Showing papers on "Stressor published in 1993"

Stress and immunity in humans: a meta-analytic review.

Abstract: This article presents a meta-analysis of the literature on stress and immunity in humans. The primary analyses include all relevant studies irrespective of the measure or manipulation of stress. The results of these analyses show substantial evidence for a relation between stress and decreases in functional immune measures (proliferative response to mitogens and natural killer cell activity). Stress is also related to numbers and percent of circulating white blood cells, immunoglobulin levels, and antibody titers to herpesviruses. Subsequent analyses suggest that objective stressful events are related to larger immune changes than subjective self-reports of stress, that immune response varies with stressor duration, and that interpersonal events are related to different immune outcomes than nonsocial events. We discuss the way neuroendocrine mechanisms and health practices might explain immune alteration following stress, and outline issues that need to be investigated in this area.

Parental Stressor Scale: neonatal intensive care unit.

Abstract: This article is a report of the development of the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS:NICU), which is designed to measure parental perception of stressors arising from the physical and psychosocial environment of the neonatal intensive care unit. Stress theory, literature reviews, expert consultation, and parent interviews guided instrument development and refinement and established the content validity of the instrument. Construct validity is supported by links with theory, correlation with anxiety measures, and factor analytic results. Alpha coefficients support the tool's internal consistency. Three scales were identified: Parental Role Alterations, Sights and Sounds of the Unit, and Infant Behavior and Appearance. Available metrics allow scoring for stress occurrence levels, overall stress levels, and number of stressors experienced. The PSS:NICU can serve as a research or clinical measure to evaluate stressors experienced by parents with infants in a NICU.

Control and intrusive memories as possible determinants of chronic stress.

Abstract: Amidst confusion about the nature and usefulness of the stress construct and distinctions between acute and chronic stress, research has begun to identify mechanisms by which stress affects health and by which stress can persist beyond the physical presence of the stressor. In addition, research has begun to identify reasons for selective vulnerability to chronic stress. One of the possible reasons for chronic stress following traumatic events is the disorganizing effect of loss of control and violation of expectations for regulating aspects of one's life normally under control. Data from a longitudinal study of chronic stress at Three Mile Island in the wake of the nuclear accident there suggest that loss of control and frequent experience of intrusive memories about the accident and its aftermath were related to persistent stress responding several years after the accident. The relationships between stress responding and conditioning and consolidation of stressful memories are considered as a basis for persistent intrusive memories and chronic stress.

Husband and wife differences in response to undesirable life events.

Abstract: In the present study of 451 married couples living in the rural midwest, gender differences were examined in reports of exposure and vulnerability to specific types of undesirable life events. Consistent with expectations derived from either a social structural or identity perspective, the results demonstrated that men are more likely than women to report exposure to and to be distressed by work and financial events. Women, on the other hand, are more strongly influenced by exposure to negative events within the family but not within their network of friends. Outcomes vary according to the type of emotional distress. Financial stress, for example, increases hostility among men more than among women, but wives are more likely than husbands to report somatic complaints in response to the same stressor. The findings demonstrate the need for future research that more directly investigates the intraindividual and social mechanisms which account for gender differences in a broad range of emotional and behavioral responses to varying types of significant life changes.

Occupational stress in psychiatric nursing.

Abstract: Psychiatric nursing is invariably assumed to be a stressful area of nursing practice. Empirical evidence to support this proposition is limited, however, due to the lack of research in this field. The purpose of this project was to examine occupational stress in a specified area of psychiatric nursing. The research was exploratory and therefore the concern was discovery and description rather than the testing of clear hypotheses and the development of causal relationships. The study has four main objectives. First, to describe the various stressors present in the work of the psychiatric nurse in the acute admission wards of two district health authorities. Secondly, to measure the effects of stress using a recognized and well-validated instrument for recording levels of burnout. Thirdly, through the use of a particular theoretical framework to identify the types of coping strategy used by the participants in the study. Fourthly, to note any clear associations between the stressors, the effects of stress and the ways of coping identified in the study. The conceptual basis for the project was Lazarus's cognitive theory of stress and coping and Maslach's model of burnout.

