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Quality of life and coping strategies in Lebanese Multiple Sclerosis patients: A pilot study
Multiple Sclerosis and Related Disorders 6 (2016) 21–27
Contents lists available at ScienceDirect
Multiple Sclerosis and Related Disorders journal homepage: www.elsevier.com/locate/msard
Clinical trial
Quality of life and coping strategies in Lebanese Multiple Sclerosis patients: A pilot study Natali Farran a, Diala Ammar a,n,1, Hala Darwish b a b
Lebanese American University, Department of Social Sciences, Beirut, Lebanon American University of Beirut, Hariri School of Nursing, Beirut, Lebanon
art ic l e i nf o
a b s t r a c t
Article history: Received 16 July 2015 Received in revised form 28 November 2015 Accepted 2 December 2015
Coping strategies used by Multiple Sclerosis patients play a key role in adjusting to the disease and affect their overall quality of life. This relationship has been investigated in developed countries, but none has been studied in developing ones such as Lebanon. Factors including barriers to health care delivery, economic pressure and political instability influence which coping strategies are used and often increases the use of negative coping mechanisms. The current pilot study explored the association between different coping strategies with quality of life and depression, anxiety, fatigue and social support in 34 Lebanese Multiple Sclerosis patients. Results indicated that Multiple Sclerosis patients using positive coping strategies had significantly higher scores of quality of life (U ¼46, p ¼.038) and social support (U ¼33.5, p ¼.011), and lower depression (U¼ 44, p ¼.030) and anxiety levels (U¼ 46.5, p ¼.038) as compared to those using negative coping strategies. Specifically, escape avoidance coping strategy was associated with poor quality of life scores (r¼ .609, po .0001) and high levels of depression (r ¼ .534, p¼ .001), anxiety (r ¼ .530, p¼ .001), and fatigue (r ¼ .401, p¼ .019). Comprehensive assessment of Multiple Sclerosis taking into account coping strategies is needed to develop proper therapeutic interventions which increase quality of life. Future studies are required to confirm these results. & 2015 Elsevier B.V. All rights reserved.
Keywords: Coping strategies Quality of life Social support Multiple Sclerosis
1. Introduction Multiple Sclerosis (MS) is considered the most disabling central nervous system disorder in young adults (Chwastiak and Ehde, 2007) with major adverse impacts on the Quality of Life (QoL) in Persons with Multiple Sclerosis (PwMS) (Benito-Leon et al., 2013). This condition results in a reduction of work productivity, as well as an increase of disturbances in personal, family, and social relationships (Grima et al., 2000). The highest predictor of decreased QoL in PwMS is depression with a lifetime prevalence of 50% (Benito-Leon et al., 2013; Siegert and Abernethy, 2005). Other factors include anxiety, with a frequency rate of 21.9% (Marrie et al., 2015), and fatigue ranging from 60% to 92% of the cases. These factors have profound effects on cognitive and physical domains, and on psychosocial functioning (Wood et al., 2013). One important element for adapting and adjusting to chronic diseases including MS is psychological coping (McCabe and McKern, 2002) defined as “the overall cognitive and behavioral efforts to master, reduce or tolerate inside or outside demands n
Corresponding author. E-mail address: [email protected] (D. Ammar). 1 Address: 234-6971 16th Ave SE, T2A 0X8, Calgary, Alberta, Canada.
http://dx.doi.org/10.1016/j.msard.2015.12.003 2211-0348/& 2015 Elsevier B.V. All rights reserved.
which threaten or surpass personal resources”. Two categories of coping strategies are identified, emotion focused coping, and problem focused coping where both contain positive and negative mechanisms. The former refers to coping through managing ones emotions, whereas the latter refers to coping through changing the stressful situation (Lazarus and Folkman, 1984). Several studies have confirmed that different coping strategies used by PwMS result in different QoL outcomes and that on average, MS patients tend to use emotion focused coping strategies (Brajkovic et al., 2009; Goretti et al., 2009; Lynch et al., 2001; McCabe and McKern, 2002). One study indicated that PwMS who use wishful thinking as a coping mechanism, have the poorest QoL (P o.001) (McCabe and McKern, 2002). Furthermore, Brajkovic et al. (2009) indicated that the coping strategies humor, social emotional support, and positive reinterpretation used by PwMS had positive outcomes on anxiety, depression and fatigue levels (Brajkovic et al., 2009). The relationship between QoL and coping strategies has been studied in developed countries (Brajkovic et al., 2009; Goretti et al., 2009; Lynch et al., 2001; McCabe and McKern, 2002). This association has yet to be investigated in developing nations, where numerous factors such as barriers to health care delivery, economic pressure and political instability decrease psychological wellbeing and affect which coping strategies are used (Kimhi et al., 2010; Kronfol, 2012). Generally, individuals resort to negative
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coping strategies when constant stressors are present (Brantley et al., 2002). In Lebanon, the number of patients with MS is estimated to be between 1200 and 1700, with a female to male ratio of 1.8:1.0 (Yamout et al., 2008). Identifying coping strategies associated with poor QoL in these countries is important for orienting therapeutic interventions. This pilot study thus aims at exploring the relationship between coping strategies and QoL in Lebanese MS patients. The primary objective of the current study is to explore the relationship between the choice of coping strategies (confrontive coping, distancing, selfcontrolling, seeking social support, accepting responsibility, escape-avoidance, planful problem solving, and positive reappraisal) and QoL. The secondary objectives include studying the association between these coping strategies and depression, anxiety, and fatigue. In addition, the role of received social support in relation to QoL and coping strategies was further investigated. We hypothesized that escape avoidance coping strategy will be associated with poorest QoL and higher depression and anxiety levels as opposed to social support.
