ARTICLE
Auteur(s) : AK
Wahl1,2, C Mørk2, BR
Hanestad1, S Helland3
1Department of Public Health and Primary Health Care,
University of Bergen
2Department of Dermatology, Rikshospitalet University
Hospital
3Department of Dermatology, Haukeland University
Hospital, Norway
accepté le 11 Janvier 2006
Chronic dermatological diseases, such as psoriasis and eczema, can
make demands on patients which may exhaust their ability to cope
and lead to significant social impairment and psychological
morbidity. This is especially the case in times of exacerbation of
the disease [1-3]. Studies show that psychological factors play an
important role in at least 30% of skin diseases. In many cases, the
influence of the disease on quality of life is a stronger predictor
for psychiatric morbidity than the degree of affection determined
by the doctor [4]. One, among other explanations for this, may be
found to be related to the individual’s ability to cope and the
strategies used.‘Coping’ is commonly regarded as a cognitive and
behavioural attempt to deal with, reduce or tolerate external
and/or internal demands that are experienced as being beyond the
person’s resources [5].Coping is thereby linked to the use of
different strategies and is an important mediating factor in terms
of how the person adapts to the realities of the illness. It is not
clear, however, which of the coping strategies or modes used to
cope are the most effective. What is good and bad must be seen in
the light of the situation in which problems occur [5].There have
been few studies carried out in relation to coping by patients with
chronic skin diseases. Most of the studies performed have evaluated
coping with chronic dermatological diseases in general without
focusing on specifically stressing clinical settings, such as
exacerbation of disease symptoms. It has previously been reported
that strategies of the optimistic and control type were most often
used to deal with stress and problems related to daily living and
functioning with psoriasis [6]. Studies have shown that people with
psoriasis using emotional coping reported greater disability,
poorer mental health and quality of life [7].However, to our
knowledge, no studies have evaluated and compared coping during
exacerbation of the disease in the period prior to admission to the
dermatology ward in persons with psoriasis and chronic eczema. The
purpose of this article is to look further into this matter. We
attempt to answer the following questions:
- – Which coping strategies are used before admission to
the dermatology ward?
- – Are there differences in the use of coping strategies
between the various diagnosed groups?
- – Are there differences in the use of coping strategies
between the sexes?
- – What relationship is there between age and duration of
illness and the use of coping strategies?
- – What relationship is there between the use of coping
strategies and the experience of difficulties linked to living and
functioning with the skin disease?
- – Is there a relationship between coping strategy and
quality of life?
Material and methods
Design
Data were gathered with a survey form filled in upon admission to
the dermatology ward.
Subjects
The present paper is based on subjects with psoriasis and chronic
eczema who were admitted over a period of one year to the
dermatology ward at the five Norwegian regional hospitals with
dermatological departments. The patients concerned were chosen and
asked to participate by the nurse heading the project, and doctors
responsible for the patients. All included patients gave written
informed consent. The study was authorized by the Norwegian Social
Science Data Archives and the Regional Committee for Medical Ethics
– region II provided ethical approval for the study.
Instruments
Coping
The Jalowiec Coping Scale (JCS) was applied to measure the use of
coping strategies. This questionnaire contains 60 different coping
strategies that are combined under the following eight different
categories: confrontational (tried to change the situation),
evasive (put off facing up to the problem), optimistic (tried to
think positively), fatalistic (accepted the situation because very
little could be done), emotional (worried about the problem),
palliative (tried to keep busy and work harder), supportive
(depended on others to help you out) and belief-in-oneself
(preferred to work things out yourself).
The patients were asked about the coping strategies they used to
face their disease during the last weeks before admission in a
dermatology ward, and to determine and indicate how much they used
each coping strategy in terms of skin disease-related problems on a
scale rating from 0-3, where 0 indicates non-use and 3 frequent use
[8]. In this study, it was decided to use relative scores to
illustrate the use of coping, i.e. the average score for each
coping category is divided by the average score for all of the
categories. Relative scores have the advantage that they compensate
for discrepancies in numbers of questions in each scale as well as
for individual differences in responses. Relative scores,
therefore, indicate how much of a person’s coping can be related to
the individual coping category. JCS has been translated into
Norwegian and has been previously used in Norwegian psoriasis
patients [6, 7].
