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HEALTH COMMUNICATION, 15(2), 203–218 Copyright © 2003, Lawrence Erlbaum Associates, Inc.

Assessing Communication Competence in an Online Study: Toward Informing Subsequent Interventions Among Older Adults With Cancer, Their Lay Caregivers, and Peers

Jim L. Query, Jr.

School of Communication University of Houston

Kevin Wright

Department of Communication University of Memphis

Employing quantitative and qualitative measures, online and paper versions, we tested Kreps’s (1988) relational health communication model by examining relations among social support, communication competence, and perceived stress in a study of well-elders, elderly individuals with cancer, and their lay caregivers (N = 76). Grounding the qualitative part of the study in the narrative paradigm (Fisher, 1984), we used the critical incident technique (Flanagan, 1954) to collect participant narra- tives focusing on positive and negative expressions of social support. The results in- dicated partial support for the relational health communication model. In particular, participants who were more communicatively competent were found to have lower levels of perceived stress, and they were more satisfied with the support offered by members of their support network. In addition, the critical incidents revealed that participants received significantly more emotional and esteem support from their network than other social support types. Key limitations and future directions are also identified.

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The World Wide Web (WWW) has become a pervasive, if not integral, part of the information age by providing a rich array of forums that can facilitate inter- action (Flint, 1999). New practices, with far-reaching implications, have also emerged via the WWW such as e-health, telemedicine, alternative medicine Web sites, and online support communities (see Baur, Deering, & Hsu, 2001; Rice, 2001; Wright, 1999, 2000). And although there is also a “dark side” to this me- dium, which can involve deception, invasion of privacy, inaccurate and mislead- ing information, and potentially harmful hoaxes concerning so-called cures (Biermann, Golladay, Greenfield, & Baker, 1999), its potential, especially for educators and researchers, is clear, particularly in the disciplines spanning health, communication, and aging arenas (Query, 2001; see also Brennan & Fink, 1997; Cody, Dunn, Hoppin, & Wendt, 1999). Further suggestive of the technology’s appeal is the increasing number of indi- viduals “surfing” for health-related information (Rice & Katz, 2001). In addition to the potential pitfalls alluded to previously, however, other formidable obstacles may limit the effectiveness of the technology and its dissemination of timely, sen- sitive, and cutting-edge information. One such force is the “gray gap,” in which few elders have WWW access. In a nationally representative survey, among 26,094 adults (18 and over), Pew Internet and American Life (2001) reported that only 15% of Americans over 65 had access to the Internet. Troubling also is that 81% of those surveyed over the age of 50 indicated they would definitely not go online. Exacerbating this situation further is the paucity of research examining the utility of the WWW among well-elders, elderly individuals with cancer, and their lay caregivers. In light of these physical, attitudinal, and theoretical barriers, an im- petus is thus provided for health communication researchers and educators to eval- uate the merits of the technology and develop intervention strategies to lessen the adverse impacts of these obstacles.

THEORETICAL FOUNDATIONS

Dating back to Neanderthal times, many individuals have observed that coping with life’s trials and tribulations is best facilitated through enduring relational ties spanning one’s life span (see Durkheim, 1897/1951; Kahn, & Antonucci, 1981). Often compared to a web (Adelman, 1989; Pilisuk & Parks, 1986), these social support networks are forged, maintained, and altered by on-going communication among their members. As Albrecht and Adelman (1987a, p. 14) suggested, “Social support is a process inextricably woven into communication behavior.” This inter- twined nature of communication and social support also influences a variety of health outcomes (Kreps, O’Hair, & Clowers, 1995) and distinct populations, such as individuals living with AIDS/HIV (Flint & Adelman, 1998; Frey, Adelman, Flint, & Query, 2000; Frey, Query, Adelman, & Flint, 1998); caregivers for indi-