2. Material and methods 2.1. Subjects Thirty-four MS patients were recruited on volunteer basis via social media within Lebanon, this included online groups for PwMS. Volunteers reported whether or not their diagnosis was confirmed by a physician; only those with an official diagnoses were recruited. Other inclusion criteria were patients with any type of MS, on any medications, and age 4 18 years. Exclusion criteria were history of psychotic disorders or any neurological disorder other than MS. Patients also had to be proficient in English language. 2.2. Procedure and measures Eligible volunteers were asked to fill out the questionnaires at their discretion either online or through using the hardcopy version. All results were anonymous and Informed Consents were obtained. The collected Data was entered electronically for subsequent analysis. Written data was placed in a locked cabinet and electronic data was password protected. Questionnaires included subject demographics, Multiple Sclerosis International Quality of Life Questionnaire, Ways of Coping Questionnaire, Beck Depression Inventory II, Beck Anxiety Inventory, Fatigue Severity Scale, and Social Provisions Scale. The study was approved by the Institutional Review Board (IRB) at the Lebanese American University (LAU). 2.2.1. MusiQoL Multiple Sclerosis International Quality Of Life Questionnaire The MusiQoL reflects the point of view of patients with MS on the impact of the disease on their daily life. The questionnaire is self-administered with a total of 31 items, the questionnaire consists of 9 dimensions which are: activity of daily living, coping, psychological well-being, relationships (healthcare system), relationships (family), relationships (friends), rejection, sentimental and sexual life, and symptoms (Simeoni et al., 2008). In our sample, MusiQoL has shown good reliability with Cronbach's alpha ¼.89. 2.2.2. WOCQ Ways of Coping Questionnaire The WOCQ has been validated on MS patients and is widely used in this population (McCabe, 2005; Scherer and Brodzinski, 1990). It is a self-reported measurement of the thoughts and
actions people use to handle stressful encounters. The questionnaire consists of 66 items scored on a 4 point Likert scale. Eight coping strategies are assessed in this questionnaire which are: confrontive coping, distancing, self-controlling, seeking social support, accepting responsibility, escape-avoidance, planful problem solving, and positive reappraisal (Folkman and Lazarus, 1988). In our sample, WOCQ has shown excellent reliability with Cronbach's alpha ¼.93. 2.2.3. BDI-II Beck Depression Inventory II A 21-question multiple-choice self-report inventory which measures the severity of depression. It is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex Scores: 0–13 (minimal depression); 14–19 (mild depression); 20–28 (moderate depression); 29–63 (severe depression) (Powles, 1974). In our sample, this scale has shown good reliability with Cronbach's alpha ¼.89. 2.2.4. BAI Beck Anxiety Inventory The BAI is a 21 multiple choice self-report questionnaire to measure anxiety levels. The questions assess anxiety symptoms such as tingling sensations or fearing the worse. The maximum score possible is 63, where each item's score may range from 0 (not at all) to 3 points (I could barely stand it). Scores ranging from 0 to 7 indicate minimal level of anxiety, from 8 to 15 mild anxiety, 16 to 25 moderate anxiety, and 26 to 63 refers to severe anxiety (Steer and Beck, 1997). The BAI has shown excellent internal consistency (Cronbach's alpha ¼.93). 2.2.5. FSS Fatigue Severity Scale The FSS self-report questionnaire is designed to assess disabling fatigue in individuals with Multiple Sclerosis. The scale was designed to look at fatigue/function measures which is the connection between fatigue intensity and functional disability. FSS consists of 9 questions and uses a 7 point likert scale ranging from strongly disagree to strongly agree. The scores from each question are summed to indicate the total score with lower scores indicating less fatigue in everyday life (Krupp et al., 1989). The FSS in the current study showed excellent reliability with Cronbach's alpha ¼.93. 2.2.6. SPS Social Provisions Scale SPS examines the provisions of social relationships. These provisions reflect what one receives from his/her relationships with other people. The instrument contains 24 items, four for each of the following social support provisions: attachment (emotional closeness), social integration (a sense of belonging to a group of friends), reassurance of worth (recognition of one's competence), reliable alliance (assurance that others can be counted on in times of stress), guidance (advice or information), and opportunity for nurturance (providing assistance to others). Half of the items describe the presence of a type of support and the others describe the absence of a type of support. The questionnaire is self-administered scoring on a 4 point Likert scale ranging from 0 being “strongly disagree” and 4 “strongly agree”. Scores can be derived for each of the six provisions as well as for a global social support score by summing all items. A higher score indicates higher degree of perceived support (Cutrona and Russell, 1987). The SPS has shown excellent internal consistency with Cronbach's alpha ¼ .90. 2.3. Statistical analysis Bivariate correlations between different variables: anxiety, depression, social support, coping strategies, and quality of life (total
N. Farran et al. / Multiple Sclerosis and Related Disorders 6 (2016) 21–27
and dimensions) were performed using Pearson correlation coefficient. This analysis was also performed between different coping strategies and depression, anxiety, and fatigue. Partial correlations were run to determine the relationship between all coping strategies and QoL, in addition to the dimensions of QoL while controlling for social support. The Mann–Whitney U-test was performed to compare differences between positive coping strategies (planful problem solving, positive reappraisal, and seeking social support) and negative coping strategies (escape avoidance, confrontive coping, distancing, self-controlling, and accepting responsibility) as related to QoL. The negative or positive strategies were computed according to the guidelines provided by Folkman and Lazarus (1988), Participants were then categorized as using mostly negative or positive coping strategies according to which group of coping strategies received a higher score. This test was also performed to compare differences of the two types of coping strategies as related to depression, anxiety, fatigue and social support. Data is expressed as percentages or mean 7SD. Significance was set as p o0.05. Statistical Package for Social Science (SPSS) version 22 was used for all statistical analysis.
3. Results 3.1. Demographic data A total of 34 subjects diagnosed with MS (mean age was 36 711 years) were recruited for this study with 56% being females. The majority of the participants in our sample were from low income status (refer to Table 1). After categorizing the subjects into those using more often negative or positive coping strategies, frequencies indicated an unequal distribution in income status. Specifically, individuals with lower incomes used more often negative coping strategies. The majority of the participants (37%) using this coping strategy had lower income (500–999$) compared to the most reported income (1000–1499$ in 35% of participants) among those who use positive coping strategies more often. In addition, all participants with salaries equal to or more than 3500$ used positive coping strategies more often. On the other hand, frequency distributions were nearly identical when comparing the marital status between the negative or positive coping strategies groups. Other demographic characteristics are presented in Table 1. 3.2. Clinical data The most common type of MS among the subjects was relapsing remitting (64.71%), and the least common was progressive relapsing MS (2.94%) (refer to Table 2). MS was diagnosed 9 7 8 years ago on average and subjects reported that symptoms started being experienced 12 7 10 years ago. 66.67% of the sample was receiving disease modifying therapy, whereas 20.59% were on psychotic medications, and 14.71% were undergoing psychotherapy. 3.3. Depression, anxiety, fatigue, and social support A total of 55.88% of the subjects had minimal depression, 20.59% mild depression, 17.65% moderate depression, and 5.88% had severe depression. The mean total depression score was 13.387 9.37. A total of 32.35% of the subjects had minimal anxiety, 17.65% mild anxiety, 29.41% moderate anxiety, and 20.59% had severe anxiety. The mean total anxiety score was 16.44 712.71. The mean fatigue score was 34.38 714.03 and that of social support was 76.59 715.43.
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Table 1 Demographic data N ¼ 34. Gender Female (%) Male (%)
56 44
Age (years)
367 11
Residence province Beirut Lebanon (%) Mount Lebanon (%) North Lebanon (%) South Lebanon (%)
48.48 42.42 6.06 3.03
Marital status Single, never married (%) Dating (%) Married (%) Divorced (%)
44.12 11.76 35.29 8.82
Employment status Employed full time (%) Employed part time (%) Unemployed; looking for work (%) Full time homemaker (%) Unemployed due to MS (%) Unemployed due to other health conditions (%) Student (%) Retired (%)
52.94 5.88 5.88 5.88 8.82 2.94 11.76 5.88
Average income per month (%) 0–499$ 500–999$ 1000–1499$ 1500–1999$ 2000–2499$ 2500–3499$ 3500$ or more
17.65 17.65 29.41 8.82 5.88 5.88 14.71
Table 2 Clinical data. MS type (%) Patient did not Know Progressive relapsing Secondary progressive Primary progressive Relapsing remitting Disease durationa
14.71 2.94 11.76 5.88 64.71 97 8 years
b
Symptom duration
12 710 years
Undergoing disease modifying therapy Yes (%) No (%)
66.67 33.33
Undergoing psychotherapy Yes (%) No (%)
14.71 85.29
Taking psychiatric medications Yes (%) No (%)
20.59 79.41
a b
Time elapsed since the diagnosis of MS was made. Time since onset of MS symptoms.