Quality of life
Quality of life is measured by aid of the Norwegian version of the
Dermatologic Life Quality Index (DLQI-N) [9]. The form was
originally developed by Finlay and is now used internationally in
many studies [10]. DLQI-N comprises ten questions that concern
dermatologic symptoms, one’s personal perceptions of the skin,
restriction of skin afflictions and treatment in order to function
daily. Alternative responses that may be chosen for each individual
question span from 0 (not at all) to 3 (significantly) and these
are added together to yield a total score (0-30), wherein the
higher values indicate poorer quality of life.
The perception of living with the disease
This was assessed by posing a single-item question about whether
the patients find it difficult to live with psoriasis or eczema.
The question contains six alternative responses (1. Yes, I feel it
is a burden; 2. Yes, I think about it a lot; 3. Yes, sometimes; 4.
No, rarely; 5. No, I hardly ever think about it; and 6. I feel
exactly the same as people who do not suffer from psoriasis or
eczema).
Socio-demographic and clinical variables
Socio-demographic (questions on patient background, such as age,
sex, civil status and education, work), and clinical data were
recorded.
Statistical analysis
SPSS version 11 is used as an analysis programme in this study.
Descriptive data are used to describe the use of coping strategies.
In terms of the differences and relationships between
socio-demographic factors, disease groups and perception of
difficulties resulting from the disease, as well as coping, cross
tabs with chi square, independent t-test, one-way ANOVA and
correlation (Pearson’s r) analyses were used. Correlation analysis
(Pearson’s r) was used to examine the relationship between various
coping strategies and quality of life, and the perception of living
with the disease.
Results
Participants’ characteristics
In total 212 patients with a dermatologist-confirmed diagnosis of
psoriasis (n = 146) and chronic eczema (n = 66) (108 men and 104
women; mean ± SD age 48 ± 16.7 years) were recruited to the study.
47% were married and 80% of the respondents had an education level
up to and including secondary school. 43% report not been admitted
to the dermatology ward within the past two years, while 23% have
been admitted once, and 18% twice. For further information about
the different disease groups, see (Table
1). There were no statistical significant differences
between the disease groups with regard to background variables,
except for age. The eczema group was younger than the psoriasis
group (p = 0.023).
Table 1 Characteristics of the psoriasis and the eczema
samples
|
Psoriasis (n = 146)
|
Eczema (n = 66)
|
P values for differences
|
|
Gender (n)
|
|
|
|
|
Male
|
69
|
38
|
.178
|
|
Female
|
76
|
28
|
|
|
Age mean (SD) years
|
49.5 (15.6)
|
43.8 (18.2)
|
.023
|
|
Education
|
|
|
|
|
Primary school
|
57
|
16
|
.225
|
|
Secondary school
|
60
|
34
|
|
|
University /college < 4 years
|
19
|
9
|
|
|
University/college > 4 years
|
8
|
5
|
|
|
Marital status
|
|
|
|
|
Married
|
70
|
28
|
.770
|
|
Not married
|
4
|
23
|
|
|
Divorced
|
22
|
9
|
|
|
Widowed
|
10
|
3
|
|
|
Length of disorder mean (SD) years
|
19.1 (14.3)
|
22.0 (15.9)
|
.200
|
|
Number of admissions during the last two years mean (SD)
|
1.3 (1.7)
|
1.3 (1.4)
|
.844
|
Use of coping strategies
The results indicate that the optimistic, belief-in-oneself and
confrontational strategies are most frequently used among patients
who are admitted to the dermatology ward for treatment of chronic
dermatologic diseases. The coping strategies used least are of the
emotional and fatalistic type (Table
2).
