Coping with Stress among
Middle-Aged and
Older Women and Men with
Arthritis
Yoshi Iwasaki, Ph.D.
Janice Butcher, Ph.D.
Faculty
of
Physical Education and Recreation Studies
Health, Leisure & Human Performance Research Institute
102 Frank Kennedy Centre
Fax: (204) 474-7634
Email:
iwasakiy@ms.umanitoba.ca
Citation:
Iwasaki Y. &
Butcher J.
(2004) Common Stress-Coping Methods Shared by Older Women
and Men with Arthritis. International
Journal of Psychosocial Rehabilitation. 8, 179-208
The study was supported by the Government of
Canada,
Social Sciences and Humanities Research Council of Canada (SSHRC),
Strategic
Program, Research Development Initiative (RDI) Grants
Abstract
Arthritis is considered a stressful, chronic
illness,
highly prevalent in our society. Because of chronic, multiple
challenges or
stressors that people with arthritis experience, the use of
stress-coping strategies
may be important for counteracting the negative impact of stress among
these
individuals. The purpose of the present study was to examine the ways
in which
middle-aged and older women and men with arthritis cope with stress,
including
the potential contribution of leisure to stress-coping. To provide a
context
for this examination, their meanings and sources of stress were
identified, as
well. This exploratory study used a series of focus groups segmented by
gender.
The focus group data suggested the prevalence of stress in
participants’ lives,
and living with arthritis was considered a major source of stress,
particularly
combined with the aging process. Specific common themes of
stress-coping
strategies identified include: (a) keeping active and busy, (b)
exercise/physical activity, (c) educational—gaining knowledge about
arthritis,
(d) socialization/social support/friendship, (e) spiritual coping, (f)
acceptance—acknowledging stress, (g) helping others—altruistic
benefits, and (h) leisure as a means of coping with stress.
Also,
identified were two overarching themes of stress-coping strategies that
cut
across or tie the above eight specific themes together to broadly and
holistically conceptualize core meanings of stress-coping for
middle-aged and
older women and men with arthritis—(1) leading an active life, and (2)
taking
control of one’s life. Furthermore, the present study suggested some
gender
differences in stress-coping strategies. Implications of the findings
are
discussed with respect to the need for multi-dimensional and
comprehensive,
behavioral and psychosocial interventions for this population group.
Introduction
Arthritis is a major health and psycho-social problem in contemporary
society.
In the
Arthritis is considered a stressful chronic illness (Melanson & Downe-Wamboldt, 2003). It is known that the persistent pain, joint stiffness, and joint damage of arthritis not only produce substantial physical disability, but also negatively influence numerous aspects of individuals’ lives, including functional ability, work, family and social relationships, and psychological status (Escalante & del Rincon, 1999; Yelin & Callahan, 1995; Katz, 1998), as well as lost or reduced independence, uncertainly, and role changes (Melanson & Downe-Wamboldt, 2003). It is also known that the economic burden for individuals with arthritis is significant. For example, Doherty, Brandt, and Lohmander (1998) found that persons with rheumatoid arthritis (RA) suffer from a 50 % drop in their income over a 9-year period. Furthermore, it has been shown that living with arthritis is associated with decreased quality of life (Nadal, 2001).
Huyser and Parker (1998) provided an integrative review on stress and RA. They identified three major factors relevant to the relationship between stress and RA: (a) physiological (stress-related physiological systems that are activated in demanding situations; e.g., immune systems), (b) environmental (situational factors that function as stressors or negative life events such as financial and interpersonal problems), and (c) psychological (individual characteristics such as how persons appraise stressors). They demonstrated the multifaceted nature of stress that individuals with arthritis encounter or experience in their lives.
According to Katz (1998), major stressors that arthritis sufferers typically experience include: pain, fatigue, changes in physical appearance, unpredictability of symptoms, burden of taking care of the disease, medication side effects, and functional impairment. Recently, in their study of older women with RA and OA, Zautra and Smith (2001) found that depressive symptoms were significantly related to weekly elevations in arthritis pain, negative events, perceived stress, and negative affect for RA patients, and to elevations in arthritis pain and negative affect for OA patients.
