Lifestyle and perceptional changes among college students since September 11.

Abstract: This study investigated emotional, attitudinal, perceptional, and behavioral changes among college students since the September 11 [9-11] terrorist attacks using a cross-sectional survey of 1,059 students. Of the total respondents, 15% to 21% reported Post-Traumatic Stress Disorder (PTSD) symptoms. The majority of the respondents have become more concerned about their personal safety (61%) and safety of family members (74%). Logistic regression analyses indicated that personal responsibility was a significant predictor for experiencing many changes of interest, while gender, race, locus of control, class standing, or age were significant predictors for different outcome variables. This study also analyzed and synthesized the qualitative data obtained from an open-ended question regarding life changes.

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The terrorist attacks on September 11, 2001, deprived more than 3,000 people of their lives and exposed everyone in the United States to an unprecedented, traumatic impact. According to a survey conducted three to five days after the 9-11 attacks (Schuster et al., 2001), 44% of the adult respondents reported one or more substantial symptoms of stress. Another survey conducted weeks after the attacks (Disaster and Trauma, 2002) reported an increase in the number of people who showed depression, trouble in sleeping, nightmares, or difficulty in concentrating. Disaster and Trauma also reported that the number of new prescriptions for sleeping and antidepressant medications rose by 28% and 17% respectively in the New York area. Galea et al. (2002) supported this report in their survey performed five to eight weeks after the attacks, reporting that 13.6% of the respondents in Manhattan showed PTSD or depression symptoms.

Repeated, disturbing memories, thoughts, or dreams; having difficulty concentrating; trouble falling asleep; increased irritability; or increased incidents of angry outbursts are among the symptoms of PTSD (National Institute of Mental Health [NIMH], 2001). A nationwide longitudinal study (Silver, Holman, McIntosh, Poulin, & Gil-Rivas, 2002) affirmed the increased PTSD symptoms among the general population even months after the 9-11 attacks. Silver et al. (2002) reported that 17% of the U.S. population outside of New York City showed PTSD symptoms two months after the attacks and 5.8% did so at six months. These findings contrast with the findings of Schlenger et al. (2002) who reported that overall distress levels in the country were within normal ranges except for the New York City metropolitan area at one to two months after the attacks.

Silver et al. (2002), however, concluded in their study that the psychological effects of the 9-11 attacks were hot limited to those who experienced effects directly, and that the extent of impacts could not be predicted by objective measures of exposure or loss. Silver et al. (2002) reported that the degree to which people suffered post-traumatic symptoms was associated with use of coping strategies. Wang and Patten (2002) affirmed this, reporting their findings that turning to religion and talking to others as coping strategies moderated the risk of major depression among women in the presence of stressors. Thoits (1995) and Unger et al. (1998) also emphasized the importance of coping strategies in reducing the negative effects of stress on mental and physical health. Actually, the survey conducted a few days after the attacks (Schuster et al., 2001) revealed that 90% of the respondents coped by turning to religion and 98% by talking with others.

Turner and Noh (1983) reported differential vulnerability to stressors depending on the levels of personal locus of control and social support. Locus of control is, according to Rotter, defined as "a generalized belief about one's ability to control events by virtue of one's own efforts" (p. 125) (as cited in Lerman, & Glanz, 1997). Thoits (1995) noted gender difference in the use of coping strategies, maintaining that women are more likely to seek social support and turn to prayer to alleviate stress.

To the authors' knowledge, no study has ever been conducted to examine the emotional, attitudinal, perceptional, and behavioral changes among college students since the 9-11 attacks. Unger et al. (1998) maintain that youths may be at high risk for depression and maladaptive behaviors when confronted with stressful life events since they tend to have low levels of effective coping skills, intrapersonal resources, and social support in addition to dealing with a variety of stressors such as moving to a new school, body image concerns, acceptance by peers, sexuality issues, and school work. This study examined various impacts of the 9-11 attacks among college students including differential effects of gender, race, class standing, age, locus of control, and personal responsibility.

