Quality of Life and Coping Strategies in Coronary Heart Disease Patients
This study aims to find the relationship between quality of life and coping strategies in coronary heart disease patients. Two hundred coronary heart disease patients at Tehran Heart Center, who had been diagnosed with the disease 3 months before, were selected and filled out The Coping Inventory for Stressful Situations (CISS) and Quality of Life-SF36. Results showed a discrepancy between quality of life indices and coping strategies. Task-oriented strategy had a positive and significant relationship with total quality of life and PF indices while it had a negative and significant relationship with MH, RE and RP indices. Emotional-oriented strategy had a positive and significant relationship with RP and RE indices while it had a negative and significant relationship with PF, GH, PH, total psychological health and total quality of life indices. Avoidance-oriented strategy had a negative and significant relationship only with MH index. Furthermore, quality of life aspects (physical and psychological) had a positive and significant relationship with emotional-oriented strategy, but it did not have a significant relationship with task-oriented and avoidance-oriented strategies. Also, the social aspect of quality of life did not have a significant relationship with any of the strategies. Considering the effect of stress on decreasing the quality of life, we recommend a psychologist train coping strategies to coronary heart disease patients along with medical treatments in order to improve recovery, maintain health and reduce recurrence.
One of the diseases that root in psycho-socio-economic status is cardiopulmonary diseases which become more prevalent year by year. It is estimated that almost 25 million deaths will occur because of coronary heart diseases in the year 2020. Many factors are involved in these diseases including stress (Sigstad et al., 2005). Stress causes several symptoms in cardiac patients: physical such as sleep disturbance, headache and appetite change; psychological such as anger, hopelessness, isolation and depression; behavioral like fast speaking, restlessness and chain smoking, all of which decrease quality of life. In other words, physical, psychological and behavioral aspects of stress contribute to coronary heart diseases and reduce quality of life (Schultz and Winstead, 2002).
One of the variables associated with quality of life is coping strategies in which people use cognitive behavior to control internal and external, threatening or harmful desires (Lazarus, 1973; Sheridan and Radmacher, 1992). Coping and quality of life affect diseases from childhood to adulthood. In different viewpoints, some parts of coping and quality of life overlay in that coping reflects a process of active involvement at a specific time and quality of life is a consequence rather than a process (Sheen et al., 2005). Selecting a strategy can affect the consequence of quality of life which can be positive or negative (Sigstad et al., 2005).
If people use successful and adaptive coping strategies to reduce stress, they can have a major role in their physical and psychological health and thus their quality of life. Coping strategy affects peoples` reaction to diseases because their physical and psychological responses to diseases are more desirable and more relaxed while unsuccessful and incompatible coping strategies not only do not reduce stress but also cause more severe psychosomatic reactions to the disease (Potter and Perry, 1999).
There are many studies about the relationship between quality of life and coping
strategy, for instance on heart failure (Doering et al., 2004), older
heart patients (Klein et al., 2007), on stroke (Darligton et al.,
2007), after heart surgery (Mathisen et al., 2007). Sheen et al.
(2005) believe patients who have more activity after having heart disease and
use task-oriented strategy improve faster. The long-term consequence of this
strategy is more persistent health. Meanwhile, emotional-oriented strategy is
associated with psychosomatic tension syndrome including anxiety and anger.
Sigstad et al. (2005) showed patients with lower quality of life use
incompatible coping strategy. Elderen et al. (2003), Kimberly et al.
(2003) and Vosvick et al. (2003) found out that quality of life is lower
in patients using emotional-oriented, avoidance and incompatible strategies
and it is related with depressive syndrome and weaker health.
Considering the practical importance of the relationship between quality of life and coping strategies and in order to know the relationship between coronary heart diseases and these two factors, we conducted this study to find the relationship between quality of life and coping strategies in coronary heart disease patients. This is the first time to do such a study in Iran.
MATERIALS AND METHODS
The study was post hoc, correlation method. Out of all coronary heart disease patients at Tehran Heart Center, 200 people were selected. Their age ranged from 30 to 80 years old with a mean of 55. One-hundred and thirty eight were male and 62 were female. 66.5% had a high school diploma and the rest had a higher certificate. 93% were married and 7% were single.
We used two questionnaires in this study; the first one was Coping Inventory for Stressful Situations (CISS) to evaluate coping strategies and the second one was quality of life questionnaire-SF36 to evaluate quality of life. Questionnaires were given to individuals, who firstly filled out SF36 and secondly did CISS.
The Coping Inventory for Stressful Situations (CISS) is a 48-item self-report inventory designed to measure three basic coping styles: Task Oriented, Emotion Oriented and Avoidance Oriented coping. Reliability index of this questionnaire was 0.90, 0.85 and 0.82 for task-oriented, emotional-oriented and avoidance-oriented, respectively (Endler and Parker, 1990).