Because of chronic, multiple challenges or stressors that people with arthritis experience, the use of effective stress-coping strategies may be important for counteracting the negative impact of stress among these individuals (Smith, Wallston, Dwyer, 2003). Supporting this notion, in their longitudinal study, Evers, Kraaimaat, Geenen, Jacobs, and Bijlsma (2003) found that disease activity in early RA at the three- and five-year follow-ups was significantly predicted by coping and social support at the time of diagnosis after adjusting for disease activity at first assessment, other biomedical and psychosocial factors, and use of medication.
An examination of coping strategies that people with arthritis use to deal with stress has significant implications (Melanson & Downe-Wamboldt, 2003). Aside from its contribution to theoretical advancements, an understanding of the ways in which people with arthritis cope with stress is essential for developing policies and programs to deal with the sources of stress in their lives, and to establish an effective support system to proactively counteract the negative impact of stress on their health. Particularly, an increasing recognition of the behavioral and psycho-social impact of arthritis has led to a growing awareness for the need to incorporate behavioral and psycho-social intervention approaches into biomedical treatment for managing arthritis (Simon et al., 2002). In their discussion of recent advances and future directions in the biopsychosocial assessment and treatment of arthritis, Keefe et al. (2002) emphasized,
“Coping is a topic that is
clearly receiving growing
attention from arthritis researchers. Perhaps the major reason for this
is that
data gathered on coping may have important implications for the
prevention and
treatment of arthritis pain and disability. Many of the psychosocial
interventions now being used for persons with arthritis are designed to
modify
coping strategies initially identified as important in the arthritis
coping
research literature” (p. 646).
Despite the growth of research on stress, coping, and arthritis, a very limited attention has been given to the potential role of leisure as a stress-coping resource or strategy. Advocating the importance of positive events including leisure as a means of coping with stress, Folkman and Moskowitz (2000a) argued, “historically, coping has most often been evaluated in relation to its effectiveness in regulating distress… What has been underrepresented in coping research is an approach that looks at the other side of the coin, an approach that examines positive affect in the stress process” (p. 647). Research needs to be carried out to understand “the coping processes that people use to generate positive affect in the midst of stress” (Folkman & Moskowitz, 2000a, p. 652). The experience of positive events (e.g., getting together with friends) also potentially helps to generate positive meaning in the midst of stress (Folkman & Moskowitz, 2000a). One of the important sources that contribute to generating positive affect (including enjoyment, happiness, and hope) and meaning (e.g., assuring preciousness of life), while people with arthritis experience stress, appears to be enjoyable and meaningful leisure pursuits. In fact, leisure, stress, and coping research represents an evolving and maturing area of inquiry in the leisure research field (see a special issue of Leisure Sciences on leisure, stress, and coping, edited by Iwasaki and Schneider, 2003).
The purpose of the present study was to examine the ways in which middle-aged and older women and men with arthritis cope with stress, including a specific attention being given to the potential contribution of leisure to stress-coping. To provide a context for this examination, their meanings and sources of stress were identified, as well. As an exploratory study, a series of focus groups was conducted to gain an understanding of stress-coping strategies from the perspectives of participants themselves. The use of qualitative methodologies such as focus groups, interviews, or case studies has important implications for advancing an understanding of the ways in which persons with arthritis cope with stress. However, in comparison to the popularity of quantitative methods, very little attempt has been made to employ qualitative methods in arthritis and coping research (Turner, Barlow, & Ilbery, 2002). Discussing future directions in arthritis research, Keefe et al. (2002) suggested that although qualitative methodologies are demanding and time-consuming, “this type of research can potentially lead to new insights into the nature and process of coping” for people with arthritis (p. 646). The present study focused on examining middle-aged and older persons since, as noted earlier, arthritis is substantially more prevalent among older than among younger individuals. Due to the course and prevalence of the disease and all the other losses associated with the aging process, it is very common that older persons with arthritis often feel helpless and ultimately depressed (Nadal, 2001).