Sources of Occupational Stress Among Firefighter/EMTs and Firefighter/Paramedics and Correlations with Job-related Outcomes

Abstract: Introduction/Objective:This paper reports the results of an initial effort to develop and test measure of the various sources of job-related stress in firefighter and paramedic emergenc service workers.Methods:A 57-item paper and pencil measure of occupational stressor in firefighter/Emergency Medical Technicians (EMTs) and firefighter/paramedics was developed and administered by anonymous mail survey.Results:More than 2,000 (50% rate of return) emergency service workers comple and returned the surveys. The responses of 1,730 firefighter/EMTs and 253 firefighter/paramedics were very similar in terms of the degree to which job stressors were bothersome. A factor analysis of replies yielded 14 statistically independent “Occupational Stressor” factors which together accounted for 66.3% of the instrument's variance. These Sources of Occupational Stress (SOOS) factor scale scores essentially did not correlate with a measure the social desirability test-taking bias. Finall SOOS factors were identified that correlated with job satisfaction and work-related morale of the respondents. Conflict with administration was the job stressor factor that most strongly correlated with reports of low job satisfaction and poor work morale in both study groups.Conclusion:The findings suggest that firefighter and paramedic job stress is very complicated and multi-faceted. Based on this preliminary investigation, the SOOS instrument appears to have adequate reliability and concurrent validity.

The availability of personal and external coping resources: their impact on job stress and employee attitudes during organizational restructuring

Abstract: This study examines the relationships among personal coping resources, social support, external coping resources, job stressors and job strains in a sample of 110 American Telephone and Telegraph employees undergoing a major organizational restructuring. The study expanded on a model suggested by Ashford (1988) by defining another category of coping resources that employees may draw upon to deal with the stressors and strains which occur during major organizational changes. External coping resources were defined as those which provided employees with a sense of ‘vicarious control’ in stressful situations. Results indicated that personal coping resources, social support and external coping resources had a direct effect upon job stressor and strain levels. No ‘buffering’ effect of these coplng resources was found. Hierarchical regression analyses indicated that external coping resources added to the prediction of job stressors and strains even when pertonal coping resources and social support were ...

Organizational-level interventions to reduce occupational stressors

Abstract: Occupational stress research continues to grow, and is increasingly being used to inform national policy on worker health and well-being. Most models of occupational stress emphasize notions of person-environment fit. Two approaches for intervention to minimize adverse consequences of occupational stress follow from such models. One emphasizes the strengthening and enhancement of indwiduals and their resources, the other emphasizes the reduction ofcommon workplace-based sources ofoccupational stress. This paper reviews 10 organizational-level interventions to reduce stress at work which have been examined in various field studies. These interventions were generally found to have positive effects, and, given the limited success of individual-level interventions in addressing occupational sources of stress, should be encouraged.

Coping with rheumatoid arthritis.

Abstract: RA patients may develop a coping style early in the illness and utilize their favourite strategies when confronted with the stressor of illness. Little distinction was found between specific illness stressors, i.e. pain vs. disability, or whether a strategy had been successfully used before. In the face of a new illness, strategies may be tried out over a period of time, as the stressor is one for which everyday coping strategies are no longer appropriate or sufficient. As one health psychologist has written, 'Individuals' coping responses are often spontaneous; that is, people do what comes naturally to them and what has worked in the past. But sometimes these efforts will not be enough. The stressor may be so novel, so chronic, or so elusive that people's own efforts may be unsuccessful in reducing stress' (Taylor, 1985, p 213).

Stress, Social Support, and Psychological Distress Among the Chinese Elderly

Abstract: This study examined the relationships among stress, social support, and depressive symptoms with data provided by a large representative sample (N = 2,721) of older adults who live in the People's Republic of China. Many Western investigators believe that elderly people respond to stressful experiences by mobilizing assistance from their significant others. However, recent American studies suggest that this may not always be true, and that when certain stressors arise, older adults may actually receive less support from significant others. The purpose of our study was to evaluate these competing views in a culturally diverse setting. The findings reveal that both perspectives have something to offer and that financial strain (i.e., one kind of stressor) may increase some kinds of assistance (i.e., economic support) at the same time that it erodes other types of support (e.g., emotional support).