3.4. Coping strategies Two thirds of patients were using positive coping strategies more often than negative ones. The Mann–Whitney U-test indicated that MS patients using positive coping strategies had
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N. Farran et al. / Multiple Sclerosis and Related Disorders 6 (2016) 21–27
Table 3 Comparison of quality of life across positive and negative coping strategies groups.
Quality of life n
Positive coping strategies group (n ¼23)
Negative coping strategies group (n¼ 8)
Mean rank
Sum of ranks
Mean rank
Sum of ranks
U
18.00
414.00
10.25
82.00
46.000 .038n
p
Significance level at 0.05 (2-tailed).
The Index QoL was 62.15 717.36 over 100. The highest scoring category was Rejection (79.78 7 27.18), followed by Relationships with family (70.59 734.83). The least scoring category was Sentimental and Sexual Life with a mean score of 46.69 7 34.58. 3.6. Correlations Significant correlations were found between QoL and social support, depression, anxiety and fatigue constructs. Social support was positively correlated (r ¼.728, p o.001), whereas depression (r ¼ .750, p o.001), anxiety (r ¼ .635, p o.001), and fatigue (r ¼ .533, p ¼.001) were negatively correlated with QoL. Specifically, all aforementioned constructs were significantly correlated with the psychological wellbeing dimension of QoL (depression r ¼ .861, po .001; anxiety r ¼ .810, p o.001; fatigue r ¼ .428, p ¼.012; and social support r¼ .417, p ¼.018). Depression and anxiety were both moreover correlated with 4 other dimensions. Social support additionally correlated with 5 other dimensions of QoL including coping (r ¼.496, p ¼.004) (refer to Table 5). The partial correlation between total QoL and self-controlling coping strategy became stronger (r ¼ .538, p ¼.012) (refer to Table 7 for previous correlations), while that between total QoL and escape avoidance coping strategy became weaker but remained significant (r ¼ .542, p ¼.002). The coping dimension of QoL decreases its relationship with escape avoidance coping strategy but remained significant (r ¼ .408, p ¼.023). Different coping strategies correlated with depression, anxiety and fatigue. Depression was positively correlated with the coping strategies accepting responsibility (r ¼.361, p ¼.036) and escape-avoidance (r ¼.534, p ¼.001). Anxiety was positively correlated with 4 coping Table 4 Comparison of depression, anxiety, fatigue, and social support across positive and negative coping strategies groups. Positive coping strategies group (n¼ 23)
Negative coping strategies group (n ¼8)
Mean rank
Sum of ranks
Mean rank
Sum of ranks
13.91 14.02 14.61 17.40
320.00 322.50 336.00 365.50
22.00 21.69 20.00 8.69
176.00 173.50 160.00 69.50
Significance level at 0.05 (2-tailed). Significance level at 0.01 (2-tailed).
nn
QoL categories ADL
RFriends Symptoms RFamily RHS SSL
3.5. Quality of life
n
QoL
PW
significantly higher QoL scores as compared to those using negative ones (U¼46, p ¼.038) (refer to Table 3). In addition, social support was higher in MS patients using positive coping strategies (U¼ 33.5, p ¼ .011), whereas MS patients using negative coping strategies exhibited higher depression (U¼ 44, p¼ .030) and anxiety levels (U¼46.5, p ¼.038) (refer to Table 4).
Depression Anxiety Fatigue Social support
Table 5 Pearson correlations between depression, anxiety, fatigue, social support, quality of life and different categories of quality of life (N ¼34).
U
Coping Rejection
Depression
Anxiety
Fatigue
Social support
r p
.750nn o.001
.635nn o.001
.533nn .001
.728nn o.001
r p r p r p r p r p r p r p r p r p
.649nn o.001 .861nn o.001 .113 .526 .581nn o.001 .004 .983 .063 .725 .227 .196 .727nn o.001 .669nn o.001
.704nn o.001 .810nn o.001 .027 .878 .463nn .006 .081 .649 .124 .484 .029 .869 .578nn o.001 .710nn o.001
.372n .030 .428n .012 .215 .223 .338 .050 .215 .221 .204 .248 .440nn .009 .211 .231 .252 .150
.204 .264 .417n .018 .588nn o.001 .413n .019 .428n .014 .098 .595 .598nn o.001 .496nn .004 .329 .066
ADL: Activities of Daily Living. PW: Psychological Well-being. RFriends: Relationships with Friends. RFamily: Relationships with Family. RHS: Relationship with Healthcare System. SSL: Sentimental and Sexual Life. r: Pearson Correlation Coefficient. p: Significance (2-tailed). n
Correlation is significant at the 0.05 level (2-tailed). Correlation is significant at the 0.01 level (2-tailed).
nn
strategies, confrontive coping (r ¼ .407, p¼ .017), self-controlling (r ¼.373, p ¼.030), accepting responsibility (r ¼.378, p ¼.028), and escape avoidance (r ¼.530, p ¼.001). Finally, fatigue was significantly correlated with self-controlling coping strategies (r ¼.381, p ¼.026), and escape avoidance (r ¼.401, p ¼.019) (refer to Table 6). Negative correlations were found between QoL and 3 coping strategies which are self-controlling (r ¼ .427, p ¼.012), accepting responsibility (r ¼ .346, p¼ .045), and escape avoidance (r ¼ .609, po .001). The coping dimension of QoL was negatively correlated with 3 of the coping strategies including accepting responsibility (r ¼ .388, p ¼.024), escape avoidance (r ¼ .519, p¼ .002), and confrontive coping (r ¼ .364, p ¼.034). Activities of daily living on the other hand was negatively correlated with 4 coping strategies which are confrontive coping (r ¼ .395, p¼ .021), self-controlling (r ¼ .357, p ¼.038), accepting responsibility (r ¼ .384, p ¼.025), and escape avoidance (r ¼ .414, p¼ .015). Finally, psychological wellbeing was negatively correlated with confrontive coping (r ¼ .354, p ¼.040), accepting responsibility (r¼ .352, p ¼.041), and escape avoidance (r ¼ .575, po .001) (refer to Table 7).
p
4. Discussion
44.000 46.500 60.000 33.500
.030n .038n .158 .011nn
The present study is the first to explore the relationship between different coping strategies and QoL in Lebanese MS patients. The secondary objectives included studying the association between these coping strategies and depression, anxiety, and fatigue. In addition, the role of received social support in relation to QoL and coping strategies was further investigated. Our findings demonstrated that MS patients used emotion
N. Farran et al. / Multiple Sclerosis and Related Disorders 6 (2016) 21–27
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Table 6 Pearson correlations between coping strategies and depression, anxiety, fatigue and social support (N ¼ 34). Coping strategies
Depression
r p Anxiety r p Fatigue r p Social support r p
Confrontive coping
Distancing Self-controlling Seeking social support
Accepting responsibility
Escape avoidance
Planful problem solving
Positive reappraisal
.261 .137 .407n .017 .149 .401 .012 .948
.016 .927 .010 .956 .011 .952 .057 .755
.361n .036 .378n .028 .143 .421 .179 .328
.534nn .001 .530nn .001 .401n .019 .327 .067
.017 .922 .110 .535 .183 .299 .220 .227
.003 .989 .004 .983 .316 .068 .086 .640
.330 .057 .373n .030 .381n .026 .038 .838
.062 .726 .097 .587 .156 .379 .267 .140
ADL: Activities of Daily Living. PW: Psychological Well-being. RFriends: Relationships with Friends. RFamily: Relationships with Family. RHS: Relationship with Healthcare System. SSL: Sentimental and Sexual Life. r: Pearson correlation coefficient. p: Significance (2-tailed). n
Correlation is significant at the 0.05 level (2-tailed). Correlation is significant at the 0.01 level (2-tailed).
nn
focused strategies more often than problem focused ones. Those using the negative coping strategies; as opposed to the positive ones, had lower QoL scores and social support. This group also showed higher depression and anxiety levels. Furthermore, individual coping strategies had different relations with QoL overall, the dimensions of QoL, depression, anxiety, fatigue, and social support. Specifically, escape-avoidance coping strategy had the
highest negative association with QoL overall and with four of its dimensions, namely, activities of daily living, psychological wellbeing, coping, and rejection. Received social support on the other hand had a positive association with QoL overall and on five of its dimensions which are psychological wellbeing, relationships with friends and family, symptoms, sentimental and sexual life, and coping.
