Coping Strategies Furthering Post-Traumatic Growth in Multiple Sclerosis: A Longitudinal Study

Citation: Gil-González, I.; Martín-Rodríguez, A.; Conrad, R.; Pérez-San-Gregorio, M.Á. Coping Strategies Furthering Post-Traumatic Growth in Multiple Sclerosis: A Longitudinal Study. Int. J. Environ. Res. Public Health 2022,19, 12679. https://doi.org/10.3390/ ijerph191912679 Academic Editor: Paul B. Tchounwou Received: 14 September 2022 Accepted: 30 September 2022 Published: 4 October 2022 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). International Journal of Environmental Research and Public Health Article Coping Strategies Furthering Post-Traumatic Growth in Multiple Sclerosis: A Longitudinal Study Irene Gil-González 1,*,†, Agustín Martín-Rodríguez 1,†, Rupert Conrad 2,† and MaríaÁngeles Pérez-San-Gregorio 1,† 1Department of Personality, Assessment, and Psychological Treatment, University of Seville, 41018 Seville, Spain 2Department of Psychosomatic Medicine and Psychotherapy, University Hospital Muenster, 48149 Muenster, Germany *Correspondence: [email protected]; Tel.: +34-619-911-706 † These authors contributed equally to this work. Abstract: (1) Background: Patients’ behavioral attempts in dealing with Multiple sclerosis (MS) play an important role in post-traumatic growth (PTG). In a longitudinal study, we aimed to identify coping strategies predicting PTG. (2) Methods: 260 MS patients answered the Post-traumatic Growth Inventory and the Brief COPE Questionnaire at three time points during a 36-month follow-up period. (3) Results: an interaction effect between PTG level and assessment time was found for emotional support, positive reframing, active coping, and planning coping strategies. Positive reframing, emotional support, instrumental support, religion, planning, and self-distraction positively predicted PTG. (4) Conclusions: to encourage PTG development, early interventions in MS patients are recommended to promote adaptive coping, particularly positive reframing, social support, active coping, planning, religion, and self-distraction. Keywords: multiple sclerosis; post-traumatic growth; coping strategies 1. Introduction Multiple sclerosis (MS) is a chronic neurodegenerative disease impacting a wide spectrum of patients’ life domains, as well as physical, psychological, and social well-being [ 1 – 3 ]. Unpredictable progression and a highly heterogenous symptomatology pose a great challenge for affected patients, which also may lead to positive psychological changes [ 4 ]. Inner growth after struggling with a life-threatening situation is denominated “post-traumatic growth” (PTG). The term “post-traumatic” means that growth is the consequence of a critical life event. “Growth” refers to a mental and emotional inner state above the initial level [5]. Factors underlying PTG have been widely explored in the scientific literature, with special emphasis on coping strategies. Conceptually, coping strategies are defined as cognitive and behavioral efforts to manage specific external and/or internal demands [6]. In general, problem-focused coping as well as avoidance coping styles, have been related to PTG, [ 7 , 8 ] highlighting the complexity of coping with situational demands to constructively process a trauma. In people living with serious medical conditions, sharing negative emotions and cognitive processing are associated with positive health outcomes. Patients and survivors reporting higher PTG use more frequently adaptive coping strategies, such as problem-focused coping, positive reappraisal, seeking emotional support, and acceptance [ 9 ]. Moreover, it has been suggested that problem-focused and social support strategies play an important role in