METHODS

SUBJECTS

Undergraduate students at four Midwestern universities were surveyed on their lifestyle changes as well as emotional, attitudinal, and perceptional changes since the September 11 terrorist attacks. A total of 1,059 students completed the questionnaire during the spring semester of 2002. All the subjects were recruited by instructors who taught elective courses at each campus. The questionnaire was group administered during a class session and voluntary participation and anonymity were ensured. Although it was not a random sample, the subjects were reasonably representative of general undergraduate students in the Midwest.

INSTRUMENT

The survey instrument was created to measure emotional disturbance, increased concern about safety/ security, life threatening perception, behavioral changes, and life changes among college students caused by the 9-11 attacks. Based on the literature, questions were generated to assess both interpersonal and intrapersonal changes. A jury of experts reviewed a draft of the survey and made changes where necessary. The survey questionnaire was pilot tested in a small class of students to determine the length of time for the completion of the survey and to identify unclear or difficult questions. Questions were eliminated, refined, or clarified after the pilot test.

The questionnaire consisted of rive sections: item(s) assessing (1) emotional disturbance, (2) increased concern about safety/security, (3) life threatening perception, (4) behavioral changes, and (5) life changes. The emotional disturbance section consisted of six Likert-type items with a five-point scale. The alternatives were "extremely," "quite often," "moderately," "seldom," and "not at all." The increased concern about safety/security section consisted of 12 items with dichotomous response alternatives (yes/no). The life threatening perception section consisted of three items with two yes/no questions and one item of three alternatives (yes, no, and maybe). The behavioral changes section consisted of two Likert-type items (five-point scale) and 10 yes/no items. Lastly, one item asked if any life changes had occurred because of the 9-11 attacks. If the answer was yes, respondents were asked to list those life changes.

DATA ANALYSIS

Analysis was limited to those subjects who responded completely and validly to all items on the questionnaire. Invalid responses were excluded from the analyses. As a result, approximately 82% of the total subjects (873 out of 1,059) were included in the analysis.

Frequencies and percentages of each response by item were tabulated for the 34 closed-ended question items. The responses to an open-ended question were qualitatively analyzed, synthesized, and interpreted into major categories. The association between categorical dependent variables and demographic variables were examined using Chi-square significance tests.

Logistic regressions were performed using the Statistical Package for the Social Sciences, windows version 11.0 (SPSS Inc., September 2001) to model determinants of experiencing emotional disturbance, increased concern about safety/security, life threatening perception, behavioral changes, and life changes. Independent variables included not only demographic variables, but also subjects' scores of safe behavior, internal locus of control, and personal responsibility with regard to safety. Variables were removed using a backward, stepwise procedure with the criterion of log-likelihood ratio at the .05 level. Where necessary, the items with rive response alternatives were dichotomized into low or high with the middle responses being disregarded. When categorical variables were coded, the category that was clearly defined with no small number of cases was chosen as a reference group.

RESULTS DEMOGRAPHICS

The majority (80%) of the sample ranged in age from 19-22 years. In terms of academic standing, about 39% of the students were freshmen, 24% sophomores, 19% juniors, and 17% seniors. The sample was predominantly comprised of White students (87%). Six percent of the subjects were Black, 3% Asian or Asian-American, and 2% Hispanic or Latino. In terms of geographic region, where one lived most of the rime while he or she was growing up, 28% of the subjects lived in a medium city or surrounding areas, 25% a small city or surrounding areas, 23% in a large city or surrounding areas, 150 in a small town not very dose to a city, and 10% in a rural area. Approximately 58% were females and 42% were males.

EMOTIONAL DISTURBANCE

As shown in Table 1, 58% of the respondents reported that they had felt very upset when reminded of the 9-11 attacks.

Eighteen to twenty-one percent of the total respondents reported they had been bothered with symptoms of repeated, disturbing memories, thoughts, or dreams; having difficulty concentrating; trouble falling asleep; or increased irritability. Fifteen percent reported that they had experienced increased incidents of angry outbursts. Surprisingly, 6% to 7% of the total respondents reported that they had suffered these PTSD symptoms "extremely frequently" or "quite often."

Investigators further examined determinants of emotional disturbance. Table 2 shows the results of logistic regression analyses as well as Chi-square significance tests to model the determinants of self-reported changes, with all included variables significant.