Table 7 Pearson Correlations Between Coping Strategies, Quality of Life and Different Categories of Quality of Life (N ¼34). Coping strategies
QoL
r p
QoL categories ADL r p PW r p RFriends r p Symptoms r p RFamily r p RHS r p SSL r p Coping r p Rejection r p
Confrontive coping
Distancing Self-controlling Seeking social support
.292 .094
.200 .257
.427n .012
.395n .021 .354n .040 .240 .171 .248 .158 .024 .895 .031 .863 .003 .987 .364n .034 .403n .018
.099 .579 .082 .645 .010 .954 .075 .674 .363n .035 .114 .520 .007 .966 .049 .785 .209 .235
.357n .038 .292 .093 .077 .664 .302 .082 .255 .146 .084 .637 .176 .318 .305 .080 .320 .065
ADL: Activities of Daily Living. PW: Psychological Well-being. RFriends: Relationships with Friends. RFamily: Relationships with Family. RHS: Relationship with Healthcare System. SSL: Sentimental and Sexual Life. r: Pearson correlation coefficient. p: Significance (2-tailed). n
Correlation is significant at the 0.05 level (2-tailed). Correlation is significant at the 0.01 level (2-tailed).
nn
Accepting responsibility
Escape avoidance
Planful problem solving
Positive reappraisal
.023 .898
.346n .045
.609nn o.001
.056 .754
.080 .653
.016 .929 .029 .872 .063 .721 .058 .747 .084 .638 .208 .238 .061 .732 .067 .706 .089 .617
.384n .025 .352n .041 .091 .607 .207 .241 .140 .430 .098 .583 .012 .946 .388n .024 .256 .143
.414n .015 .575nn o.001 .221 .210 .295 .090 .310 .074 .001 .997 .228 .195 .519nn .002 .518nn .002
.197 .264 .099 .578 .387n .024 .214 .224 .116 .513 .024 .893 .015 .933 .115 .518 .242 .167
.070 .692 .013 .941 .123 .487 .001 .995 .048 .788 .122 .493 .284 .103 .102 .564 .099 .576
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The association of negative coping strategies with poor QoL is in line with the literature (Brajkovic et al., 2009; Goretti et al., 2009; McCabe and McKern, 2002). Although different scales for investigating coping strategies in MS patients were previously used (Brajkovic et al., 2009; Montel and Bungener, 2007), common negative coping strategies associated with poor QoL may be identified such as self-controlling (Montel and Bungener, 2007) and acceptance (Brajkovic et al., 2009). Escape avoidance as a maladaptive coping mechanism is widely recognized (Folkman, 2013), and its negative impact on the QoL of PwMS has been reported previously (Brajkovic et al., 2009; Goretti et al., 2009; McCabe and McKern, 2002). This coping strategy involves one's disengaging attempts or staying away from a stressful situation and its behavioral and cognitive/emotional consequences. Common mechanisms for escape avoidance coping are denial, wishful thinking, avoidant actions, and cognitive avoidance. These mechanisms are associated with several clinical features such as fatigue, psychiatric comorbidity, and psychosocial problems (Folkman, 2013). Indeed, denial was previously reported as a predictor of anxiety in PwMS (Brajkovic et al., 2009). In our sample, escape avoidance was associated with anxiety in addition to depression and fatigue. This coping mechanism requires enormous time, effort, and energy which may lead to impairments in functioning and exacerbate anxiety and depression symptoms (Kashdan et al., 2006). Nevertheless, the relationship between these constructs in PwMS and with the disease is still poorly understood. Future studies are warranted to investigate how escape avoidance may mediate the relationship of depression, anxiety, fatigue and QoL in MS patients. Another important factor influencing QoL and coping strategies used in PwMS is social support (Brajkovic et al., 2009; Goretti et al., 2009; McCabe and McKern, 2002). However, to our knowledge, the current study is the first to assess received social support in relation to the coping strategies used. In our sample, MS patients with lower social support resorted to the negative coping strategies more often and had lower overall QoL scores. On the other hand, social support was positively associated with the coping and psychological wellbeing dimensions of QoL. In line with this, one study conducted in the same region indicated that received social support and satisfaction with this social support is an important predictor of QoL in PwMS (Yamout et al., 2013). It should be noted however that the scale used to assess social support in the latter study was a 2-item summary of 2 scales; the SSQT (Social Support Questionnaire for Transactions) and the SSQS (Social Support Questionnaire for Satisfaction), whereas a 24 item SPS was used in our study. While the authors of the study by Yamout et al. (2013) have attributed this prediction to the quality of social support in the patients who lived in urban areas (Yamout et al., 2013), we believe that in addition to that, the social construct of Lebanon plays a key role. Lebanon is considered a collectivistic culture (Rego and Cunha, 2009), where psychological wellbeing is highly associated with family functioning (Kazarian, 2005). Social support is one of the most effective means by which people cope with stressful events and it plays a key role in collectivistic cultures. This includes reaching out to family, friends, coworkers and forming community ties (Kim et al., 2008). Indeed, received social support in our sample of PwMS was positively associated with all psychosocial domains of QoL. However, after controlling for social support in our study, the relationships between self-controlling and escape avoidance coping strategies and QoL remained significant, albeit weaker for the latter. This indicates that social support is not the only mediator of QoL in PwMS. Future studies should investigate other possible mediating factors related to coping strategies such as resilience and hope (Tugade et al., 2004).
5. Conclusions Which coping strategies are used depends on environmental and other factors (Folkman, 2013). Constant stressors present in in developing countries such as poor health care delivery, low income, economic and political instability lead individuals to resort to emotion focused coping strategies including the negative ones such as escape avoidance (Brantley et al., 2002; Kimhi et al., 2010). Comprehensive assessment of MS patients comprising mood status and coping strategies is important. Clinical applications include therapeutic interventions which alleviate symptoms of depression, anxiety and fatigue, and enhance the practice of adaptive coping strategies. This comprises the focus on social support while decreasing the use of maladaptive strategies such as escape-avoidance. Taken together, these interventions may enhance the QoL of MS patients. Future studies are needed to better understand the relationships between these constructs and others in PwMS and to further investigate the profile of coping strategies and their effects in various environments.
Conflict of Interest The authors declare no conflict of interest.