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viduals with Alzheimer’s disease (Query & Flint, 1996; Query & Kreps, 1996); online, elderly support group members (Wright, 2000); and elderly individuals liv- ing in retirement homes (Query & James, 1989). Proceeding from this backdrop, and casting a large “net” that may lead to con- ceptual synthesis, we theoretically ground this study by testing the relational health communication model (Kreps, 1988), drawing from the narrative paradigm (Fisher, 1987), and using the critical incident technique (CIT; Flanagan, 1954) to collect participant narratives focusing on the expression of social support. We con- tend that the inextricable nature of the relations among communication, social sup- port, and health outcomes mandates such an approach. Addressing the relational health communication model, Kreps (1988) posited that communication compe- tence levels shape a rich array of health outcomes across challenging terrain. That is, individuals who perceive they are competent communicators should be better enabled to influence an array of health outcomes (such as social support satisfac- tion, therapeutic communication, etc.). As alluded to previously, Query and asso- ciates have previously tested this model and found varying levels of support among sharply distinct populations (Frey et al., 1998; Query & James, 1989; Query & Kreps, 1996; Query, Parry, & Flint, 1992). Believing that social desirability played a role in shaping the preceding results, in this investigation we examine coping lev- els instead of cognitive depression (for a more detailed review of the preceding variables, see Query & Kreps, 1996). The narrative paradigm, in brief, suggests that storytelling is a fundamental hu- man endeavor (Fisher, 1987). Moreover, sufficiently detailed narratives can help identify attitudes, beliefs, values, heroes, and villains that shape decision making and interaction patterns (Ellingson & Buzzanell, 1999; Fisher, 1987; Smith, 1992; Sunwolf, 2001; Vanderford, Smith, & Harris, 1992). In the context of social sup- port, then, it may be possible to uncover stories that shed light on the various di- mensions of the construct. Such narratives could also inform our understanding of the associations among physiological, symbolic, and relational processes that in- fluence perceived health status (see Kleinman, 1988; Query & Kreps, 1993). Addi- tional research further reinforces the potential, therapeutic value of narratives across challenging health care contexts (see Ruben, 1993; Slagle, 1999). Relative to Kreps’s (1988) relational health communication model, qualitative data (narra- tives) have the potential to illustrate instances of supportive, mixed, and nonsupportive interaction and could help uncover how communication compe- tence levels shape the nature of “lived experience.” Such information could then be used to inform the development of community-based interventions by creating and disseminating “training” exemplars that could enable individuals to elicit and ren- der social support effectively across life crises. We are thus contending that a sound model should encompass quantitative and qualitative measures to better es- tablish its theoretical and pragmatic utility. A similar argument has been advanced by Greenbaum and Query (1999).

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Kreps, Query, and associates have shown that the CIT (Flanagan, 1954), a reli- able and valid data collection process, is well suited to gathering narratives that represent positive, negative, and mundane encounters (Kreps & Query, 1992; Query & Kreps, 1993; Query, Kreps, Arneson, & Caso, 2001; see also Brenders, 2001). Five progressive steps comprise the CIT. These include (a) identifying the activity to be studied; (b) developing data collection standards, with the collected reports containing descriptions of actual behaviors observed by the respondents; (c) collecting the data; (d) analyzing and classifying the data by culling similarities and recurring themes from the reported experiences; and (e) interpreting the data.

HYPOTHESIS 1 JUSTIFICATION

A series of studies have indicated that elderly individuals reporting distinct com- munication competence levels experience varying levels of social support satisfac- tion, numbers of social supports, and quality of health outcomes. Query and James (1989), for example, studied 66 elderly individuals residing in three different se- nior communities in the Midwest. Although the authors did not find a statistically significant relationship between communication competence and social support satisfaction level, the variables were in the direction predicted (i.e., moderately communication-competent individuals reported higher levels of social support sat- isfaction than individuals perceiving themselves to have lower levels of communi- cation competence), and the authors found that elders with higher communication competence did rely on larger support networks than less communicatively com- petent elders. In a similar study, Query (1990) investigated these relations among 90 lay caregivers for individuals with Alzheimer’s disease as well as cognitive de- pression level. Although social support satisfaction, number of social supports, and cognitive depression level were again in the direction predicted (i.e., the mod- erately communication-competent individuals reported higher levels of social sup- port satisfaction, larger numbers of social supports, and lower levels of cognitive depression), these dependent variables were not statistically significant (Query, 1990; Query & Kreps, 1996). In a sample of 130 older nontraditional learners, however, Query et al. (1992) supported the links among communication compe- tence level and social support satisfaction as well as number of social supports. Additional research has demonstrated that there is an empirical link among com- munication competencies and social skills, social support, and health outcomes. Segrin (2001, p. 20) summarized this area of investigation by noting that “an addi- tional, and perhaps more straightforward hypothesis suggests that poor social skills are a vulnerability factor because people with poor social skills experience more negative and stressful events. This is characterized as a social skills deficit stress generation hypothesis” (see also Segrin, 1999). Hence, Hypothesis (H) 1 is posited.