Effective management of life stress: The resource–congruence model

Abstract: This article questions traditional conceptions of stress and coping and presents a more comprehensive analysis of stress management Sources of stress are expanded to include various intrapsychic and interpersonal stressors The evolution of coping strategies is described, culminating in proactive, collective, creative, existential and spiritual coping The resource–congruence model posits that coping is effective to the extent that appropriate resources are available and congruent coping strategies are employed The model emphasizes the importance of developing resources in anticipation of exigencies, and the need for acquiring cultural knowledge as to what coping strategies are suitable for a given stressor

Immunological responses to social stress: Dependence on social environment and coping abilities

Abstract: Social interactions as a consequence of the social position represent stressful conditions for the individual. Manipulation of social conditions or forming long-term social hierarchies by colony aggregation allow to investigate the regulation of immune defense mechanisms under seminatural circumstances. The present paper describes the effects of dyadic social interaction in male rats with or without direct aggressive interactions on some indices of humoral and cellular immunity. In addition, for comparative and reference purposes, in one experiment the conventional stressor of inescapable footshock was used as well. Primary humoral immune response to sheep red blood cell antigen is suppressed by repeated experience of both defeat and inescapable footshock. At individual level the social stressor is as effective as the conventional stressor of inescapable footshock, less individual rats show suppression following the social than after the conventional stress. The social stressors, i.e. being exposed to a resident or intruder of the territory, facilitate lymphocyte proliferation in the spleen by the mitogen ConA and PHA independently of the presence or absence of direct aggressive interaction. Finally, the different social stressors have some impact on the lymphocyte subpopulation in the spleen. Social stimulation without aggressive interactions increases the relative number of T-helper cells, whereas defeat leads to an increase in the T-suppressor/cytotoxic subpopulation. The data suggest multiple and differential effects of social stress on immune system functioning in the rat. Individual characteristics of the coping with stress, the social environment, and the immune indices under investigation determine the magnitude and direction of the changes in immune functioning.

Stress in school-aged children and youth

Abstract: This article reviews the literature on stress in students of grades 1–12 A model to understand stress as the inequality between perceived demands and perceived resources is presented Student stressors are identified in the family and school environments Coping with these stressors is conceptualized as problem-focused, emotion-focused, or appraisal-focused strategies that make use of personal, social, and cognitive resources Physical, emotional, and behavioral symptoms of ineffectual coping efforts are then identified After gender differences in stressors and coping are noted, instruments measuring stressors, coping strategies, and coping resources in children and youth are reviewed Finally, representative intervention programs developed for school-aged youth are described and evidence of their efficacy is presented The article concludes that there is a paucity of research on stress in children as compared to research on stress in adults

Development of a Wartime Stressor Scale for women

Abstract: Prior research has demonstrated the importance of stressor measurement as a component of evaluating posttraumatic stress disorder. Much of the work conducted in this area has focused on male combat veterans, resulting in the development of several combat exposure scales. The nature of war-zone exposure for women, however, has not been systematically addressed. This article describes the development and preliminary psychometric analyses of the Women's Wartime Stressor Scale (WWSS), an instrument designed to measure the self-report of wartime stressors by both theater and era veterans as well as civilian women who served in Vietnam. Measurement of internal consistency, test-retest reliability, and construct validity points to the potential clinical and research utility of this type of instrument

"Stop the world so I can get off for a while": Sources of daily stress in the lives of low-income single mothers of young children.

Abstract: misbehavior. Stressful exchanges involving other adults were also frequently recorded, as were financial stressors. The diary records reveal substantial interand intraindividual variability in coping strategies and in the types of barriers that mothers faced in attempting to implement these strategies. Thus, the diaries provide a useful means of examining sources of perceived stress in the daily lives of these women.

Sending your teenagers away. Controlled stress decreases neurotic vulnerability.

Abstract: Objective: To study the effect of a controlled stressor on the rate of personality maturity Design: Eighteen-month prospective controlled study Setting: General community Intervention: Experimental: Exposed to the stress of 12 months' intercultural experience Control: Remained in usual environment Main Outcome Measure: A measure of personality vulnerability/maturity derived from a canonical correlational combination of trait anxiety, locus of control, and defense style Results: Exchange students exposed to the stressor made significantly greater gains in personality maturity (028 vs 003 SD: P ≤01) than did the control students matched on this measure at baseline Conclusion: Exchange students exposed to the stress of living abroad showed a substantial decrease in vulnerability, which should decrease the risk of future neurotic disorders in this group