Table 2 Use of coping strategies, quality of life and
perception of living with disease (mean, SD, and p values for
differences between groups)
|
Psoriasis
|
Eczema
|
|
|
Mean (SD)
|
Mean (SD)
|
P values for differences
|
|
Coping strategies
|
|
|
|
|
Confrontational
|
0.14 (0.04)
|
0.13 (0.03)
|
.37
|
|
Evasive
|
0.13 (0.03)
|
0.12 (0.03)
|
.30
|
|
Optimistic
|
0.18 (0.04)
|
0.18 (0.12)
|
.89
|
|
Fatalistic
|
0.11 (0.05)
|
0.10 (0.04)
|
.37
|
|
Palliative
|
0.10 (0.03)
|
0.11 (0.03)
|
.87
|
|
Supportive
|
0.11 (0.04)
|
0.10 (0.04)
|
.79
|
|
Belief-in-oneself
|
0.15 (0.03)
|
0.15 (0.03)
|
.81
|
|
Emotional
|
0.08 (0.04)
|
0.10 (0.04)
|
.02
|
|
Quality of Life
|
19.2 (7.3)
|
19.9 (5.9)
|
.56
|
|
Perception of living with disease
|
1.8 (1.2)
|
1.7 (1.0)
|
.37
|
Differences in use of coping strategies
On examining the differences between the diagnosed groups we show
that the eczema group used the emotional coping strategy
significantly more often than the psoriasis group (p < 0.05).
There was no significant difference between the groups in terms of
use of the other coping modes. The results also indicate
significant differences between the sexes and age in relation to
the use of emotional coping strategies. Women use this type of
strategy significantly more often than men do (p < 0.01).
Younger people also use emotional coping more often than older
people (r = – .23: p < 0.01). Duration of illness is
significantly related to supportive coping strategy and
belief-in-oneself coping strategies. The longer one has had the
disease, the more often one uses the belief-in-oneself mode (r =
.26: p < 0.01). The opposite relationship is seen in terms of
supportive coping strategies. The shorter the length of illness,
the more often supportive strategies are used (r = – .25; p
< 0.01). Number of admissions shows only a statistical
significant positive correlation with the palliative coping
strategy (r = .18: p < 0.05). Lastly, level of education shows a
statistically significant positive correlation with the
confrontational coping strategy (r = .21: p < 0.01).
Relations between coping and quality of life and the perception
of living with the disease
Analyses indicate that several of the coping strategies are related
to quality of life and the perception of living with the disease
(Table 3).
Those who more often use confrontational (r = – .20: p <
0.05) and optimistic (r = – .30: p < 0.001) modes report
significantly better quality of life. More frequent use of evasive
(r = .18: p < 0.05) and emotional (r = .39: p < 0.001) modes
is related to poorer quality of life.
The same pattern is seen with regard to the relationship between
coping strategies and the perception of living with the disease.
Concerning the relationship between perception of how difficult it
is to live and function with a dermatologic disease and the use of
coping, it is indicated that those who perceive a higher degree of
difficulty in terms of living and functioning with a dermatologic
disease also use fatalistic (r = –.16: p < 0.05) and emotional
(r = – .28: p < 0.001) coping strategies significantly more
often. Those who feel that it is easier to live and function with a
dermatologic disease use confrontational (r = .26: p < 0.01) and
optimistic (r = .16: p < 0.05) coping strategies significantly
more often.
Table 3 Correlation analysis (Pearson’s r) between
coping, quality of life and the perception of living with disease
|
Quality of Life
|
Perception of living with disease
|
|
Coping strategies
|
|
|
|
Confrontational
|
– .20*
|
.26**
|
|
Evasive
|
.18*
|
– .14
|
|
Optimistic
|
– .30***
|
.16*
|
|
Fatalistic
|
.04
|
– .16*
|
|
Palliative
|
.10
|
.01
|
|
Supportive
|
.02
|
.01
|
|
Belief-in-oneself
|
.16
|
– .00
|
|
Emotional
|
.39***
|
– .28***
|
Discussion
This study has focused on how persons with chronic dermatologic
diseases who are admitted to the dermatology ward cope with an
exacerbation of the disease. The results indicate that optimistic,
confrontational and belief-in-oneself strategies are most often
used in the period prior to admission. Furthermore, it is indicated
that emotional strategies are used more by patients with eczema and
by women. Similar findings are reported in other studies. In a
study of 250 patients with psoriasis it was found that acceptation,
planning, active coping and positive thinking were most often used.