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Contents lists available at ScienceDirect
Multiple Sclerosis and Related Disorders journal homepage: www.elsevier.com/locate/msard
Clinical trial
Quality of life and coping strategies in Lebanese Multiple Sclerosis patients: A pilot study Natali Farran a, Diala Ammar a,n,1, Hala Darwish b a b
Lebanese American University, Department of Social Sciences, Beirut, Lebanon American University of Beirut, Hariri School of Nursing, Beirut, Lebanon
art ic l e i nf o
a b s t r a c t
Article history: Received 16 July 2015 Received in revised form 28 November 2015 Accepted 2 December 2015
Coping strategies used by Multiple Sclerosis patients play a key role in adjusting to the disease and affect their overall quality of life. This relationship has been investigated in developed countries, but none has been studied in developing ones such as Lebanon. Factors including barriers to health care delivery, economic pressure and political instability influence which coping strategies are used and often increases the use of negative coping mechanisms. The current pilot study explored the association between different coping strategies with quality of life and depression, anxiety, fatigue and social support in 34 Lebanese Multiple Sclerosis patients. Results indicated that Multiple Sclerosis patients using positive coping strategies had significantly higher scores of quality of life (U ¼46, p ¼.038) and social support (U ¼33.5, p ¼.011), and lower depression (U¼ 44, p ¼.030) and anxiety levels (U¼ 46.5, p ¼.038) as compared to those using negative coping strategies. Specifically, escape avoidance coping strategy was associated with poor quality of life scores (r¼ .609, po .0001) and high levels of depression (r ¼ .534, p¼ .001), anxiety (r ¼ .530, p¼ .001), and fatigue (r ¼ .401, p¼ .019). Comprehensive assessment of Multiple Sclerosis taking into account coping strategies is needed to develop proper therapeutic interventions which increase quality of life. Future studies are required to confirm these results. & 2015 Elsevier B.V. All rights reserved.
Keywords: Coping strategies Quality of life Social support Multiple Sclerosis
1. Introduction Multiple Sclerosis (MS) is considered the most disabling central nervous system disorder in young adults (Chwastiak and Ehde, 2007) with major adverse impacts on the Quality of Life (QoL) in Persons with Multiple Sclerosis (PwMS) (Benito-Leon et al., 2013). This condition results in a reduction of work productivity, as well as an increase of disturbances in personal, family, and social relationships (Grima et al., 2000). The highest predictor of decreased QoL in PwMS is depression with a lifetime prevalence of 50% (Benito-Leon et al., 2013; Siegert and Abernethy, 2005). Other factors include anxiety, with a frequency rate of 21.9% (Marrie et al., 2015), and fatigue ranging from 60% to 92% of the cases. These factors have profound effects on cognitive and physical domains, and on psychosocial functioning (Wood et al., 2013). One important element for adapting and adjusting to chronic diseases including MS is psychological coping (McCabe and McKern, 2002) defined as “the overall cognitive and behavioral efforts to master, reduce or tolerate inside or outside demands n
Corresponding author. E-mail address: [email protected] (D. Ammar). 1 Address: 234-6971 16th Ave SE, T2A 0X8, Calgary, Alberta, Canada.
http://dx.doi.org/10.1016/j.msard.2015.12.003 2211-0348/& 2015 Elsevier B.V. All rights reserved.
which threaten or surpass personal resources”. Two categories of coping strategies are identified, emotion focused coping, and problem focused coping where both contain positive and negative mechanisms. The former refers to coping through managing ones emotions, whereas the latter refers to coping through changing the stressful situation (Lazarus and Folkman, 1984). Several studies have confirmed that different coping strategies used by PwMS result in different QoL outcomes and that on average, MS patients tend to use emotion focused coping strategies (Brajkovic et al., 2009; Goretti et al., 2009; Lynch et al., 2001; McCabe and McKern, 2002). One study indicated that PwMS who use wishful thinking as a coping mechanism, have the poorest QoL (P o.001) (McCabe and McKern, 2002). Furthermore, Brajkovic et al. (2009) indicated that the coping strategies humor, social emotional support, and positive reinterpretation used by PwMS had positive outcomes on anxiety, depression and fatigue levels (Brajkovic et al., 2009). The relationship between QoL and coping strategies has been studied in developed countries (Brajkovic et al., 2009; Goretti et al., 2009; Lynch et al., 2001; McCabe and McKern, 2002). This association has yet to be investigated in developing nations, where numerous factors such as barriers to health care delivery, economic pressure and political instability decrease psychological wellbeing and affect which coping strategies are used (Kimhi et al., 2010; Kronfol, 2012). Generally, individuals resort to negative
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N. Farran et al. / Multiple Sclerosis and Related Disorders 6 (2016) 21–27
coping strategies when constant stressors are present (Brantley et al., 2002). In Lebanon, the number of patients with MS is estimated to be between 1200 and 1700, with a female to male ratio of 1.8:1.0 (Yamout et al., 2008). Identifying coping strategies associated with poor QoL in these countries is important for orienting therapeutic interventions. This pilot study thus aims at exploring the relationship between coping strategies and QoL in Lebanese MS patients. The primary objective of the current study is to explore the relationship between the choice of coping strategies (confrontive coping, distancing, selfcontrolling, seeking social support, accepting responsibility, escape-avoidance, planful problem solving, and positive reappraisal) and QoL. The secondary objectives include studying the association between these coping strategies and depression, anxiety, and fatigue. In addition, the role of received social support in relation to QoL and coping strategies was further investigated. We hypothesized that escape avoidance coping strategy will be associated with poorest QoL and higher depression and anxiety levels as opposed to social support.