promoting personal growth among people with physical disability [ 10 ]. The following coping strategies were identified as contributing factors of PTG in specific health conditions: problem-focused active coping, which involves direct actions to deal with the stressor, in cervical dystonia [ 11 ]; acceptance and putting Int. J. Environ. Res. Public Health 2022,19, 12679. https://doi.org/10.3390/ijerph191912679 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2022,19, 12679 2 of 15 into perspective in hemodialysis [ 12 ]; emotional engaging in hematopoietic cell transplantation [ 13 ]; instrumental and emotional social support in liver transplant recipients [ 14 ] and hematopoietic cell transplant recipients [ 13 ]. In people with acquired brain damage, self-distraction and humor were associated with higher PTG in addition to active coping, emotional and instrumental support, positive reframing, planning, acceptance, and use of religion/spirituality [15]. With regard to MS there is growing evidence for the relevance of coping and PTG for well-being and mental health. Thus, in a recent study using semi-structured interviews, re-evaluation of life was described as a beneficial consequence of MS experience [ 16 ]. In quantitative studies, reappraisal and positive reframing were found to predict PTG [ 17 ] and personal benefit finding [ 18 ]. However, there is a lack of studies exploring these associations over a longer period. Longitudinal data indicate an increasing progression of PTG in MS and corroborate the influence of clinical, demographic, and mental health variables with small to medium effect sizes [ 19 ]. When studying personal benefit finding, an improvement tendency over time was also observed suggesting that substantial improvement of personal growth appears later in MS adaptation [ 17 ]. An ideographic study investigating people with MS disease experience highlighted patients’ expression of gratitude for family support enhancement, religious faith promotion, and making a new identity meaning in the long run [20]. Against this backdrop, the present study aimed to investigate the association between post-traumatic growth and coping strategies over the course of 36 months with special emphasis on strategies positively predicting PTG. 2. Materials and Methods 2.1. Participants and Procedure Outpatients of Virgen Macarena University Hospital were asked to participate in three different periods: June 2017–May 2018 (T1), December 2018–December 2019 (T2), and May 2020–April 2021 (T3). Eligibility criteria included: (a) confirmed MS diagnosis according to McDonald criteria verified by their primary care neurologist; (b) aged over 18; and (c) mental, physical, and cognitive capability to fulfill the assessment protocol. Figure 1represents the sample selection process at the three different periods in different colors. The research was authorized by the Ethics Committee responsible (0846-N-18). All participants were provided with oral and written instructions and gave their informed consent to take part in the study. 2.2. Instruments Participants completed a standardized form on sociodemographic features. We collected relevant clinical information from a medical data base. 2.2.1. Post-Traumatic Growth The Spanish version of the Post-traumatic Growth Inventory (PGI-21) assesses patients’ perception of personal benefit after their experience with MS [ 21 , 22 ]. PGI-21 consists of 21 items, scored on a Likert-type scale from 0 (“no change”) to 5 (“very great degree of change”). Items group into the following five dimensions: relating to others, new possibilities, personal strength, spiritual change, and appreciation of life. In the present sample, Cronbach’s alpha was 0.92, 0.91, and 0.93 for the total score scale and 0.74–0.80, 0.77–0.83, and 0.72–0.88 for the five subscale dimensions, at T1, T2, and T3, respectively. 