self-relevant stereotype in a situation where their behavior could be construed as confirming that belief. The purpose of this study was to examine the relationships of ST on memory performance in older adults over 24 months. The ST levels on average significantly declined, or improved in the memory training, but not the health training group. Although not significant at the .01 level, the bivariate correlation indicated that change in ST was moderately related to change in verbal memory, suggesting the possibility that improvements (or reductions) in ST may be related to increases in verbal memory scores. We discovered that the unique contribution of ST into the memory performance of healthy older adults offers a possible malleable trait.

The influence of gender and race on heart failure self-care.

OBJECTIVES: To explore gender and racial differences in heart failure (HF) self-care processes and examine whether gender and race predict HF self-care. METHODS: A secondary analysis of baseline data (n = 107) from a longitudinal HF study (54.2% males; 56% non-Caucasians) was conducted. The self-care of heart failure index was used to measure self-care maintenance, management, and confidence. Descriptive statistics and univariate analyses examined gender and racial differences in HF self-care outcomes. Multiple linear regression examined whether gender and race predicted HF self-care maintenance, management, and confidence. RESULTS: Univariate analyses indicated that Caucasians reported significantly better self-care maintenance (p = 0.042), while non-Caucasians reported significantly better self-care management (p = 0.003). Males had significantly higher self-care confidence scores versus women (p = 0.017). Multiple regression analysis indicated Caucasian race predicted significantly worse self-care management (ß = -11.188; p = 0.006) versus non-Caucasian, while male gender predicted significantly higher self-care confidence scores (ß = 7.592; p = 0.010) versus female gender. Gender nor race significantly predicted self-care maintenance. DISCUSSION: Although gender and race may influence HF self-care, other factors may be more important. More research is needed to identify individual factors that contribute to HF self-care to improve education and intervention.

Fatalism, Social Support and Self-Management Perceptions among Rural African Americans Living with Diabetes and Pre-Diabetes.

Diabetes is a public health problem and a major risk factor for cardiovascular disease, the leading cause of death in the United States. Diabetes is prevalent among underserved rural populations. The purposes of this study were to perform secondary analyses of existing clinical trial data to determine whether a diabetes health promotion and disease risk reduction intervention had an effect on diabetes fatalism, social support, and perceived diabetes self-management and to provide precise estimates of the mean levels of these variables in an understudied population. Data were collected during a cluster randomized trial implemented among African American participants (n = 146) in a rural, southern area and analyzed using a linear mixed model. The results indicated that the intervention had no significant effect on perceived diabetes management (p = 0.8), diabetes fatalism (p = 0.3), or social support (p = 0.4). However, the estimates showed that, in the population, diabetes fatalism levels were moderate (95% CI = (27.6, 31.3)), and levels of social support (CI = (4.0, 4.4)) and perceived diabetes self-management (CI = (27.7, 29.3)) were high. These findings suggest that diabetes fatalism, social support, and self-management perceptions influence diabetes self-care and rural health outcomes and should be addressed in diabetes interventions.

Stress, Social Support, and Resilience in Younger Rural Women: A Structural Equation Model.

Cardiovascular disease is a global public health problem and leading cause of death. Stress is a modifiable cardiovascular disease risk factor. The objectives of this study were to examine whether stress was a predictor of resilience among rural younger women and to explore whether social support mediated the relationship between acute stress and resilience and between chronic stress and resilience. The study had a cross-sectional, descriptive design. A total of 354 women were randomly recruited in the rural, southeastern United States. Survey instruments were used to collect data about acute stress, chronic stress, social support, and resilience. A structural equation model was fit to test whether social support mediated the relationship between perceived stress and resilience and between chronic stress and resilience. Chronic stress predicted family and belongingness support and all the resilience subscales: adaptability, emotion regulation, optimism, self-efficacy, and social support. Acute stress predicted the self-efficacy subscale of resilience. Family support partially mediated the relationship between chronic stress and self-efficacy. Belongingness support partially mediated the relationships between chronic stress and the social support subscale of resilience.