2. Material and methods 2.1. Subjects Thirty-four MS patients were recruited on volunteer basis via social media within Lebanon, this included online groups for PwMS. Volunteers reported whether or not their diagnosis was confirmed by a physician; only those with an official diagnoses were recruited. Other inclusion criteria were patients with any type of MS, on any medications, and age 4 18 years. Exclusion criteria were history of psychotic disorders or any neurological disorder other than MS. Patients also had to be proficient in English language. 2.2. Procedure and measures Eligible volunteers were asked to fill out the questionnaires at their discretion either online or through using the hardcopy version. All results were anonymous and Informed Consents were obtained. The collected Data was entered electronically for subsequent analysis. Written data was placed in a locked cabinet and electronic data was password protected. Questionnaires included subject demographics, Multiple Sclerosis International Quality of Life Questionnaire, Ways of Coping Questionnaire, Beck Depression Inventory II, Beck Anxiety Inventory, Fatigue Severity Scale, and Social Provisions Scale. The study was approved by the Institutional Review Board (IRB) at the Lebanese American University (LAU). 2.2.1. MusiQoL Multiple Sclerosis International Quality Of Life Questionnaire The MusiQoL reflects the point of view of patients with MS on the impact of the disease on their daily life. The questionnaire is self-administered with a total of 31 items, the questionnaire consists of 9 dimensions which are: activity of daily living, coping, psychological well-being, relationships (healthcare system), relationships (family), relationships (friends), rejection, sentimental and sexual life, and symptoms (Simeoni et al., 2008). In our sample, MusiQoL has shown good reliability with Cronbach's alpha ¼.89. 2.2.2. WOCQ Ways of Coping Questionnaire The WOCQ has been validated on MS patients and is widely used in this population (McCabe, 2005; Scherer and Brodzinski, 1990). It is a self-reported measurement of the thoughts and
actions people use to handle stressful encounters. The questionnaire consists of 66 items scored on a 4 point Likert scale. Eight coping strategies are assessed in this questionnaire which are: confrontive coping, distancing, self-controlling, seeking social support, accepting responsibility, escape-avoidance, planful problem solving, and positive reappraisal (Folkman and Lazarus, 1988). In our sample, WOCQ has shown excellent reliability with Cronbach's alpha ¼.93. 2.2.3. BDI-II Beck Depression Inventory II A 21-question multiple-choice self-report inventory which measures the severity of depression. It is composed of items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, as well as physical symptoms such as fatigue, weight loss, and lack of interest in sex Scores: 0–13 (minimal depression); 14–19 (mild depression); 20–28 (moderate depression); 29–63 (severe depression) (Powles, 1974). In our sample, this scale has shown good reliability with Cronbach's alpha ¼.89. 2.2.4. BAI Beck Anxiety Inventory The BAI is a 21 multiple choice self-report questionnaire to measure anxiety levels. The questions assess anxiety symptoms such as tingling sensations or fearing the worse. The maximum score possible is 63, where each item's score may range from 0 (not at all) to 3 points (I could barely stand it). Scores ranging from 0 to 7 indicate minimal level of anxiety, from 8 to 15 mild anxiety, 16 to 25 moderate anxiety, and 26 to 63 refers to severe anxiety (Steer and Beck, 1997). The BAI has shown excellent internal consistency (Cronbach's alpha ¼.93). 2.2.5. FSS Fatigue Severity Scale The FSS self-report questionnaire is designed to assess disabling fatigue in individuals with Multiple Sclerosis. The scale was designed to look at fatigue/function measures which is the connection between fatigue intensity and functional disability. FSS consists of 9 questions and uses a 7 point likert scale ranging from strongly disagree to strongly agree. The scores from each question are summed to indicate the total score with lower scores indicating less fatigue in everyday life (Krupp et al., 1989). The FSS in the current study showed excellent reliability with Cronbach's alpha ¼.93. 2.2.6. SPS Social Provisions Scale SPS examines the provisions of social relationships. These provisions reflect what one receives from his/her relationships with other people. The instrument contains 24 items, four for each of the following social support provisions: attachment (emotional closeness), social integration (a sense of belonging to a group of friends), reassurance of worth (recognition of one's competence), reliable alliance (assurance that others can be counted on in times of stress), guidance (advice or information), and opportunity for nurturance (providing assistance to others). Half of the items describe the presence of a type of support and the others describe the absence of a type of support. The questionnaire is self-administered scoring on a 4 point Likert scale ranging from 0 being “strongly disagree” and 4 “strongly agree”. Scores can be derived for each of the six provisions as well as for a global social support score by summing all items. A higher score indicates higher degree of perceived support (Cutrona and Russell, 1987). The SPS has shown excellent internal consistency with Cronbach's alpha ¼ .90. 2.3. Statistical analysis Bivariate correlations between different variables: anxiety, depression, social support, coping strategies, and quality of life (total
N. Farran et al. / Multiple Sclerosis and Related Disorders 6 (2016) 21–27
and dimensions) were performed using Pearson correlation coefficient. This analysis was also performed between different coping strategies and depression, anxiety, and fatigue. Partial correlations were run to determine the relationship between all coping strategies and QoL, in addition to the dimensions of QoL while controlling for social support. The Mann–Whitney U-test was performed to compare differences between positive coping strategies (planful problem solving, positive reappraisal, and seeking social support) and negative coping strategies (escape avoidance, confrontive coping, distancing, self-controlling, and accepting responsibility) as related to QoL. The negative or positive strategies were computed according to the guidelines provided by Folkman and Lazarus (1988), Participants were then categorized as using mostly negative or positive coping strategies according to which group of coping strategies received a higher score. This test was also performed to compare differences of the two types of coping strategies as related to depression, anxiety, fatigue and social support. Data is expressed as percentages or mean 7SD. Significance was set as p o0.05. Statistical Package for Social Science (SPSS) version 22 was used for all statistical analysis.
3. Results 3.1. Demographic data A total of 34 subjects diagnosed with MS (mean age was 36 711 years) were recruited for this study with 56% being females. The majority of the participants in our sample were from low income status (refer to Table 1). After categorizing the subjects into those using more often negative or positive coping strategies, frequencies indicated an unequal distribution in income status. Specifically, individuals with lower incomes used more often negative coping strategies. The majority of the participants (37%) using this coping strategy had lower income (500–999$) compared to the most reported income (1000–1499$ in 35% of participants) among those who use positive coping strategies more often. In addition, all participants with salaries equal to or more than 3500$ used positive coping strategies more often. On the other hand, frequency distributions were nearly identical when comparing the marital status between the negative or positive coping strategies groups. Other demographic characteristics are presented in Table 1. 3.2. Clinical data The most common type of MS among the subjects was relapsing remitting (64.71%), and the least common was progressive relapsing MS (2.94%) (refer to Table 2). MS was diagnosed 9 7 8 years ago on average and subjects reported that symptoms started being experienced 12 7 10 years ago. 66.67% of the sample was receiving disease modifying therapy, whereas 20.59% were on psychotic medications, and 14.71% were undergoing psychotherapy. 3.3. Depression, anxiety, fatigue, and social support A total of 55.88% of the subjects had minimal depression, 20.59% mild depression, 17.65% moderate depression, and 5.88% had severe depression. The mean total depression score was 13.387 9.37. A total of 32.35% of the subjects had minimal anxiety, 17.65% mild anxiety, 29.41% moderate anxiety, and 20.59% had severe anxiety. The mean total anxiety score was 16.44 712.71. The mean fatigue score was 34.38 714.03 and that of social support was 76.59 715.43.
23
Table 1 Demographic data N ¼ 34. Gender Female (%) Male (%)
56 44
Age (years)
367 11
Residence province Beirut Lebanon (%) Mount Lebanon (%) North Lebanon (%) South Lebanon (%)
48.48 42.42 6.06 3.03
Marital status Single, never married (%) Dating (%) Married (%) Divorced (%)
44.12 11.76 35.29 8.82
Employment status Employed full time (%) Employed part time (%) Unemployed; looking for work (%) Full time homemaker (%) Unemployed due to MS (%) Unemployed due to other health conditions (%) Student (%) Retired (%)
52.94 5.88 5.88 5.88 8.82 2.94 11.76 5.88
Average income per month (%) 0–499$ 500–999$ 1000–1499$ 1500–1999$ 2000–2499$ 2500–3499$ 3500$ or more
17.65 17.65 29.41 8.82 5.88 5.88 14.71
Table 2 Clinical data. MS type (%) Patient did not Know Progressive relapsing Secondary progressive Primary progressive Relapsing remitting Disease durationa
14.71 2.94 11.76 5.88 64.71 97 8 years
b
Symptom duration
12 710 years
Undergoing disease modifying therapy Yes (%) No (%)
66.67 33.33
Undergoing psychotherapy Yes (%) No (%)
14.71 85.29
Taking psychiatric medications Yes (%) No (%)
20.59 79.41
a b
Time elapsed since the diagnosis of MS was made. Time since onset of MS symptoms.