Students who showed high level of personal responsibility were associated with an increase in the odds of feeling very upset when reminded of the 9-11 attacks (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.07 - 1.21) and experiencing all the PTSD symptoms. Race was also another determinant of feeling very upset when reminded of the 9-11 attacks ( [X.sup.2] = 41.33, p < .001). Black students were less likely to experience emotional upset when reminded of the 9-11 attacks (OR, 0.28; 95% CI, 0.09 - 0.84) than White students. For most of the PTSD symptoms, female students were less likely to experience PTSD symptoms than male students (increased incidents of angry outbursts: OR, 0.36; 95% CI, 0.20 - 0.67; having difficulty concentrating: OR, 0.39; 95% CI, 0.20 - 0.77; increased irritability: OR, 0.51; 95% CI, 0.28 - 0.91: and repeated, disturbing memories, thoughts, or dreams: OR, 0.51; 95% CI, 0.28 - 0.93).

INCREASED CONCERN ABOUT SAFETY/ SECURITY

Of the respondents, 61% and 74% reported having had increased concern about their own personal safety and safety of their family members, respectively, since the 9-11 attacks (Table 1). Twenty-seven percent and 44% reported increased concern about job security and financial security, respectively. About hall (52%) of the respondents reported they had been more concerned about their mode of travel and majority (80%) reported increased concern about the future of their country. Twelve percent of the respondents reported having considered purchasing a weapon to defend themselves and their family.

Logistic regression analyses to determine predictors for experiencing increased concern about personal safety, safety of family members, and safety/security of school children produced a very similar model. For all the three variables of interest, personal responsibility score and gender were round to be significant predictors. As shown in Table 2, students who showed high levels of personal responsibility were again associated with an increase in the odds of being more concerned about their own personal safety since the 9-11 attacks (OR, 1.13; 95% CI, 1.09 - 1.17). Gender was also significantly associated with increased concern about personal safety ([X.sup.2] = 30.68, p < .001). Female students were more likely to be concerned about safety and security issues since the 9-11 attacks than male students (world peace: OR, 3.10; 95% CI, 2.13 -4.51; future of country: OR, 2.09; 95% CI, 1.46 - 3.00; safety/security of school children: OR, 1.93; 95% CI, 1.44 - 2.59; personal safety: OR, 1.79; 95% CI, 1.33 - 2.45; safety of family: OR, 1.57; 95% CI, 1.14 - 2.16; and mode of travel: OR, 1.51 ; 95% CI, 1.13 - 2.02).

As for increased concern about job security since the 9-11 attacks, class standing was round to be a significant predictor ([X.sup.2] = 22.46, p < .001). Senior students were twice more likely to have increased concern about job security since the 9-11 attacks (OR, 2.05; 95% CI, 1.30 - 3.24) than sophomore students. Also, while Black students were less likely to consider improving home security (OR, 0.29; 95% CI, 0.09 - 0.97) than White students, Asian or Asian-American students were more likely to consider improving home security (OR, 2.61; 95% CI, 1.09-6.28) than White students.

LIFE THREATENING PERCEPTION

Of the respondents, 17% reported that they found themselves constantly checking on the safety of family members since the 9-11 attacks (Table 1). Also, 12% reported that they felt their lives were in danger since the 9-11 attacks. As shown in Table 2, constant checking on the safety of family members since the 9-11 attacks was explained by personal responsibility score (OR, 1.08; 95% CI, 1.04 - 1.13), gender ([X.sup.2] = 11.68, p < .001), and race ([X.sup.2] = 13.40, p < .01). Female students (OR, 1.80; 95% CI, 1.20 - 2.71) and Asian or Asian-American students (OR, 3.87; 95% CI, 1.64 - 9.10) were more likely to check on the safety of family members since the 9-11 attacks than their respective reference groups (male students and White students).

BEHAVIORAL CHANGES

Thirty-five percent of the respondents reported turning more to prayer, religion, or spirituality since the 9-11 attacks (Table 1). Thirteen percent of the respondents reported to have changed their means of transportation since the 9-11 attacks, and 7% reported to have obtained extra food, gas, or supplies in case of a terrorist attack. Also, 7% and 5% reported to have limited the places going outside home and have avoided contact with people of another race, respectively.