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H1: Elderly individuals who report distinct levels of communication com- petence will report differences in social support satisfaction and num- ber of supports as well as demonstrate differences in perceived stress levels.

HYPOTHESIS 2 JUSTIFICATION

Previous research has revealed that communication competence level influences affective dimensions of health outcomes such as social support satisfaction (Query, 1990; Query & James, 1989; Query & Kreps, 1996). This line of research also indicated that a quantitative dimension of health outcomes, such as number of social supports, was not significantly influenced by communication competence level (Query, 1990; Query & James, 1989; Query & Kreps, 1996). One of the con- tributions of these studies was to investigate affective and quantitative dimensions of health outcomes simultaneously within a linear combination. Reviewing Albee’s (1980) social support model, Leatham and Duck (1990) concluded that coping and social support are distinct: “Coping is the mobilization of personal re- sources, both psychological and tangible, to deal with life stresses” (p. 2). They further noted, “If those resources are governed by the individual under strain, it is part of the coping process” (Leatham & Duck, 1990, p. 2). The converse, eliciting resources governed by others, would constitute social support (Leatham & Duck, 1990). These conceptualizations implicate communication competencies as indi- viduals will have to create messages, interpret the stressful situations, marshal ap- propriate resources, and ascertain the efficacy of individual and other-initiated re- sponses. It would seem reasonable to conclude, also, that coping is the process most directly under the control of an individual. In concert with this notion, H2 is advanced.

H2: A linear combination of perceived stress level and social support satis- faction will significantly discriminate among elderly individuals vary- ing in communication competence levels, with perceived stress pro- viding the greatest contribution to the discriminative function.

RESEARCH QUESTION 1 JUSTIFICATION

As indicated previously, narrative data captured by the CIT (Flanagan, 1954) can yield a variety of heuristic and pragmatic benefits. In their review of the literature, Query et al. (2001) reported how this theoretical and methodological coupling had been used to help a staggering array of organizations throughout the world manage their communication practices. In addition to spanning qualitative and quantitative

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domains, such an approach can provide insight into the “lived experience” of the participants, serve as a forum for sharing their voices, provide exemplars of effec- tive and ineffective message behavior, and act as a catalyst for fostering adaptation across a variety of life’s landscapes. Vanderford et al. (1992) used the narrative paradigm among medical residents and persons with AIDS to help better coordi- nate the delivery of quality health care. Compelling arguments positioning com- munication as the central process in successful aging (Hummert & Nussbaum, 2001), cancer education, prevention, and treatment (Kreps, 2001), and health pro- motion (Freimuth, Edgar, & Fitzpatrick, 1993) further support a multimethodological approach to studying how older adults live with cancer, how their lay caregivers provide support, and how cohort peers adapt to various life transitions. A research question (RQ) follows.

RQ1: How do the narratives of elderly individuals living with cancer, their lay caregivers, and peers exemplify social support and coping pro- cesses?

METHOD

Recruitment of Participants

We advertised the study along with a link to an online questionnaire on more than 50 cancer-related e-mail list serves and discussion groups. We sought the permis- sion of list serve owners and discussion group moderators before posting an adver- tisement that described the nature of the study, the minimum age of 50 for partici- pation, and an online informed consent form. In addition, we contacted potential participants through the help of our teaching assistants, and these individuals were given the link to the online questionnaire. Several individuals without online ac- cess also completed the paper version of the survey.

Questionnaire Instrumentation

We measured social support network size and network satisfaction using Sarason, Sarason, Shearin, and Pierce’s (1987) shortened version of the Social Support Questionnaire. This instrument asks respondents to indicate the number of individuals to whom they can turn for various types of social support and also their level of satisfaction with the support they receive from members of their support network on a 6-point, Likert-type scale, with 6 indicating a high level of satisfaction. Items included questions such as, “How many people can you really count on to help you feel better when you are feeling generally down-in-the dumps?” and how satisfied are you with that support? The reliability coefficients