Use of alcohol, religion and repression were least used. This study
also showed great similarities in the use of coping strategies
between different diseases. When compared with normal controls,
patients with psoriasis as a whole tended to use significantly less
active coping strategies, planning, positive reinterpretation and
humour. There were marked similarities between the frequency of use
of particular coping strategies in patients with psoriasis and
patients with other medical conditions [11]. It appears that
illness brings with it a generic form of coping that may require
shaping to fit the individual demands of diseases such as
psoriasis.
Another finding in our study is that long illness duration is
related to the more frequent use of strategies of the type
belief-in-oneself and less frequent use of supportive strategies.
We have not found studies that report similar findings related to
chronic dermatological diseases. The fact that people who have
lived and functioned longer with the disease, more often trust
their own evaluation of the situation and use fewer supportive
strategies, may be explained by their having established individual
knowledge concerning the illness, thereby making them less
dependent on support from others to cope with problems related to
the disease.
The results of our study also indicate that the perception of it
being difficult to live and function with a chronic dermatological
disease is related to a more frequent use of emotional strategies.
Use of confrontational strategies is related to better quality of
life and the notion that the illness is easier to live with. Coping
is regarded as an important mediating factor in terms of adapting
to the illness. Concerning chronic illness, several studies show
that more use of active, expressive and optimistic strategies is
related to improved ability to function and better psychological
well-being [12].
Wahl et al. [7] found that patients with psoriasis who used
emotional coping strategies reported more disability, poorer mental
health and worse overall quality of life. Furthermore, patients who
more frequently used normalising/optimistic coping reported higher
levels of mental health. Rapp et al. [13] found in a study of 318
individuals with psoriasis that commonly used coping strategies
such as telling others about psoriasis, covering the lesions and
avoiding people were associated with greater decrements in health
related quality of life after controlling for covariates. How
patients cope with the social aspects of psoriasis is associated
with their quality of life. In a longitudinal study of 69 patients
with psoriasis it was found that that a strong illness identity was
associated with more visits to the outpatient clinic, and worse
outcome on physical health, social functioning, mental health,
health perceptions and depression. Strong beliefs that the disease
is controllable/curable and that the disease has disabling
consequences were also related to more clinic visits and more
negatively perceived health, respectively. Patients who initially
engaged in coping characterized by more expression of emotions,
seeking more social support, seeking more distraction, and less
passive coping were prescribed a lower number of different
therapies, were less anxious, less depressed, and had a better
physical health 1 year later [14].
It is important to have knowledge concerning the use of coping
strategies and quality of life among patients with chronic
dermatological diseases, such as psoriasis and eczema, in order to
integrate psychological interventions and coping techniques into
standard care protocols. Results from a recently published study by
Fortune et al. [15] suggest that while clearance of psoriasis
produces a significant reduction in factors specific to psoriasis
(disability and stress), it does not impact upon psychological
distress, on patients’ beliefs about psoriasis or on coping. This
observation highlights the complex features of patients’
psychological experience of psoriasis and may provide further
impetus for integration of psychological interventions into
standard care protocols.
Conclusion
The present study found that optimistic, belief-in-oneself and
confrontational coping strategies are most frequently used by
subjects with psoriasis and chronic eczema in the period prior to
admission to a dermatological ward. We also found that longer
duration of the disease is related to more frequent use of
belief-in-oneself strategies, while shorter duration is related to
more frequent use of more supportive strategies. Furthermore, more
frequent use of confrontational and optimistic modes is
significantly related to better quality of life. More frequent use
of emotional and evasive modes is significantly related to poorer
quality of life. In general, as for other studies within this
field, our findings highlight the need for integrating
psychological interventions into standard care protocols.
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