Coping with disaster: The case of Israeli adolescents under threat of missile attack

Abstract: This study examined the relationship of coping resources, optimism, perceived control, and coping strategies, to anxiety, to physical symptoms, and cognitive functioning in a group of Israeli adolescents during a real crisis situation. Data were gathered via structured questionnaires on a sample of 109 adolescents (69 males, 40 females) during the Persian Gulf War. Although adolescents reported a mixture of palliative and active coping strategies, it was the use of palliative coping efforts that predicted greater anxiety and physical symptoms. That active coping did not meaningfully predict negative stress reactions may have been a function of the severity of the stressor and the resultant high levels of anxiety that were engendered. The implications of this study for stress and coping in a naturalistic traumatic situation were discussed.

Staff stressors at a developmental center and state hospital.

Abstract: Clinicians and administrators (N = 322) at a large state hospital/developmental center were surveyed regarding stressful experiences at work. A factor analysis of stress reports yielded two underlying constructs: Lack of Administrative Control and Practice-Related Stress. A subsequent regression analysis found that philosophical opposition to behavior therapy significantly predicted job stress. No differences were found between stress levels of staff members who worked with individuals who had mental retardation versus mental illness. Differences existed in reported stress by job categories; nurses, developmental specialists, and psychiatric technicians reported greater job-related stress than did other professional groups. Understanding the nature of job-related stress is necessary for developing stress management programs for in-patient personnel.

Medical students' differential use of coping strategies as a function of stressor type, year of training, and gender.

Abstract: The cognitive-transactional model of stress was used to study the process by which medical students cope with stress. The study examined the coping responses employed by male and female first- and fourth-year medical students as a function of those situations they appraised as most stressful. Multivariate analyses of variance (MANOVAs) revealed that preferred coping strategies varied by stressor type and year of training. In dealing with medical-school-related stressors, first-year students used self-blame and problem-solving styles of coping more than did fourth-year students. When dealing with interpersonal stressors, however, fourth-year students tended to use confrontive coping more than did first-year students. Surprisingly, whether the student was a man or a woman had no impact on coping responses. The findings underscored the importance of the moderating impact of the appraisal process on the coping strategies employed to manage stressful situations. Implications for medical education, as well as for future research on coping with stress, are discussed.

Structured Clinical Interview Techniques

Abstract: The assessment of the depth and degree of impairment or distress following exposure to traumatic stress has long been an activity of the clinician who has endeavored to assist those who are suffering from traumatic stress syndromes. The issue of whether or not a psychiatric diagnosis such as posttraumatic stress disorder (PTSD) (in the DSM-III-R; American Psychiatric Association, 1987) or prolonged posttraumatic stress disorder (in the ICD-9-CM) best characterizes the psychological processes following exposure to traumatic Stressors depends on a variety of factors, not all of which are scientific. Nonetheless, the recognition of the basic uniformity of psychological and biological reactions following exposure to the range of traumatic Stressors has been aided by the formalization of diagnostic criteria. The social implications of carrying a psychiatric diagnosis as a consequence of displaying a near universal pattern of reactions subsequent to surviving exposure to a traumatic Stressor are weighty and need social attention. But the continuing understanding of the features and phenomena of traumatic stress has been considerably advanced by the appearance and use of structured diagnostic interview techniques.