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for this instrument were .91 for the support network size dimension and .94 for the support satisfaction dimension. Communication competence was measured by using the Communication Com- petence Scale originally developed by Wiemann (1977) and later modified by Brunner (1984). This instrument contains 36 items organized along a 5-point Likert-type scale, with 1 indicating a high level of agreement. Sample items in- cluded, “I find it easy to get along with others” and “I can adapt to changing situa- tions.” Wiemann’s (1977) measure encompasses five dimensions of communica- tion competence: affiliation–support, social relaxation, empathy, behavioral flexibility, and interaction management. Individuals with low scores on this mea- sure were evaluated as perceiving themselves as communicatively competent, whereas individuals with high scores were assessed as perceiving themselves as less communicatively competent. The reliability coefficient for this instrument was .92. Perceived life stress was measured with Cohen, Karmack, and Mermelstein’s (1983) Global Measure of Perceived Stress. This instrument required respondents to indicate on a 5-point scale (ranging from never to very often) how often they thought or reacted to daily stressful events in various ways. A high score indicates a large amount of perceived stress, whereas a low score indicates a relatively low amount of perceived stress. Items included questions such as, “In the last month, how often have you felt that things were going your way?” and “In the last month, how often have you felt confident about your ability to handle your personal prob- lems?” The reliability coefficient for this instrument was .85.

Sample Characteristics

Seventy-six older adults (N = 76) between the ages of 50 and 79 (M = 59.61; SD = 7.34) responded to the questionnaire. Of these individuals, there were 26 male and

  • 50 female respondents. The participants were from 20 different states and repre-

sented most regions of the country. In terms of education level, the majority of the

participants indicated they either had at least some college (23 people) or a gradu- ate degree (22 respondents). The majority of the sample (45 participants) indicated they were married. As far as computer-mediated communication was concerned, respondents reported communicating with others on the Internet 7.14 hr per week (SD = 9.62), but in terms of actually seeking support online, participants reported spending only 2.99 hr per week (SD = 4.43). Thirty-eight participants reported having been diagnosed with cancer, whereas

  • 41 people mentioned that they were caregivers for someone with cancer or had

been caregivers for someone during the past 10 years. The most frequent types of cancer that caregivers reported dealing with were lung cancer (10 people), prostate cancer (7 respondents), and colon cancer (3 individuals).

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RESULTS

H1 was tested using a three-group multivariate analysis of variance design with communication competence as the independent variable. H2 was tested using a discriminant analysis with communication competence as the predictor or classifi- cation variable. The probability level for both the multivariate and univariate sig- nificance was set at .05. Group membership was determined by these cutoffs:

Group 1 = x < 1.75; Group 2 = 1.75 < x < 2.16; and Group 3 = x > 2.16, with 26, 28, and 22 participants comprising the respective groups. Note that scores closer to 1 denote higher levels of communication competence. RQ1 was tested using an in- ductive approach in which recurring categories and themes were first culled and then counted by Jim L. Query. H1 predicted a difference in social support satisfaction (M = 5.44, SD = .87), number of supports (M = 2.46, SD = 1.51), and perceived stress levels (M = 15.5, SD = 6.89) based on communication competence level (M = 2.00; SD = .49). We had divided the participants into three groups prior to the analysis (see data analy- sis section), and Group 1’s dependent variables were as follows: perceived stress levels, M = 12.42, SD = 5.62; social support satisfaction, M = 5.56, SD = .80; num- ber of social supports, M = 2.74, SD = 1.83. Group 2’s dependent variables follow:

perceived stress levels, M = 14.79, SD = 6.36; social support satisfaction, M = 5.70, SD = .54; number of social supports, M = 2.58, SD = 1.31. Group 3’s dependent variables were perceived stress levels, M = 20.05, SD = 6.76; social support satis- faction, M = 4.95, SD = 1.09; number of social supports, M = 2.06, SD = 1.51. The results of the multivariate analysis of variance provided partial support for rejecting the null hypothesis, Wilks’s λ = .75, F(2, 73) = 3.67, p = .002; ob- served power = .95, p = .05. In light of this significant omnibus test, the univariates were then examined. Perceived stress levels was significant, F(2, 75) = 9.18, p = .000, and social support satisfaction was significant, F(2, 75)= 5.60, p = .005. Number of social supports was nonsignificant, with p = .278. A post hoc analysis (Tukey’s honestly significant difference) revealed that individuals who were more communicatively competent, Groups 1 and 2, reported signifi- cantly lower perceived stress scores than participants who were less competent, Group 3. In addition, more competent individuals, Groups 1 and 2, reported sig- nificantly higher support satisfaction scores than those individuals who were less competent, Group 3. (The post hoc analysis is available at http://www.home- stead.com/profjims/directory.html). H2 predicted that across communication competence levels, perceived stress levels would make a stronger contribution to distinguishing among the levels than social support satisfaction. The results supported rejecting the null hypothesis with one significant canonical discriminant function emerging: Wilks’s λ = .75, eigenvalue = .28, canonical correlation = .47, 4 df, and p = .000.