2.2.2. Coping Strategies The Brief COPE Questionnaire (COPE-28) evaluates different actions in dealing with stressful situations [ 23 ]. The COPE-28 contains 28 items scored on a Likert scale from 0 (“I have not been doing this at all”) to 3 (“I have been doing this a lot”). Test results provide information about 14 subscales: (1) acceptance; (2) emotional support; (3) humor; Int. J. Environ. Res. Public Health 2022,19, 12679 3 of 15 (4) positive reframing; (5) religion; (6) active coping; (7) instrumental support; (8) planning; (9) behavioral disengagement; (10) denial; (11) self-distraction; (12) self-blaming; (13) substance use; and (14) venting. The Spanish version was applied to our sample [ 24 ]. Cronbach’s alpha ranged from 0.61 to 0.84 at T1; 0.70 to 0.96 at T2; and 0.63 to 0.95 at T3 for the above-mentioned subscales. Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 3 of 16 Figure 1. Study flow-chart. *Note. CIS= Clinically isolated syndrome. The sample selection process at the three different periods in different colors. 2.2. Instruments Participants completed a standardized form on sociodemographic features. We collected relevant clinical information from a medical data base. 2.2.1. Post-Traumatic Growth The Spanish version of the Post-traumatic Growth Inventory (PGI-21) assesses patients’ perception of personal benefit after their experience with MS [21,22]. PGI-21 consists of 21 items, scored on a Likert-type scale from 0 (“no change”) to 5 (“very great degree of change”). Items group into the following five dimensions: relating to others, new possibilities, personal strength, spiritual change, and appreciation of life. In the present sample, Cronbach’s alpha was 0.92, 0.91, and 0.93 for the total score scale and 0.74–0.80, 0.77–0.83, and 0.72–0.88 for the five subscale dimensions, at T1, T2, and T3, respectively. 2.2.2. Coping Strategies The Brief COPE Questionnaire (COPE-28) evaluates different actions in dealing with stressful situations [23]. The COPE-28 contains 28 items scored on a Likert scale from 0 (“I have not been doing this at all”) to 3 (“I have been doing this a lot”). Test results provide information about 14 subscales: (1) acceptance; (2) emotional support; (3) humor; (4) positive reframing; (5) religion; (6) active coping; (7) instrumental support; (8) planning; (9) Figure 1. Study flow-chart. * Note. CIS = Clinically isolated syndrome. The sample selection process at the three different periods in different colors. 2.2.3. Expanded Disability Status Scale (EDSS) The Expanded Disability Status Scale (EDSS) is the predominantly used scale to measure disability in MS. Its efficacy and reliability have been proven at every disease stage. EDSS scores range from 0, indicating regular neurological functioning, to 10. The scales assess different functional systems (FS): visual functions, brainstem functions, pyramidal functions, cerefellar functions, sensory functions, bowel and bladder functions, cerebral functions, and ambulation. A 5-point EDSS score means no ambulatory problem. In EDSS scores over 5 points, the ambulation status is the main factor determining the degree of disability [25–27]. 