Quality of life SF36 questionnaire has 36 items. There are 3 main scales of total physical health, total psychological health and total quality of life. In addition, there are 8 subscales: physical functioning (PF), role functioning-physical (RP), bodily pain (BP), general health (GH), vitality (V), social functioning (SF), role functioning- emotional (RE) and mental health (MH) (Ware and Gandek, 1994). Reliability of the questionnaire has been reported 0.73 to 0.90 (Cronbach alpha coefficient) by Brazier et al. (1992), Bell and Kahn (1996), Lyons et al. (1994), Jenkinson et al. (1994) and Ware and Sherbourne. (1992). To analyze data, we used correlation method.
RESULTS AND DISCUSSION
To evaluate the relationship between quality of life and coping strategies,
Table 1 was made using correlation index. As it is seen, quality
of life has no significant relationship with avoidance-oriented strategy, but
has a significantly positive relationship with task-oriented strategy (p<0.05)
and a significantly negative relationship with emotional-oriented strategy (p<0.01).
Table 2 shows the relationship between aspects quality of
life (physical, psychological and total). There is a negative significant relationship
between emotional-oriented strategy and physical and psychological components
and total of quality of life (p<0.05-p<0.01). In addition, there is no
significant relationship between quality of life aspects and task-oriented and
avoidance-oriented strategies. Furthermore, there is a positive significant
relationship between task-oriented strategy and total of quality of life (p<0.05).
In order to assess the relationship between coping strategies and quality of
life indices, Table 3 was made. As it is seen, task-oriented
strategy had a positive significant relationship with PF index and a negative
and significant relationship with MH, RE and RP indices. Emotional-oriented
strategy had a positive and significant relationship with RP and RE indices
and a negative and significant relationship with PF, GH and PH indices. Avoidance-oriented
strategy had a negative and significant relationship with only MH index.
This study on the relationship between quality of life and coping strategies
(task-oriented, emotional-oriented and avoidance-oriented) showed there is a
significant relationship between task oriented strategy and quality of life
in patients with coronary heart diseases. Those who apply this strategy, divide
the problem in to smaller and more controllable parts and use cognitive and
rational aspects, flexibility, looking ahead and analyze the stresses more precisely
and use available resources. If people apply this strategy, which is the most
effective one (Sheridan and Radmacher, 1992), they will enjoy positive and longer
consequences. In addition, as Gray (2000) believes, using task-oriented strategy
makes people objective-oriented. When people use this strategy, they are inclined
toward meditation (self-caring), spirit elevation and increasing self-confidence,
all of which increase total quality of life. This study also showed that quality
of life had a negative and significant relationship with emotional-oriented
strategy. We can justify this finding this way: since emotional-oriented strategy
means blaming one-self for becoming emotional and angry, stress increases in
some cases and reactions are headed toward the person. This, in turn, causes
irrational interpretations of the events and creates a vicious cycle and increases
anxiety and worry. This kind of behavior is related to low adaptability in physical
as well as psychological aspect of quality of life. Present findings are in
agreement with those of Sigstad et al. (2005), Elderen et al.
(2003), Sheen et al. (2005), Kimberly et al. (2003) and Katharina
and Laederach-Hofmann (2003).
||Correlation coefficients between quality of life of coronary
heart disease patients and coping strategies
|**: p<0.01, n = 200
Finally, it was shown there was no relationship between quality of life and
avoidance-oriented strategy. However, there is evidence of a relationship between
them (Myaskovsky et al., 2003). To clarify this disagreement, we argue
that age can be a confounding factor in task-oriented strategy, (Bearnz and
Johnson, 1998) and stress controlling methods are used more often with age.
Also, Wright and Brown (1987) report that people have different coping strategies,
which are affected by age. Older people do not use incompatible strategies very
often. On the other hand, Klein et al. (2007) believe older people with
chronic diseases may keep away from the disease and its management, so they
might not choose the right coping strategy. Since mean age of our subjects is
high and they suffer from a chronic disease, it is a possible explanation why
we did not find a relationship between quality of life and avoidance-oriented
strategy, which is an incompatible one.
Another finding in this study is the negative significant relationship between
psychosomatic aspect of quality of life and emotional-oriented strategy. In
emotional-oriented strategy, people blame themselves and direct the reactions
toward themselves, so they get angry and believe the stressing factor is not
controllable. Furthermore, since there is a relationship between quality of
life aspects, every factor affects other ones; for example, somatic problems
cause anxiety and depression and hence affect psychological status of people.
Therefore, we can conclude that this behavior and strategy affects psychosomatic
aspects of quality of life in that physical aspect reduces the energy of the
person and affect sleep, rest, capacity and work power of the person. Likewise,
the psychological aspect of quality of life causes depression, fear and anger,
so the psychological status of the person is disturbed. These finding are in
agreement with those of Potter and Perry (1999) and Kimberly et al. (2003).
Regarding a negative significant relationship between economic aspect of quality of life and coping strategies, we can say there is strong relationship between income and quality of life, between welfare, comfort and enjoying quality of life. Schultz and Winstead (2002) believe economic status is an important part of quality of life. Since financial status is related to feeling secure, self- confident and useful, people feel less secure, self-confident and useful when they have a low income. As a result, when they encounter a problem, they express self-directed emotional reactions such as blaming themselves in order to decrease their stress. In the present study, we found the highest variance in emotional-oriented strategy is determined by economic aspect of quality of life (9%). Furthermore, Carver et al. (1998) showed people with more personal and environmental resources such as higher income and better job apply task-oriented strategy more and incompatible strategy less.