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Addressing the first research question, we first categorized the incidents as pos- itive or negative. A total of 116 critical incidents were reported. After we examined the 79 reported, positive critical incidents, 102 responses were classified as resid- ing within five categories of social support. (Because an incident can contain sev- eral discrete descriptors about the same situation, this latter number often exceeds the total number of incidents.) The social support categories included emo- tional–esteem, instrumental, informational, motivational, and a general category for those responses too broad to classify (see Wills, 1985). Of these, 48 responses were deemed emotional–esteem, 33 as instrumental, 9 as motivational, 7 as infor- mational, and 5 as general. A chi-square analysis was then conducted to ascertain if any social support dimension occurred more than chance alone. The study’s par- ticipants thus received significantly more emotional–esteem than the other noted social support types, χ 2 (4) = 73.40, p <.05. Exemplars of each category are con- tained in Table 1. After examining the 47 reported, negative critical incidents, we found that 44 responses could be further analyzed. Of these, 26 identified specific, nonsupportive behaviors; 7 were non–behavior specific; and 11 occurred in non–health care contexts. The nonsupportive behaviors ranged from others being unable or unwilling to help, not understanding the crisis, or imposing their agenda and needs onto the person seeking social support. Participants also reported expe- riencing a wide range of intense, negative emotions including anger, frustration, bitterness, unhappiness, and loneliness. Exemplars of negative incidents are avail- able at http://www.homestead.com/profjims/directory.html.

LIMITATIONS

Before we interpret the results, it is essential to address salient limitations that tem- per our ability to generalize the findings. A self-report data collection method was

used and limits how much the results can be generalized to other well-elders, elderly individuals with cancer, and their lay caregivers. As Albrecht and Adelman (1987b)

argued,however,socialsupportrecipientsareinthebestpositiontoevaluatetheeffi-

cacyofsuchmessages.Asecondlimitationisthatouronlinesampleofolderadultsis not representative of the general older adult population; however, we never intended to generalize the study findings to the general older adult population. In addition, recent survey data of Internet usage patterns suggest that more older adults are projected to use the Internet in substantial numbers within the next decade (Morrell, Mayhorn, & Bennett, 2000). Studies of current seniors who are using the InternetforhealthconcernsmaygiveussomeinsightintotheutilityoftheInternetas a source of social support for people facing health concerns such as cancer. A third concern was the relatively small sample size and its impact on external va- lidity levels. Although we found that the sample size provided sufficient statistical power for the multivariate procedures, more participants in each of the groups would

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TABLE 1 Positive Critical Incidents

Social Support

Positive Critical

Positive Critical

Positive Critical

Positive Critical

Category

Positive Critical Incident 1

Incident 2

Incident 3

Incident 4

Incident 5

Emotional

Received support on a forum for people with breast cancer. The participants are an unusually sensitive, nonjudgmental group who help one another with all and every aspect that concerns breast cancer patients. Hair loss from chemo was an especially horrific experience for me because of issues from early childhood that centered around hair. This forum was one place I could go to and not be invalidated or berated for my overreactive behavior.

The first time my spouse put on my ostomy bag, which was necessary because the valve that was put in during installation of my Indiana pouch, NEO bladder, had failed. Really had a feeling of closeness and of working together.

I found that I was not alone, and that my friend and I had to travel a similar path as we both had similar cancers.

When my father died, my husband allowed me to deal with the grief in my own way, but was there and supportive, willing to listen, to hold, to hug.

I called my friend, M, who listened without comment to my expression of feelings.

Instrumental

In January 2001, I underwent a radical cystectomy. I was overwhelmed by the numerous unsolicited offers of assistance, phone calls, gifts, get-well cards, and visits even from mere acquaintances.

My lover found a way to be in the hall after my surgery. He just sat there till I wheeled by, still drowsy.

Volunteered to come to hospital to visit and to pick me up when discharged.

Church members relieved me from hospital to get some rest when my husband was ill.