2.3. Statistical Analysis Descriptive analyses were calculated to report sample characteristics. A one-way analysis of variance (ANOVA) was used for quantitative variables (age, EDSS, months since diagnosis, and months since the outbreak) and a Chi-squared test was used for qualitative variables (gender, partnership, occupation, educational level, and MS subtype) to detect differences in sociodemographic and clinical variables between three subgroups defined by PTG level (low, medium, and high). Int. J. Environ. Res. Public Health 2022,19, 12679 4 of 15 A 3 × 3 mixed factorial ANOVA with Bonferroni post-hoc tests was calculated to study the influence of initial post-traumatic growth level (low: ≥ 36, medium: 37–60, and high: 61–97) on the use of coping strategies in follow-up assessments (T1, T2, and T3). To identify potential biopsychosocial predictors of post-traumatic growth level, three different stepwise multivariate regression models were calculated. Total post-traumatic growth level at T1, T2, and T3 were considered dependent variables. Coping strategies at T1, T2, and T3 were introduced as predictors. Statistics were conducted using SPSS Statistics version 26 (IBM, Armonk, NY, USA). Significance level was set to p< 0.05. Effect size coefficients were calculated using G*Power Software 3.1 (University of Duesseldorf, Duesseldorf, Germany) and interpreted according to Cohen ´ s (1988) recommendations for w (0.10 = small, 0.30 = medium, and 0.50 = large), for f (0.10 = small, 0.25 = medium, and 0.40 = large), f2 (0.02 = small, 0.15 = medium, and 0.35 = large effects) and d (0.20 = small, 0.50 = medium, and 0.80 = large effects) [28]. 3. Results The final sample was composed of 260 adults with MS. The sample comprised 179 (68.83%) women and 81 (31.27%) men. The mean age was 45 (SD = 10.60). The mean EDSS at T1 was 3.20 (SD = 1.93), and the most reported MS type was relapsing remittent. Participants’ demographics and clinical characteristics are reported in Table 1. Table 1. Comparison of sociodemographic and clinical characteristic of the three different posttraumatic growth level groups at T1. Post-Traumatic Growth Level Intergroup Comparisons Effect Size Low (n = 85) Medium (n = 84) High (n = 91) χ2pCohen´sw Gender n (%) 0.222 0.895 0.029 (N) Male 28 (32.9) 26 (31) 27 (29.7) Female 57 (67.1) 58 (69) 64 (70.3) Partnership n (%) 1.871 0.392 0.084 (N) No partner 59 (69.4) 66 (78.6) 68 (74.7) Partner 26 (30.6) 18 (21.4) 23 (25.3) Occupation n (%) 1.247 0.536 0.068 (N) Employed/In education 34 (40) 27 (32.1) 31 (34.1) Unemployed 51 (60) 57 (67.9) 60 (65.9) Educational level n (%) 8.039 0.090 0.175 (S) Primary education 8 (9.4) 10 (11.9) 17 (18.7) Secondary education 26 (30.6) 34 (40.5) 22 (24.2) University or higher 51 (60) 40 (47.6) 52 (57.1) MS subtype n (%) 0.541 0.763 0.046 (N) Remittent 76 (89.4) 72 (85.7) 80 (87.9) Progressive 9 (10.6) 12 (14.3) 11 (12.1) F (2,257) pCohen´sd Age (M ±SD) 45.7 ±11.1 45.4 ±10.9 44.1 ±9.9 0.581 0.560 0.015 (N) EDSS (M ±SD) 3.1 ±1.8 3.1 ±1.9 3.4 ±2.1 0.704 0.495 0.040 (N) Months since diagnosis (M ±SD) 140.3 ±98.4 147.6 ±92.3 146.2 ±77.8 0.159 0.853 0.021 (N) Months since outbreak (M ±SD) 181.4 ±112.9 190.8 ±112.4 184.4 ±108.4 0.084 0.919 0.020 (N) Table note: S = small effect size, N = effect size. 3.1. Post-Traumatic Growth Levels and Assessment Time on Coping Strategies The influence of initial post-traumatic growth level on the use of coping strategies was studied. The total sample was divided into three groups according to their PGI-21 total score at T1: 85 patients with low post-traumatic growth (32.7%; 0–36 points), 84 with Int. J. Environ. Res. Public Health 2022,19, 12679 5 of 15 medium post-traumatic growth (32.3%; 37–60 points), and 91 with high post-traumatic growth (35%; 61–97 points). One-way ANOVA and Chi square test analyses did not find any significant difference in sociodemographic and clinical sample characteristics between the three groups’ posttraumatic growth levels (Table 1). 