As shown in Table 2, becoming more spiritual since the 9-11 attacks was associated with personal responsibility score (OR, 1.12; 95% CI, 1.07 - 1.17) and gender ([X.sup.2] = 17.66, p < .001). Female students were more likely to have been spiritual since the 9-11 attacks (OR, 1.70; 95% CI, 1.24 - 2.32) than male students. The behavioral change of obtaining extra food, gas, or supplies in case of a terrorist attack was associated with personal responsibility score, locus of control score, and race ([X.sup.2] = 12.96, p < .05). Students who showed a high level of personal responsibility were associated with an increase in the odds of conducting file behavior to obtain extra food, gas, or supplies (OR, 1.12; 95% CI, 1.05 - 1.21). Students who showed internal locus of control were associated with a decrease in the odds of performing that behavior (OR, 0.87; 95% CI, 0.78 - 0.97). Also, Asian or Asian-American students were more likely to attempt to obtain extra food, gas, or supplies (OR, 3.59; 95% CI, 1.35 - 9.54), and more likely to change their means of transportation (OR, 4.17; 95% CI, 1.77- 9.86) than White students.

LIFE CHANGES

Twenty-three percent (200) of the respondents reported some changes had occurred in their life because of the 9-11 attacks. Among those reporting life changes, 60% (120) listed changes they had experienced. A wide variety of life changes were identified by the respondents. The qualitative data generated, analyzed, and then synthesized into general categories, from most frequently to least frequently cited, are presented in Table 3.

As Table 3 shows, the most conspicuous change was that students had become more anxious and emotional. It included fear of going to densely populated areas, apprehension about deployment of self or loved ones, feeling scared or worried without known reasons, and considering moving to another country after graduation. The next general change was that students had become more appreciative of life, family, and friends, which included realizing life is precious, not taking life for granted, hOt getting angry over little things in life, taking care of family members more, and more frequent contacts with family and friends. Another change was related to means of transportation. Some students reported discontinuance of using air travel and others reported fewer use of air travel. The fourth change was increased concern about society and politics, which included watching news more frequently than before and being more aware of world peace. The fifth change was financial loss, which had to do with loss of a job, decreased work hours, and postponement of wedding arrangements, mainly due to unexpected reduced income. Being more patriotic and spiritual was among the other changes. Some students decided to join the army or ROTC and others found themselves praying more.

DISCUSSION AND CONCLUSIONS

Obviously, the September 11 terrorist attacks were an unprecedented, unique tragic event. Findings from this study indicate that it has considerably affected college students' lifestyles, their attitudes, perceptions, and mental/emotional health. Of the total respondents, 15% to 21% reported PTSD symptoms such as repeated, disturbing memories, droughts, or dreams; having difficulty concentrating; increased irritability; or increased incidents of angry outbursts. According to NIMH (2001), people are diagnosed as FTSD when these symptoms last more than one month. Even though this survey did not ask the respondents the duration of these symptoms, many college students are likely to surfer from PTSD. The fact that 6% to 7% of the total respondents had suffered these PTSD symptoms "extremely frequently" or "quite often" indicates considerably large prevalence of PTSD among college students due to the September 11 terrorist attacks. This is supported by the qualitative data of self-reported life changes in which the most frequently cited life change among college students was being more anxious and emotional.

The findings from this study also reveal that the majority of college students have become more concerned about their personal safety (61%), safety of family members (74%), mode of travel (52%), future of country (80%), and world peace (81%) since the September 11 terrorist attacks. These changes reflect substantial attitudinal changes among college students due to the 9-11 attacks. The social, political, and economic implications of these changes are beyond the scope of this study. However, the researchers identify several positive by products as well as negative impacts of the 9-11 attacks. The terrible and tragic event seems to have contributed to the strengthening of family bonding, finding more meaning out of life, increased patriotism, increased concern about society and world peace, and people's spirituality. Future research may be conducted to find out the effective period of those positive effects as well as the magnitude and prevalence of negative impacts as rime passes.