Bearnz, A. and L. Johnson, 1998. Stress, coping mechanisms. J. Psychosomatics, 23: 14-14.
Bell, D.S. and C.E. Jr. Kahn, 1996. Assessing Health status via the World Wide Web. Proceedings of the AMIA Annual Fall Symposium, (AMIAAF96), Hanley and Belfus, Philadelphia, pp: 338-342.
Brazier, J.E., R. Harper, N.M. Jones, A. O'Cathain, K.J. Thomas, T. Usherwood and L. Westlake, 1992. Validating the SF-36 health survey questionnaire: New outcome measure for primary care. BMJ., 305: 160-164.
Carver, C.S., C. Pozo-Kaderman, A.A. Price, V. Noriega, S.D. Harris and R.P. Derhagopian et al., 1998. Concerns about aspects of body image and adjustment to early stage breast cancer. Psychosomatic. Med., 60: 168-174.
Darligton, A.S., D.W. Dippel, G.M. Ribbers, R. van Balen, J. Passchier and J.J. Busschbach, 2007. Coping strategies as determinants of quality of life in stroke patients: A longitudinal study. Cerebro Vascu. Dis., 23: 401-407.
Doering, L.V., K. Dracup, M.A. Caldwell, D.K. Moser, V.S. Erickson, G. Fonarow and M. Hamilton, 2004. Is coping style linked to emotional state in heart failure patients? J. Card Fail., 10: 344-349.
Direct Link |
Elderen, T.V., M.A. Etched and V. Kemp, 2003. Modeling predictors of QOL with coronary heart after angioplasty. J. Soc. Behav. Med., 26: 49-60.
Endler, N.S. and J.D. Parker, 1990. Multidimensional assessment of coping: A critical evaluation. J. Personality Soc. Psych., 58: 844-845.
Gray, M., 2000. Life style of diabetic spectrum coping and behavior. Diabetes, 13: 167-167.
Jenkinson, C., L. Wright and A. Coulter, 1994. Criterion validity and reliability of the SF-36 in a population sample. Qual. Life Res., 3: 7-12.
Katharina, M. and K.L. Hofmann, 2003. Effects of comprehensive rehabilitation program on QOL in patients with chronic heart failure. J. Prog. Cardiovascu. Nurs., 18: 169-176.
Kimberly, M., B. Coracle, S. Norman and M. Endler, 2003. Psychological predictors of cardiac rehabilitation patient's QOL. J. Applied Biobehav. Res., 8: 26-26.
Klein, D.M., C.L. Turvey and C.J. Pies, 2007. Relationship of coping styles with quality of life and depressive symptoms in older heart failure patients. J. Aging Health, 19: 22-38.
CrossRef | Direct Link |
Lazarus, A., 1973. On assertive behavior. J. Behav. Ther., 14: 69-69.
Lyons, R.A., I.M. Perry and B.N.C. Littlepage, 1994. Evidence for the validity of the Short-form 36 Questionnaire (SF-36) in an elderly population. Age Ageing., 23: 182-184.
Direct Link |
Mathisen, L., M.H. Andersen, M. Veenstra, A.K. Wahl, B.R. Hanastad and E. Fosse, 2007. Quality of life can both influence and be an outcome of general health perceptions after heart surgery. Health QOL. Outcomes, 5: 27-27.
Myaskovsky, L., S.E. Switzer, M. Hall, R.L. Karmos and K.R. McCurry, 2003. Strategies candidates are related to QOL in psych-social function and social domains and psycho domains. J. Am. Heart., 13: 183-192.
Potter, P.A. and A.G. Perry, 1999. Maximizing management of patients with heart failure. J. Clin. Cardiol., 23: 10-10.
Schultz, A. and P. Winstead, 2002. Predictors of QOL in rural patients with cancer. J. Cancer Nur., 24: 120-482.
Sheen, B.J., H.F. Myers and C.P. McCrae, 2006. Psycho-social predictors of cardiac QOL outcomes. J. Psychosomatic, 6: 3-11.
CrossRef | PubMed |
Sheridan, C.L. and S.A. Radmacher, 1992. Health Psychology: Challenging the Biomedical Model. John Wiley and Sons Inc., New York.
Sigstad, H.M., S.S. Froland and A. Stray-Pedersen, 2005. Coping QOL and holpe in adults primary antibody deficiencies. J. Health QOL Outcamer, 3: 31-31.
Vosvick, M., C. Koopman, C. Gore-Felton, C. Thoresen, J. Krumboltz and D. Spiegel, 2003. Relationship of functional quality of life to strategies for coping with the stress of living with HIV/AIDS. Psychosomatics, 44: 51-58.
Direct Link |
Ware, J. and B. Gandek, 1994. The SF36 health survey: Development and using mental health research and the IQ project. J. Mental. Health, 123: 73-73.
Ware, J.E. and C.D. Sherbourne, 1992. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med. Care, 30: 473-483.
Wright, M. and A. Brown, 1987. Coping with stress. J. Psychol., 13: 23-23.