3.1.1. Effects of Post-Traumatic Growth and Assessment Time on Coping Strategies As is presented in Table 2and Figure 2, interaction effects between the initial level of post-traumatic growth and the assessment time were found for the following coping strategies: emotional support [F (4,514) = 4.252, p< 0.0001], positive reframing [ F (4,514) = 4.395 , p< 0.0001 ], active coping [F (4,514) = 6.612, p< 0.0001], and planning [F (4,514) = 5.107, p< 0.0001 ]. Simple effects show that these four coping strategies were used less frequently at T1 than T2 and T3 (d ranging from 0.58 to 1.03, medium to large effect size), and were more frequently used by patients in the high PTG group than in the low PTG group (d ranging from 0.29 to 0.43, small effect size). See Table 3. Table 2. Coping strategies: differences in coping strategies use by evaluation phase and initial post-traumatic growth. (3 ×3 mixed factorial analysis of variance). Main Effects (Cohen´sf) Phase Post-Traumatic Growth Interaction Effects (Cohen´sf) F (2,514) F (2,257) F (4,514) Acceptance 26.463 ** 0.320 M 2.869 0.149 S 0.378 0.054 N Emotional support 82.898 ** 0.568 L 7.050 ** 0.234 S 4.252 ** 0.181 S Humor 82.970 ** 0.568 L 4.623 0.190 S 1.383 0.105 S Positive reframing 75.263 ** 0.541 L 5381 ** 0.204 S 4.395 ** 0.184 S Religion 9.566 ** 0.193 S 1.019 0.089 N 1.239 0.1 S Active coping 102.369 ** 0.631 L 11.2 ** 0.29 M 6.612 ** 0.226 S Instrumental support 15.780 ** 0.250 M 5.107 ** 0.198 S 0.923 0.083 N Planning 86.358 ** 0.580 L 3.239 * 0.206 S 5.107 ** 0.198 S Behavioral disengagement 0.015 0 N 1.091 0.008 N 1.393 0.011 N Denial 0.325 0.031 N 1.298 0.100 S 3.035 0.153 S Self-distraction 49.652 ** 0.439 L 3.319 * 0.160 S 0.780 0.077 N Self-blaming 109.678 ** 0.653 L 0.767 0.077 N 0.364 0.054 N Substance use 1.008 0.063 N 0.792 0.044 N 1.012 0.089 N Venting 24.560 ** 0.308 M 0.736 0.077 N 1.246 0.101 S Table note: L = large effect size, M = medium effect size, S = small effect size, N = null effect size. Significance value * p< 0.05, ** p< 0.001. Int. J. Environ. Res. Public Health 2022,19, 12679 6 of 15 Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 7 of 16 Figure 2. Interaction effects between initial level of post-traumatic growth and evaluation phases. Figure 2. Interaction effects between initial level of post-traumatic growth and evaluation phases. Int. J. Environ. Res. Public Health 2022,19, 12679 7 of 15 Table 3. Coping strategies: differences between coping strategies used according to post-traumatic growth level and evaluation phases. Post-Traumatic Growth Level M (SD) Phases Comparisons p(Cohen’s d) Low (a) n = 85 Medium (b) n = 84 High (c) n = 91 1 2 3 Group Levels Phases a–b a–c b–c 1–2 1–3 2–3 Acceptance 2.40 (0.81) 2.44 (0.72) 2.56 (0.57) 2.28 (0.73) 2.58 (0.56) 2.56 (0.60) 1 0.05 N 0.072 0.23 S 0.237 0.18 N <0.001 0.58 M <0.001 0.42 S 1 0.03 N Emotional support 1.75 (0.95) 1.96 (0.77) 2.15 (0.91) 1.52 (0.92) 2.07 (0.96) 2.26 (0.83) 0.178 0.24 S 0.001 0.43 S 0.211 0.23 S <0.0001 0.58 M <0.0001 0.88 L 0.005 0.21 S Humor 1.81 (1.05) 1.83 (1.04) 2.13 (1.10) 1.42 (1.10) 2.24 (0.98) 2.11 (1.02) 1 0.02 N 0.023 0.30 S 0.035 0.28 S <0.0001 0.79 M <0.0001 0.65 M 0.103 0.13 N Positive reframing 1.84 (0.95) 2.03 (0.81) 2.17 (0.93) 1.57 (0.94) 2.21 (0.88) 2.26 (0.87) 0.196 0.22 S 0.004 0.30 S 0.504 0.16 N <0.0001 0.70 M <0.0001 0.76 M 1 0.06 N Religion means 0.90 (0.88) 1.06 (0.73) 1.07 (0.94) 0.86 (0.98) 1.06 (1.07) 1.09 (1.08) 0.701 0.19 N 0.605 0.19 N 1 0.01 N 0.001 0.20 S <0.0001 0.22 S 1 0.03 N Active coping 2.25 (0.85) 2.36 (0.65) 2.52 (0.67) 1.94 (0.79) 2.50 (0.62) 2.67 (0.58) 0.121 0.15 N <0.0001 0.35 S 0.029 0.24 S <0.0001 0.78 M <0.0001 1.03 L 0.004 0.28 S Instrumental support 1.42 (0.78) 1.55 (0.84) 1.76 (0.90) 1.38 (0.86) 1.64 (0.98) 1.73 (0.96) 0.713 0.16 N 0.005 0.40 S 0.158 0.24 S <0.0001 0.28 S <0.0001 0.38 