Students who showed a high level of personal responsibility were more likely to experience many changes of interest than those who showed a low level of personal responsibility. Lotus of control contrasts with personal responsibility. For the behavioral change of obtaining extra food, gas, or supplies and experiencing emotional disturbances, such as repeated, disturbing memories, thoughts, or dreams; having difficulty concentrating; and trouble falling asleep, students who showed internal locus of control were less likely to experience those changes than those who showed external locus of control. Thus, it is presumed that personal responsibility and locus of control have to do with sensitivity to environmental changes. Again, this needs to be affirmed by further research.

Another notable finding of this study was different gender effects for different sets of changes since the 9-11 attacks. While male students were more likely to experience PTSD symptoms than female students, female students were much more likely to be concerned about safety and security issues than male students since the 9-11 attacks. Also, female students were 70% more likely to have turned to prayer, religion, or spirituality since the 9-11 attacks than male students. From this finding, it is presumed that female students may have employed coping strategies more effectively than male students, which led to reduced susceptibility of female students to PTSD symptoms.

Another interesting finding of this study was the association between race and some of the emotional and behavioral changes. Black students were 72% less likely to experience emotional upset when reminded of the 9-11 attacks and 71% less likely to consider improving home security than White students. However, Asian or Asian-American students were 317% more likely to change their means of transportation, 259% more likely to attempt to obtain extra food, gas, or supplies, and 161% more likely to consider improving home security than White students. These findings suggest that Black students were less susceptible and Asian or Asian-American students were more susceptible to the traumatic event than White students.

The findings of this study should be interpreted in light of the following limitations. First, this study, that employed a cross-sectional survey design, provided a means to test the association between independent variables and dependent variables. Causal relationships should not be inferred from the present findings. Second, since no control group could be utilized for this study because of the unexpected nature of the catastrophic event, some of the responses may have been influenced by variables other than the 9-11 attacks. For example, even though it was found that senior students were more likely to be concerned about job security since the 9-11 attacks than sophomore students, being close to graduation rather than the catastrophic event may have accounted for part of the effects. Third, this study was exploratory in nature; consequently, it used the convenience sampling technique. Future studies should utilize one of the probability sampling methods. Further, it is suggested that further research be conducted to affirm the findings of this study. As an exploratory study, however, this study revealed important information about the impact of the September 11 terrorist attacks among college students.

Table 1. Frequencies and Percentages of Responses to the Questions on
Emotional, Attitudinal, Perceptional, and Behavioral Changes since the
September 11 Attacks (N = 873).

Changes experienced                   A          B            C

Emotional Disturbance

Feeling very upset when reminded   27   (3)   87   (10)   392   (45)
Repeated, disturbing memories,     16   (2)   36    (4)   131   (15)
  dreams
Increased irritability             15   (2)   39    (5)   121   (14)
Increased incidents of angry       19   (2)   31    (4)    82    (9)
  outbursts

Changes experienced                    D            E

Emotional Disturbance

Feeling very upset when reminded   256   (29)   111   (13)
Repeated, disturbing memories,     319   (37)   371   (43)
  dreams
Increased irritability             229   (26)   469   (54)
Increased incidents of angry       185   (21)   556   (64)
  outbursts

Changes experienced                              Yes          No

Increased Concern about Safety/Security

Personal Safety                               536   (61)   337   (39)
Safety of family                              644   (74)   229   (26)
Job security                                  240   (27)   633   (73)
Mode of travel                                458   (52)   415   (48)
Safety/security of school children            483   (55)   390   (45)
Future of country                             695   (80)   178   (20)
Considering purchasing a weapon               103   (12)   770   (88)

Life Threatening Perception

Constantly checking safety of family          152   (17)   721   (83)
  members
Feeling life is in danger since the 9-11      100   (12)   521   (60)

Behavioral Changes

Have turned more to prayer, religion, or      305   (35)   568   (65)
  spirituality
Have donated blood or increased frequency     136   (16)   737   (84)
  of donating
Have obtained extra food, gas, or supplies     64    (7)   809   (93)
Have limited the places going outside home     59    (7)   814   (93)
Have changed means of transportation          110   (13)   763   (87)
Have avoided contact with people of another    45    (5)   828   (95)

Life Changes

Life changes have occurred                    200   (23)   673   (77)

Note. Values enclosed in parentheses represent percentages. A =
Extremely; B = Quite often; C = Moderately; D = Seldom; E = Not at all.
Some of the findings were not presented here due to space limitations.
Those results are available from the authors upon written request.