3.4. Coping strategies Two thirds of patients were using positive coping strategies more often than negative ones. The Mann–Whitney U-test indicated that MS patients using positive coping strategies had
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N. Farran et al. / Multiple Sclerosis and Related Disorders 6 (2016) 21–27
Table 3 Comparison of quality of life across positive and negative coping strategies groups.
Quality of life n
Positive coping strategies group (n ¼23)
Negative coping strategies group (n¼ 8)
Mean rank
Sum of ranks
Mean rank
Sum of ranks
U
18.00
414.00
10.25
82.00
46.000 .038n
p
Significance level at 0.05 (2-tailed).
The Index QoL was 62.15 717.36 over 100. The highest scoring category was Rejection (79.78 7 27.18), followed by Relationships with family (70.59 734.83). The least scoring category was Sentimental and Sexual Life with a mean score of 46.69 7 34.58. 3.6. Correlations Significant correlations were found between QoL and social support, depression, anxiety and fatigue constructs. Social support was positively correlated (r ¼.728, p o.001), whereas depression (r ¼ .750, p o.001), anxiety (r ¼ .635, p o.001), and fatigue (r ¼ .533, p ¼.001) were negatively correlated with QoL. Specifically, all aforementioned constructs were significantly correlated with the psychological wellbeing dimension of QoL (depression r ¼ .861, po .001; anxiety r ¼ .810, p o.001; fatigue r ¼ .428, p ¼.012; and social support r¼ .417, p ¼.018). Depression and anxiety were both moreover correlated with 4 other dimensions. Social support additionally correlated with 5 other dimensions of QoL including coping (r ¼.496, p ¼.004) (refer to Table 5). The partial correlation between total QoL and self-controlling coping strategy became stronger (r ¼ .538, p ¼.012) (refer to Table 7 for previous correlations), while that between total QoL and escape avoidance coping strategy became weaker but remained significant (r ¼ .542, p ¼.002). The coping dimension of QoL decreases its relationship with escape avoidance coping strategy but remained significant (r ¼ .408, p ¼.023). Different coping strategies correlated with depression, anxiety and fatigue. Depression was positively correlated with the coping strategies accepting responsibility (r ¼.361, p ¼.036) and escape-avoidance (r ¼.534, p ¼.001). Anxiety was positively correlated with 4 coping Table 4 Comparison of depression, anxiety, fatigue, and social support across positive and negative coping strategies groups. Positive coping strategies group (n¼ 23)
Negative coping strategies group (n ¼8)
Mean rank
Sum of ranks
Mean rank
Sum of ranks
13.91 14.02 14.61 17.40
320.00 322.50 336.00 365.50
22.00 21.69 20.00 8.69
176.00 173.50 160.00 69.50
Significance level at 0.05 (2-tailed). Significance level at 0.01 (2-tailed).
nn
QoL categories ADL
RFriends Symptoms RFamily RHS SSL
3.5. Quality of life
n
QoL
PW
significantly higher QoL scores as compared to those using negative ones (U¼46, p ¼.038) (refer to Table 3). In addition, social support was higher in MS patients using positive coping strategies (U¼ 33.5, p ¼ .011), whereas MS patients using negative coping strategies exhibited higher depression (U¼ 44, p¼ .030) and anxiety levels (U¼46.5, p ¼.038) (refer to Table 4).
Depression Anxiety Fatigue Social support
Table 5 Pearson correlations between depression, anxiety, fatigue, social support, quality of life and different categories of quality of life (N ¼34).
U
Coping Rejection
Depression
Anxiety
Fatigue
Social support
r p
.750nn o.001
.635nn o.001
.533nn .001
.728nn o.001
r p r p r p r p r p r p r p r p r p
.649nn o.001 .861nn o.001 .113 .526 .581nn o.001 .004 .983 .063 .725 .227 .196 .727nn o.001 .669nn o.001
.704nn o.001 .810nn o.001 .027 .878 .463nn .006 .081 .649 .124 .484 .029 .869 .578nn o.001 .710nn o.001
.372n .030 .428n .012 .215 .223 .338 .050 .215 .221 .204 .248 .440nn .009 .211 .231 .252 .150
.204 .264 .417n .018 .588nn o.001 .413n .019 .428n .014 .098 .595 .598nn o.001 .496nn .004 .329 .066
ADL: Activities of Daily Living. PW: Psychological Well-being. RFriends: Relationships with Friends. RFamily: Relationships with Family. RHS: Relationship with Healthcare System. SSL: Sentimental and Sexual Life. r: Pearson Correlation Coefficient. p: Significance (2-tailed). n
Correlation is significant at the 0.05 level (2-tailed). Correlation is significant at the 0.01 level (2-tailed).
nn
strategies, confrontive coping (r ¼ .407, p¼ .017), self-controlling (r ¼.373, p ¼.030), accepting responsibility (r ¼.378, p ¼.028), and escape avoidance (r ¼.530, p ¼.001). Finally, fatigue was significantly correlated with self-controlling coping strategies (r ¼.381, p ¼.026), and escape avoidance (r ¼.401, p ¼.019) (refer to Table 6). Negative correlations were found between QoL and 3 coping strategies which are self-controlling (r ¼ .427, p ¼.012), accepting responsibility (r ¼ .346, p¼ .045), and escape avoidance (r ¼ .609, po .001). The coping dimension of QoL was negatively correlated with 3 of the coping strategies including accepting responsibility (r ¼ .388, p ¼.024), escape avoidance (r ¼ .519, p¼ .002), and confrontive coping (r ¼ .364, p ¼.034). Activities of daily living on the other hand was negatively correlated with 4 coping strategies which are confrontive coping (r ¼ .395, p¼ .021), self-controlling (r ¼ .357, p ¼.038), accepting responsibility (r ¼ .384, p ¼.025), and escape avoidance (r ¼ .414, p¼ .015). Finally, psychological wellbeing was negatively correlated with confrontive coping (r ¼ .354, p ¼.040), accepting responsibility (r¼ .352, p ¼.041), and escape avoidance (r ¼ .575, po .001) (refer to Table 7).
p
4. Discussion
44.000 46.500 60.000 33.500
.030n .038n .158 .011nn
The present study is the first to explore the relationship between different coping strategies and QoL in Lebanese MS patients. The secondary objectives included studying the association between these coping strategies and depression, anxiety, and fatigue. In addition, the role of received social support in relation to QoL and coping strategies was further investigated. Our findings demonstrated that MS patients used emotion
N. Farran et al. / Multiple Sclerosis and Related Disorders 6 (2016) 21–27
25
Table 6 Pearson correlations between coping strategies and depression, anxiety, fatigue and social support (N ¼ 34). Coping strategies
Depression
r p Anxiety r p Fatigue r p Social support r p
Confrontive coping
Distancing Self-controlling Seeking social support
Accepting responsibility
Escape avoidance
Planful problem solving
Positive reappraisal
.261 .137 .407n .017 .149 .401 .012 .948
.016 .927 .010 .956 .011 .952 .057 .755
.361n .036 .378n .028 .143 .421 .179 .328
.534nn .001 .530nn .001 .401n .019 .327 .067
.017 .922 .110 .535 .183 .299 .220 .227
.003 .989 .004 .983 .316 .068 .086 .640
.330 .057 .373n .030 .381n .026 .038 .838
.062 .726 .097 .587 .156 .379 .267 .140
ADL: Activities of Daily Living. PW: Psychological Well-being. RFriends: Relationships with Friends. RFamily: Relationships with Family. RHS: Relationship with Healthcare System. SSL: Sentimental and Sexual Life. r: Pearson correlation coefficient. p: Significance (2-tailed). n
Correlation is significant at the 0.05 level (2-tailed). Correlation is significant at the 0.01 level (2-tailed).
nn
focused strategies more often than problem focused ones. Those using the negative coping strategies; as opposed to the positive ones, had lower QoL scores and social support. This group also showed higher depression and anxiety levels. Furthermore, individual coping strategies had different relations with QoL overall, the dimensions of QoL, depression, anxiety, fatigue, and social support. Specifically, escape-avoidance coping strategy had the
highest negative association with QoL overall and with four of its dimensions, namely, activities of daily living, psychological wellbeing, coping, and rejection. Received social support on the other hand had a positive association with QoL overall and on five of its dimensions which are psychological wellbeing, relationships with friends and family, symptoms, sentimental and sexual life, and coping.