S 0.555 0.09 N Planning 1.78 (0.78) 1.94 (0.76) 2.01 (0.82) 1.47 (0.83) 1.99 (0.90) 2.27 (0.81) 0.293 0.20 S 0.039 0.29 S 1 0.09 N <0.0001 0.60 M <0.0001 0.98 L <0.001 0.33 S Behavioral disengagement 0.39 (0.57) 0.37 (0.52) 0.40 (0.66) 0.39 (0.59) 0.39 (0.61) 0.38 (0.54) 1 0.04 N 1 0.02 N 0.427 0.05 N 1 0 N 1 0.02 N 1 0.02 N Denial 0.46 (0.62) 0.45 (0.73) 0.36 (0.57) 0.41 (0.64) 0.42 (0.61) 0.45 (0.63) 1 0.02 N 0.469 0.17 N 0.535 0.14 N 1 0.02 N 1 0.06 N 1 0.05 N Self-distraction 1.40 (1.05) 1.51 (0.92) 1.77 (1.07) 1.57 (1.02) 2.05 (0.94) 2.28 (0.78) 0.552 0.11 N 0.032 0.35 S 0.678 0.26 S <0.0001 0.50 M <0.0001 0.78 M 0.003 0.26 S Self-blaming 1.61 (0.99) 1.74 (0.88) 1.71 (1.02) 1.15 (0.97) 1.83 (0.90) 2.07 (0.81) 0.703 0.14 N 1 0.09 N 1 0.03 N <0.0001 0.77 M <0.0001 1.02 L <0.0001 0.28 S Substance use 0.10 (0.35) 0.113 (0.23) 0.13 (0.47) 0.11 (0.37) 0.14 (0.51) 0.10 (0.35) 1 0.04 N 0.742 0.07 N 1 0.05 N <0.0001 0.07 N <0.0001 0.02 N 0.705 0.09 N Venting 0.97 (0.83) 0.89 (0.68) 1.15 (0.81) 1.01 (0.78) 1.26 (0.80) 1.37 (0.64) 1 0.11 N 1 0.12 N 0.766 0.35 S <0.0001 0.32 S <0.0001 0.50 M 0.138 0.15 N Table note: L = large effect size, M = medium effect size, S = small effect size, N = null effect size. Int. J. Environ. Res. Public Health 2022,19, 12679 8 of 15 Comparisons between different follow-ups in the three PTG groups are reported in Table 4. The variable time showed significant effects on these coping strategies in the low PTG group (d ranging from 0.45 to 1.24, small to large effect size), except for positive reframing from T2 to T3 (p= 0.529, d = 0.15). In addition, time also had an effect in the medium PTG group (ds from 0.61 to 1.06, medium to large effect size) and the high PTG group (d ranging from 0.42 to 0.67) when comparing the use of the four strategies at T1 with T2 and T3. Apart from planning (p= 0.048, d = 0.29), no significant difference was found between T2 and T3 in the use of these strategies in the medium and high PTG groups. Table 4. Coping strategies: differences in coping strategies use between evaluation phases by initial post-traumatic growth level. Comparison between Phases, p(Cohen´sd) Low CP Medium CP High CP 1–2 1–3 2–3 1–2 1–3 2–3 1–2 1–3 2–3 Emotional support <0.0001 0.61 M <0.0001 1.06 L <0.0001 0.50 M <0.0001 0.72 M <0.0001 0.86 L 1 0.09 N <0.0001 0.49 S <0.0001 0.57 M 1 0.05 N Positive reframing <0.0001 0.85 L <0.0001 1.05 L 0.529 0.15 N <0.0001 0.87 L <0.0001 0.90 L 1 0.02 N 0.002 0.46 S 0.003 0.39 S 1 0.05 N Active coping <0.0001 0.85 L <0.0001 1.24 L <0.0001 0.45 S <0.0001 0.78 M <0.0001 1.06 L 0.318 0.23 S <0.0001 0.60 M <0.0001 0.65 M 1 0.08 N Planning <0.0001 0.79 M <0.0001 1.18 L <0.0001 0.50 M <0.0001 0.61 M <0.0001 1.01 L 0.048 0.29 S 0.003 0.42 S <0.0001 0.67 M 0.642 0.22 S Table note: L = large effect size, M = medium effect size, S = small effect size, N = null effect size. 3.1.2. Main Effects: Post-Traumatic Growth Level Effect on Coping Strategies Regarding main effects, initial post-traumatic growth level was significant for instrumental support [F (2,257) = 5.107, p= 0.007] and self-distraction [F (2,257) = 3.319, p= 0.038] (Table 2). Simple effect results reported in Table 3indicate that instrumental support and selfdistraction were significantly more frequent in the high PTG group compared to the low PTG group (d = 0.40 and 0.35, small effect size). 