Table 2. Determinants of Self-Reported Emotional, Attitudinal,
Perceptional, and Behavioral Changes since the September 11 Attacks
(N= 873).

Changes experienced   Determinants      [X.sup.2]   df   OR

Feeling very upset
when reminded
                      PR                                 1.13 ***
                      Race              41.33 ***   16
                      Black                              0.28 *
                      Hispanic                           0.71
                      White                              1.0

Increased concern
about personal
safety
                      PR                                 1.13 ***
                      Gender            30.68 ***    1
                      Female                             1.79 ***
                      Male                               1.0

Increased concern
about job security
                      Class standing    22.46 ***    3
                      Freshman                           0.78
                      Sophomore                          1.0
                      Junior                             1.35
                      Senior                             2.05 **

Increased concern
about safety/
security of school
children
                      PR                                 1.09 ***
                      Gender            30.51 ***    1
                      Female                             1.93 ***
                      Male                               1.0

Constantly checking
safety of family
members
                      PR                                 1.08 ***
                      Gender            11.68 ***    1
                      Female                             1.80 **
                      Male                               1.0
                      Race              13.40 **     4
                      Asian or Asian-                    3.87 ***
                        American
                      White                              1.0

Have obtained
extra food, gas,
or supplies
                      PR                                 1.12 ***
                      LC                                 0.87 *
                      Race              12.96 *      4
                      Asian or Asian-                    3.59 **
                        American
                      White                              1.0

Life changes have
occurred
                      Age               10.31 *      4
                      19-20                              1.0
                      21-22                              1.50 *
                      25 or older                        2.95 **

Changes experienced   Determinants      95% CI

Feeling very upset
when reminded
                      PR                1.07-1.21
                      Race
                      Black             0.09-0.84
                      Hispanic          0.14-3.58
                      White             Reference

Increased concern
about personal
safety
                      PR                1.09-1.17
                      Gender
                      Female            1.33-2.41
                      Male              Reference

Increased concern
about job security
                      Class standing
                      Freshman          0.52-1.18
                      Sophomore         Reference
                      Junior            0.85-2.15
                      Senior            1.30-3.24

Increased concern
about safety/
security of school
children
                      PR                1.06-1.13
                      Gender
                      Female            1.44-2.59
                      Male              Reference

Constantly checking
safety of family
members
                      PR                1.04-1.13
                      Gender
                      Female            1.20-2.71
                      Male              Reference
                      Race
                      Asian or Asian-   1.64-9.10
                        American
                      White             Reference

Have obtained
extra food, gas,
or supplies
                      PR                1.05-1.21
                      LC                0.78-0.97
                      Race
                      Asian or Asian-   1.35-9.54
                        American
                      White             Reference

Life changes have
occurred
                      Age
                      19-20             Reference
                      21-22             1.02-2.19
                      25 or older       1.41-6.18

Note. OR = Adjusted Odds Ratio; CI = Confidence Interval; PR = Personal
responsibility; LC = Locus of control. Some of the findings were not
presented here due to space limitations. Those results are available
from the authors upon written request. * p <.05. ** p <.01.
*** p <.001.

Table 3. Summary of Qualitative Data of Self-Reported Life Changes
among College Students since the September 11 Attacks.