My children visit me each weekend and when I’m sad, they take me out.

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Motivational

The women in my breast cancer

We made our decisions

  • I conveyed to my friend that

From daughter, she

group told me how well I was doing with treatment, how well I looked and generally encouraged me.

alone [despite having similar cancers], but supported each other in our choices of treatment for prostate cancer.

  • I was not a good

communicator. She reassured me that I was and to do it all the time, that I just had to do it more.

  • I was very pleased and told

helps me to see the positive side of dissatisfying situations.

Informational

I have received support from oncology.com when dealing with my husband’s cancer. The site provides an opportunity to talk to others who are dealing with the same type of cancer and we share experiences.

After the conversations, you were able to understand better what had occurred and agreed that the advice was good or acceptable.

It made my day and lifted my spirits, which were pretty low at the time. It was from a stranger I met during a transaction on ebay. She emails me constantly with uplifting messages and

I use the Internet for research. People have been very helpful in answering questions.

General

My husband was very supportive when I was told that

When I found out I had prostate cancer, many

encouragement.

the person I was very

When I got cancer, many people were

I had cancer.

people were supportive.

pleased with the support.

genuinely concerned and offered and gave me more support than I ever imagined.

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have facilitated more accurate comparisons of individuals based on their level of communication competence. A fourth limitation is that the study only collected data from individuals who were recipients of social support instead of from both support recipients and providers. Obtaining measures from both types of individuals would allow for an analysis of social support behaviors from a transactional perspective, which might better reflect the complex nature of supportive communication. Finally, given the complexity of life’s transitions and cancer, it would have been helpful to administer the questionnaire over time and to better tailor it to incorpo- rate distinct cancer types. Obviously, some forms of cancer are more aggressive than others, and this characteristic could account for individual differences in per- ceived stress, support network size, and support satisfaction. In addition, it would have been helpful to examine how social support (for individuals living with can- cer, their lay caregivers, and peers) changes throughout the stages of the disease.

DISCUSSION

By partially confirming H1, this study extends some of the earlier findings re- ported by Query and associates. What is particularly revealing in this investigation is that individuals viewing themselves as highest in communication competence experienced significantly different stress levels than their counterparts. This find- ing helps further demonstrate that communication skills play an integral role in shaping health outcomes. Considered in the context of the other studies, this find- ing suggests that future community-based interventions should attend to commu- nication competencies of older adults. As these skills develop over the life span, they can also be periodically enhanced and modified to better meet many of life’s challenges. Of course, no one set of skills should be viewed as a panacea. These re- sults also indicated that individuals with higher levels of communication compe- tence were more satisfied with the support they received than were individuals re- porting lower levels of communication competence. Again, this finding extends much of the social support literature and clearly argues for targeting relational out- comes, which are inextricably linked to health outcomes. Relative to future inter- ventions, online and face to face, this finding emphasizes that it is the quality of supportive exchanges that matters, and not the size of one’s network. Hence, simu- lations and other educational interventions should be designed to help older indi- viduals better understand the nature of supportive encounters. The confirmation of H2, although needing additional confirmation in future re- search, appears to be promising. Outcomes within the control of older adults, such as perceived stress level, can be influenced by developing and sustaining commu- nication competencies. Misidentification, misprioritizing, and misunderstanding of life challenges may be less likely to occur if one’s communication competence level is highly developed. And there is scant debate concerning the role that mes-

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sage encoding and decoding play in defining “stress” and in selecting how one ulti- mately responds to the “stressor.” Social support satisfaction, then, may also bear the brunt of communication skill deficits. In regard to RQ1, the analysis revealed that the expression of emotional support occurred most frequently. This finding is consistent with the prevailing view that emotional support, of all the support types, is most closely tied to health outcomes (Broadhead et al., 1983; Wills & Fegan, 2001). The critical incidents also provided a vivid glimpse into the lives of older adults living with cancer, their lay caregivers, and their peers. Even a brief perusal of those narratives attests to the powerful role that social support and meaning exchange skills can play as individuals negotiate life’s trials, tribulations, and daily challenges. Future interventions should seek to capture, translate, and disseminate similar “lived experiences” so that others may have the opportunity to sojourn successfully.

ACKNOWLEDGMENT

We gratefully acknowledge the assistance of Alicia Denney, Patricia Feinman, Erica Kees, Patricia Phillips, and Ashley Tilka on this article.

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