3.1.3. Main Effects: Assessment Time on Coping Strategies The time factor was also significant for acceptance [F (2,514) = 26.463, p< 0.0001], humor [F (2,514) = 82.970, p< 0.0001], religion [F (2,514) = 9.566, p< 0.0001], instrumental support [F (2,514) = 15.780, p< 0.0001], self-distraction [F (2,514) = 49.652, p< 0.0001], self-blame [F (2,514) = 109.678, p< 0.0001], and venting [F (2,514) = 24.560, p< 0.0001] (Table 2). These coping strategies were used less frequently at T1 compared to T2 and T3 (d ranging from 0.20 to 1.02, from small to large effect size). For self-distraction (p= 0.03, d = 0.26 ) and self-blaming (p< 0.0001, d = 0.28), the comparison between T2 and T3 was also significant, with a small effect size (Table 3). 3.2. Predictors of Post-Traumatic Growth The total post-traumatic growth score was regressed on coping strategies at the three time points. As is presented in Table 5, a higher score in positive reframing ( β = 0.188, p< 0.001), emotional support ( β = 0.152, p= 0.002), planning ( β = 0.134, p= 0.008), religion means ( β = 0.115, p= 0.017), and self-distraction ( β = 0.098, p= 0.044) predicted greater PGI-21 total score levels at T1. These five coping strategies explained 20.1% of PGI-21 total score variance with a medium effect size (f2= 0.251). Int. J. Environ. Res. Public Health 2022,19, 12679 9 of 15 Table 5. T1 Post-traumatic growth (CP-21) Multiple linear regression model. FR2B SE.B β1-βf2 Model 1 54.523 (1.405) 0.119 ** 34.292 2.159 0.99 0.135 (S) Positive reframing 8.798 1.192 0.344 ** Model 2 37.997 (2.404) 0.158 ** 28.824 2.456 0.99 0.187 (M) Positive reframing 7.001 1.236 0.274 ** Emotional support 5.402 1.238 0.211 ** Model 3 29.391 (3.403) 0.180 ** 25.331 2.659 0.99 0.222 (M) Positive reframing 5.869 1.272 0.230 ** Emotional support 4.604 1.248 0.180 ** Planning 4.471 1.386 0.158 ** Model 4 24.082 (4.402) 0.193 * 24.812 2.647 0.99 0.239 (M) Positive reframing 5.306 1.281 0.208 ** Emotional support 3.791 1.277 0.148 ** Planning 4.457 1.376 0.158 ** Religion means 3.054 1.165 0.126 ** Model 5 20.227 (5.401) 0.201 * 22.896 2.802 0.99 0.251 (M) Positive reframing 4.806 1.300 0.188 ** Emotional support 3.883 1.273 0.152 ** Planning 3.784 1.410 0.134 ** Religion means 2.789 1.168 0.115 * Self-distraction 2.361 1.170 0.098 * Table note: M = medium effect size, S = small effect size. Significance value * p< 0.05, ** p< 0.001. In descending order of contribution, religion means ( β = 0.281, p< 0.001), emotional support ( β = 0.255, p< 0.001), active coping ( β = 0.164, p= 0.001), positive reframing ( β= 0.119 ,p= 0.023), and self-distraction ( β = 0.107, p= 0.037) positively predicted PGI- total score at T2. All variables included in the model accounted for 29.4% of PGI-21 total score variance. The effect size coefficient indicated a large effect size (f2= 0.416) (Table 6). Table 6. T2 Post-traumatic growth (CP-21) Multiple linear regression model. FR2B SE.B β1-βf2 Model 1 43.189 (1.322) 0.118 ** 52.846 1.614 0.99 0.134 (S) Religion means 7.356 1.119 0.344 ** Model 2 47.097 (2.323) 0.227 ** 36.552 2.860 1 0.294 (M) Religion means 7.094 1.050 0.332 ** Emotional support 7.876 1.173 0.330 ** Model 3 38.739 (3.321) 0.266 ** 21.330 4.606 1 0.362 (L) Religion means 6.955 1.025 0.325 ** Emotional support 6.985 1.164 0.292 ** Active coping 6.927 1.668 0.202 ** Model 4 31.681 (4.320) 0.284 ** 18.040 4.703 1 0.396 (L) Religion means 6.388 1.034 0.299 ** Emotional support 6.414 1.169 0.269 ** Active coping 5.793 1.698 0.169 ** Positive reframing 3.586 1.270 0.144 ** Model 5 26.496 (5.319) 0.294 * 15.609 4.820 1 0.416 (L) Religion means 6.011 1.044 0.281 ** Emotional support 6.084 1.174 0.255 ** Active coping 5.616 1.691 0.164 ** Positive reframing 2.956 1.298 0.119 * Self-distraction 2.608 1.242 0.107 * Table note: L = large effect size, M = medium effect size, S = small effect size. Significance value * p< 0.05, ** p< 0.001. At T3, the coping strategies that predicted the PGI-21 total score were positive reframing ( β = 0.269, p< 0.001), instrumental support ( β = 0.215, p< 0.001) and religion ( β = 0.158,