Support Systems and Stress Reduction among Workers Caring for Dependent Parents

Abstract: This study investigated the impact of three types of support--from family and friends, the workplace, and community services agencies--on the perceived stress and health outcomes of 133 employed caregivers of defendent parents. The stressor-support-stress-reaction model guided the research. Support from family and friends and community agencies was found to buffer the negative impact of caregiving and work and family role strain, and a supportive work environment was one predictor of lessened phisical strain. Most families in the United States can expect to care for their frail elderly parents and work at the same time, according to the American Association of Retired Persons (1989), which reported that 55 percent of all caregivers to the elderly population are employed. These employed caregivers include executives as well as laborers (Fortune Magazine & John Hancock Financial Services, 1989) and are relatively young--many begin caregiving in their late thirties and early forties (Creedon, 1987; Northeast Utilities System, 1987; Travelers Insurance Company, 1985). Employed caregivers report more stress (health, family, and work) than do employees with no dependent care responsibilities (Creedon, 1987; Neal, Chapman, Ingersoll-Dayton, Emlen, & Boise, 1990; Scharlach & Boyd, 1989). In response to this stress, 9 to 22 percent of the caregivers quit their jobs (Brody, Kleban, Johnsen, Hoffman, & Schoonover, 1987; Petty & Friss, 1987; Stone, Cafferata, & Sangl, 1987). Others reduced or were thinking about reducing their caregiving activities (Brody et al., 1987; Northeast Utilities System, 1987; Travelers Insurance Company, 1985). This article presents the findings of a study of the formal and informal support systems used by 133 male and female employees who care for frail parents. The questions examined are as follows: Will support from family and friends, the workplace, and community services agencies lessen the negative consequences of combining work and caregiving? Do the three support systems differentially affect the outcomes of stress? The stressor-support-stress-reaction paradigm guided the research. This model predicts that stressful life events contribute to the mental and physical disease process (Pearlin, 1989; Selye, 1982) and that outcomes of illnesses are less severe when support systems are in place (Cohen & Syme, 1985; House, 1981). A stressor is defined as a life event that requires changes and adjustments in an individual's daily life. The stressors examined in this study were the parents' level of physical and mental limitations and the respondents' level of involvement in caregiving. Support is defined as the total level of assistance (informational, emotional, and concrete help) received from an individual, group, or agency that helps the individual deal with the stressful life event. Stress reactions include health outcomes and perceived stress. Health outcomes are unwanted changes in physical and mental health that may be long lasting and costly--financially, personally, and socially. Perceived stress consists of feelings of emotional, financial, relationship, and work-family strains that may contribute to unwanted changes in physical and mental health (Schultz, 1990). Thus, perceived stress is both a dependent and an independent variable. There are no known studies of the impact of support resources on the well-being of employed caregivers. However, general studies of caregivers to the elderly population uncovered several relevant patterns. First, in regard to stressors, the objective burden of caregiving (the patient's level of disability, for example) is less predictive of strain experienced by a caregiver than are subjective factors, such as the availability of support and the perceived burden of caregiving (George & Gwyther, 1986; Horowitz, 1985; Schultz, 1990; Zarit, Reever, & Bach-Peterson, 1980). Second, support from family and friends and service agencies, when assessed as being useful, reduces the negative consequences of caregiving (Barber, 1989; Chiriboga, Weiler, & Nielsen, 1989; George & Gwyther, 1986; Horowitz, 1985). …

Acute and chronic stressor effects on the antibody response to sheep red blood cells

Abstract: Exposure to inescapable foot-shock 72 h following immunization with sheep red blood cells resulted in a marked suppression of the peak splenic immunoglobulin (Ig)M plaque-forming cell response and plasma antibody titers in CD-1 mice However, the nature of this effect was influenced by the animal's stressor history In particular, if mice were initially exposed to a single stressor session immediately or 24 h following antigen treatment subsequent reexposure to the stressor (72 h following inoculation) did not provoke the immunosuppression Moreover, reexposure to the stressor-related cues elicited a marked immunoenhancement In contrast, if animals were exposed to a single stressor session 48 h prior to inoculation then later reexposure to the stressor-related cues provoked an immunosuppression Among mice that had been exposed to a repeated stressor regimen on successive days prior to inoculation, the immunosuppression ordinarily elicited by an acute stressor was absent Indeed, chronic stressor exposure typically favored potentiation of the immune response However, the immunofacilitation elicited by the chronic stressor treatment likely was unrelated to the immunoenhancing effects of pairing a stressor with antigenic challenge

Occupational stress and work satisfaction among Canadian women physicians.

Abstract: The present study examined relationships among occupational stress, job satisfaction, and various individual characteristics and job-related variables in a population of 303 women physicians. Analysis showed that time pressures and threat of malpractice litigation were sources of stress and that over-all satisfaction was related to satisfaction with both professional and social aspects of the job. Low satisfaction was related to wanting higher income, changes in practice procedures, and several stressors, such as time pressures. Stress and satisfaction were also related to attitudes toward health care. Women who experienced high stress and low satisfaction were more likely to have negative views of the functioning of the health care system. In addition, demographic and practice variables contributed to negative attitudes.