Life changes experienced                                Frequency

More anxious and emotional                                  44
  Fear of densely populated area, feeling scared and
    worried
  Apprehensive about deployment of self or loved ones
  Being more precautions at school and on job
  More concerned about safety of loved ones
  Reluctant to go out, considering moving to another
    country
  Emotional trauma due to loss of someone close
  Antagonistic to Arabs, disappointed with humanity
  As an Arab, being afraid of Americans

More appreciative of life, family, and friends              22
  Realizing life is precious, not taking life for
    granted
  Not getting angry over little things in life
  More apt to do everything I want to do
  Taking care of family members and loved ones more
  More frequent contacts with family members

Changes in means of transportation                          20
  More reluctant to fly, more worried about plane
    travel
  Fewer use of air travel, stop using air travel
  Not taking train, greater alertness in traveling

Increased concern about society and politics                12
  Watching news more frequently
  More concerned about what's going on in the world
  More aware ofworld peace

Financial loss                                               8
  Losing a job, having hard time getting a job,
    decreased work hours
  Postponement of wedding

More patriotic                                               7
  Plan to join the army or ROTC, feeling more
    patriotic

Being more spiritual                                         7
  Praying more, more trust and faith in God

Note. Total respondents who answered to the open-ended question were
120. Some respondents listed multiple life changes.

REFERENCES

Disaster and Trauma. (2002, January). The Harvard Mental Health Letter, 18, 1-5.

Galea, S., Ahern, J., Resnick, H., Kilpatrick, D., Bucuvalas, M., Gold, J., et al. (2002). Psychological sequlae of the September 11 terrorist attacks in New York City. The New England Journal of Medicine, 346(13), 982-987.

Lerman, C., & Glanz, K. (1997). Stress, coping, and health behavior. In K. Glanz, F. M. Lewis, & B. K. Rimer (Eds.), Health behavior and health education: theory, research, and practice (pp. 113-138). San Francisco CA: Jossey-Bass Inc.

National Institute of Mental Health. (2001). Facts about Post-Traumatic Stress Disorder [On-line]. Available: http://www.nimh.nih.gov/anxiety/ptsdfacts.cfm

Schlenger, W. E., Caddell, J. M., Ebert, L., Jordan, B. K., Rourke, K. M., Wilson, D., et al. (2002). Psychological reactions to terrorist attacks: Findings from the national study of Americans' reactions to September 11. The Journal of the American Medical Association, 288(5), 581-588.

Schuster, M. A., Stein, B. D., Jaycox, L. H., Collins, R. L., Marshall, G. N., Elliott, M. N., et al. (2001). A national survey of stress reactions after the September 11, 2001 terrorist attacks. The New England Journal of Medicine, 345(20), 1507-1512.

Silver, R. C., Holman, E. A., McIntosh, D. N., Poulin, M., & Gil-Rivas, V. (2002). Nationwide longitudinal study of psychological responses to September 11. The Journal of the American Medical Association, 288(10), 1235-1244.

Thoits, P. A. (1995). Stress, coping, and social support processes: Where are we? What next? Journal of Health and Social Behavior, 35(Extra Issue), 53-79.

Turner, R.J., & Noh, S. (1983). Class and psychological vulnerability among women: The significance of social support and personal control. Journal of Health and Social Behavior, 24(1), 2-15.

Unger, J. B., Kipke, M. D., Simon, T. R., Johnson, C.J., Montgomery S. B., & Iverson, E. (1998). Stress, coping, and social support among homeless youth. Journal of Adolescent Research, 13(2), 134-157.

Wang, J., & Patten, S. B. (2002). The moderating effects of coping strategies on major depression in the general population. Canadian Journal of Psychiatry, 47(2), 167-173.

HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED

Responsibility I-Assessing Individual and Community Needs for Health Education

Competency B-Distinguish between behaviors that foster and those that hinder well-being

Sub-competency 1-Investigate physical, social, emotional, and intellectual factors influencing health behavior

Dong-Chul Seo, Ph.D. is a Lecturer, Earl H. Blair, Ed.D. is an Associate Professor, Mohammad R. Torabi, Ph.D. is Chancellor's Professor and Chairperson, and Mark Kaldahl, M.S. is a doctoral student and Associate Instructor in the Department of Applied Health Science ar Indiana University. Address all correspondence to Dong-Chul Seo, Ph.D., Department of Applied Health Science, Indiana University, HPER Building 116, Bloomington, IN 47405; PHONE: [phone]; E-MAIL: [e-mail].