Table 7 Pearson Correlations Between Coping Strategies, Quality of Life and Different Categories of Quality of Life (N ¼34). Coping strategies
QoL
r p
QoL categories ADL r p PW r p RFriends r p Symptoms r p RFamily r p RHS r p SSL r p Coping r p Rejection r p
Confrontive coping
Distancing Self-controlling Seeking social support
.292 .094
.200 .257
.427n .012
.395n .021 .354n .040 .240 .171 .248 .158 .024 .895 .031 .863 .003 .987 .364n .034 .403n .018
.099 .579 .082 .645 .010 .954 .075 .674 .363n .035 .114 .520 .007 .966 .049 .785 .209 .235
.357n .038 .292 .093 .077 .664 .302 .082 .255 .146 .084 .637 .176 .318 .305 .080 .320 .065
ADL: Activities of Daily Living. PW: Psychological Well-being. RFriends: Relationships with Friends. RFamily: Relationships with Family. RHS: Relationship with Healthcare System. SSL: Sentimental and Sexual Life. r: Pearson correlation coefficient. p: Significance (2-tailed). n
Correlation is significant at the 0.05 level (2-tailed). Correlation is significant at the 0.01 level (2-tailed).
nn
Accepting responsibility
Escape avoidance
Planful problem solving
Positive reappraisal
.023 .898
.346n .045
.609nn o.001
.056 .754
.080 .653
.016 .929 .029 .872 .063 .721 .058 .747 .084 .638 .208 .238 .061 .732 .067 .706 .089 .617
.384n .025 .352n .041 .091 .607 .207 .241 .140 .430 .098 .583 .012 .946 .388n .024 .256 .143
.414n .015 .575nn o.001 .221 .210 .295 .090 .310 .074 .001 .997 .228 .195 .519nn .002 .518nn .002
.197 .264 .099 .578 .387n .024 .214 .224 .116 .513 .024 .893 .015 .933 .115 .518 .242 .167
.070 .692 .013 .941 .123 .487 .001 .995 .048 .788 .122 .493 .284 .103 .102 .564 .099 .576
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The association of negative coping strategies with poor QoL is in line with the literature (Brajkovic et al., 2009; Goretti et al., 2009; McCabe and McKern, 2002). Although different scales for investigating coping strategies in MS patients were previously used (Brajkovic et al., 2009; Montel and Bungener, 2007), common negative coping strategies associated with poor QoL may be identified such as self-controlling (Montel and Bungener, 2007) and acceptance (Brajkovic et al., 2009). Escape avoidance as a maladaptive coping mechanism is widely recognized (Folkman, 2013), and its negative impact on the QoL of PwMS has been reported previously (Brajkovic et al., 2009; Goretti et al., 2009; McCabe and McKern, 2002). This coping strategy involves one's disengaging attempts or staying away from a stressful situation and its behavioral and cognitive/emotional consequences. Common mechanisms for escape avoidance coping are denial, wishful thinking, avoidant actions, and cognitive avoidance. These mechanisms are associated with several clinical features such as fatigue, psychiatric comorbidity, and psychosocial problems (Folkman, 2013). Indeed, denial was previously reported as a predictor of anxiety in PwMS (Brajkovic et al., 2009). In our sample, escape avoidance was associated with anxiety in addition to depression and fatigue. This coping mechanism requires enormous time, effort, and energy which may lead to impairments in functioning and exacerbate anxiety and depression symptoms (Kashdan et al., 2006). Nevertheless, the relationship between these constructs in PwMS and with the disease is still poorly understood. Future studies are warranted to investigate how escape avoidance may mediate the relationship of depression, anxiety, fatigue and QoL in MS patients. Another important factor influencing QoL and coping strategies used in PwMS is social support (Brajkovic et al., 2009; Goretti et al., 2009; McCabe and McKern, 2002). However, to our knowledge, the current study is the first to assess received social support in relation to the coping strategies used. In our sample, MS patients with lower social support resorted to the negative coping strategies more often and had lower overall QoL scores. On the other hand, social support was positively associated with the coping and psychological wellbeing dimensions of QoL. In line with this, one study conducted in the same region indicated that received social support and satisfaction with this social support is an important predictor of QoL in PwMS (Yamout et al., 2013). It should be noted however that the scale used to assess social support in the latter study was a 2-item summary of 2 scales; the SSQT (Social Support Questionnaire for Transactions) and the SSQS (Social Support Questionnaire for Satisfaction), whereas a 24 item SPS was used in our study. While the authors of the study by Yamout et al. (2013) have attributed this prediction to the quality of social support in the patients who lived in urban areas (Yamout et al., 2013), we believe that in addition to that, the social construct of Lebanon plays a key role. Lebanon is considered a collectivistic culture (Rego and Cunha, 2009), where psychological wellbeing is highly associated with family functioning (Kazarian, 2005). Social support is one of the most effective means by which people cope with stressful events and it plays a key role in collectivistic cultures. This includes reaching out to family, friends, coworkers and forming community ties (Kim et al., 2008). Indeed, received social support in our sample of PwMS was positively associated with all psychosocial domains of QoL. However, after controlling for social support in our study, the relationships between self-controlling and escape avoidance coping strategies and QoL remained significant, albeit weaker for the latter. This indicates that social support is not the only mediator of QoL in PwMS. Future studies should investigate other possible mediating factors related to coping strategies such as resilience and hope (Tugade et al., 2004).
5. Conclusions Which coping strategies are used depends on environmental and other factors (Folkman, 2013). Constant stressors present in in developing countries such as poor health care delivery, low income, economic and political instability lead individuals to resort to emotion focused coping strategies including the negative ones such as escape avoidance (Brantley et al., 2002; Kimhi et al., 2010). Comprehensive assessment of MS patients comprising mood status and coping strategies is important. Clinical applications include therapeutic interventions which alleviate symptoms of depression, anxiety and fatigue, and enhance the practice of adaptive coping strategies. This comprises the focus on social support while decreasing the use of maladaptive strategies such as escape-avoidance. Taken together, these interventions may enhance the QoL of MS patients. Future studies are needed to better understand the relationships between these constructs and others in PwMS and to further investigate the profile of coping strategies and their effects in various environments.
Conflict of Interest The authors declare no conflict of interest.
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