The Dimensions of Stress Scale: Psychometric Properties1

Abstract: Although cognitive appraisal, situational properties, and attributions are important parts of the stress process, few multidimensional measures are available to examine these constructs simultaneously. This paper investigates the properties of the Dimensions of Stress Scale (DSS). The DSS is a brief self-report questionnaire designed to assess appraisals of personal relevance (salience) and control; stressor properties (novelty, duration, and predictability); and self-attributions (causality). The items were derived theoretically, using the cognitive-phenomenological model of stress and the stress literature. Empirical support for the six dimensions (scales) was generated first on a sample of elderly individuals (n= 269) and then replicated on an independent sample of younger individuals (n= 162). In both investigations, the factor structure of five of the scales was shown to approximate a simple structure. Evidence of internal consistency and content validity was also provided. The scales’ construct validity was supported by their relationships with stressor type (e. g., physical health problems, relationships, work, finances, individuals with indeterminate Western Blots, and caregivers of patients with Alzheimer's disease), coping, and depressed mood. The DSS should be useful in examining stressful experiences.

Topics and signs: defensive control of emotional expression.

Abstract: This single-case study examined frank disclosure of important topics in a brief exploratory psychotherapy, including topics closely related to a recent, unintegrated stressor life event. Quantitative measures of emotion and control variables showed heightened levels of both emotionally and defensive control during discourse on the topic of the stressor event. In future studies, such measures of verbal and nonverbal signs of emotional expression and defensive control might be used to identify topics in an unresolved state.

Predictors of chronic stress among Vietnam veterans: Stressor exposure and intrusive recall

Abstract: The present study examined the relationship between military service during the Vietnam era and chronic stress among Vietnam combat veterans, noncombat military controls, and nonmilitary age-mates. Psychological, behavioral, and biochemical indices of stress were assessed. Results demonstrated that exposure to combat was not associated with symptoms of chronic stress. However, reported intrusiveness of recalled imagery associated with stressful combat events was an important predictor of long-term symptoms of stress irrespective of combat exposure. In addition, the interaction of combat exposure and intrusive thinking was significantly related to symptoms of chronic stress. These data suggest that intrusive thinking may reflect an important individual difference variable that could help predict long-term responding to stressors.

War-induced prolonged stress and metabolic control in Type 2 diabetic patients

Abstract: Sound evidence that psychological stress may significantly worsen metabolic control in diabetic patients in lacking. The stressful effects of war on glycaemia control have not been assessed as yet. A randomly selected sample of displaced Type 2 diabetic persons (N = 44) was compared to a matched group of diabetic persons who had not been forced to leave their homes. The self-reported stress, depression level, fasting and post-prandial blood glucose, glycosylated haemoglobin and serum lipids were compared. The two groups were found to be significantly different in scores for self-reported stress and depression levels (P 0.05), except for the serum triglycerides which were found to be significantly higher in the group of displaced persons (P < 0.01). This is assumed to be the result of differences in nutrition. The results do not demonstrate an association between prolonged stress and glycaemic control in Type 2 diabetic patients. The variability of data measuring stress and depression level in two extreme groups with respect to HbA1c values suggests that individual factors which determine the response to stressors need to be explored.

Anticipation of handling the dead: effects of gender and experience.

Abstract: In addition to the direct psychological effects of disaster stressors, anticipation of stress can itself be debilitating. We examined the relationship between the anticipated stress of handling the dead and gender and experience. Experienced persons had lower anticipated stress than inexperienced persons. Inexperienced females had higher anticipated stress than inexperienced males; experienced males and females did not differ. Results provide support for an ‘inoculation’ theory of stress buffering in disaster workers.

Cardiac response of trained and untrained males to a repeated psychological stressor.

Abstract: The authors examined cardiac response to repeated exposure to a psychological stressor of aerobically conditioned (n = 15) and unconditioned subjects (n = 15). Heart rate and electrocardiographic T-wave amplitude responses of 10 trials of the Stroop Test were monitored during and after performance. Both groups' adaptation patterns were similar, with a plateauing of heart rate response after the third trial. Compared with the unconditioned group, however, the aerobically conditioned subjects recorded lower absolute heart rate responses during and after the stressor for every trial. Relative heart rate responses during the stressor and recovery were similar for both groups. There was also no difference between groups in T-wave response during or after the stressor. These data suggest that absolute heart rate response during and after repeated exposure to a psychological stressor is lower for aerobically trained individuals.