Another important concept that should be given attention in arthritis and stress-coping research is gender. It seems inappropriate to assume that effective ways of coping with stress are identical for women and men with arthritis. There appear to be gender differences not only in the experience of pain, disability, and mood, but also in the use of particular coping strategies. For example, Keefe, Lefebvre, Egert et al.’s (2000) findings highlight the salience of gender in understanding pain and disability associated with OA—women experienced significantly greater levels of pain and physical disability and showed more pain behavior than did men. In their several daily-diary studies of people with arthritis, Keefe, Affleck, and colleagues (Affleck et al., 1999; Keefe et al., 2001) found that the average daily pain of women was 72 % greater than for men, and that women used more emotion-focused coping (e.g., venting emotions, seeking spiritual comfort) than did men, while men showed a significantly greater increase in negative mood the day after a day of high pain than did women. McEwen and Stellar (1993) suggested that gender may interact with situational factors such as controllability to produce significantly different responses to stress. Recently, in her study of RA inpatients, Knotek (2001) found that the increase of anxiety, anger, and depressive symptoms associated with the lasting effect of pain feeling was steeper for older (rather than younger) patients and for female (as opposed to male) patients. She also found that fatigue, worry, and relationship stress in home and family settings grew with the duration of pain, but more for female patients than for male counterparts. Furthermore, according to Turner et al. (2002), not only is the use of qualitative methods in arthritis and coping research rare, but also qualitative research on persons with arthritis focuses mainly on the experiences of women—“no studies have focused solely on the experience of men living with OA” (p. 285). Turner et al.’s point justifies the need for conducting a qualitative study focusing on both females and males with arthritis. Although there appear to be common stressors (such as illness-specific stressors) experienced by women and men with arthritis, differences in socialization processes, expectations, and social roles between women and men may play a role in explaining gender differences in the meanings and sources of stress and the ways in which women and men with arthritis cope with stress. Consequently, in the present study, the composition of focus groups was based on gender of participants to allow for gender-based analysis.
It
is
increasingly recognized that stress and coping with stress are
important
concepts in understanding how persons deal with or adjust to arthritis.
Stress
is often considered a primary cause of disease flares for persons with
arthritis (Affleck, Pfeiffer, Tennen,
& Fifield, 1987; Keefe et al., 2002).
It has been found that
stress has a significant relationship with disease activity for
arthritis
patients. For example, in their longitudinal study of 100 RA patients,
90 OA
patients, and 90 healthy controls, Zautra,
To deal with this disease, it has been suggested that individuals living with arthritis use various coping strategies. Pain-specific coping questionnaires have been developed to assess multiple facets of pain coping, such as the Vanderbilt Multidimensional Pain Coping Inventory (Smith, Wallston, Dwyer, & Dowdy, 1997). The instrument identifies 11 distinct coping strategies: planful problem solving, positive reappraisal, distraction, confrontative coping, distancing or denial, stoicism, use of religion, self-blame, self-isolation, wishful thinking, and disengagement. However, the need to examine stressors other than pain for arthritis patients is increasingly recognized (e.g., Katz, 1998).
It has been shown that the use of social support may be effective in coping with stress among persons with arthritis. For example, Penninx et al (1997) found evidence for the buffering effect of social support—emotional support “mitigated the influence of arthritis on depressive symptoms” (p. 393), while Tak (1998) found that perceived social support significantly predicted life satisfaction of older women with OA. Another key coping resource may be the role of self-efficacy (i.e., confidence in one’s ability to successfully execute and accomplish a given task, Bandura, 1977) in dealing with stress. There is evidence that self-efficacy may function as a mediator or moderator of pain, disability, and psychosocial health status among people with arthritis (e.g., Rhee et al., 2000; Shifren, Park, Bennett, & Morrell, 1999; Miller & Cronan, 1998). Other coping strategies that may be effective in managing stress experienced by people living with arthritis include: (a) problem-focused or confrontive coping (Hermann et al., 2000; Melanson & Downe-Wamboldt, 2003; Katz, 1998), (b) relaxation strategies (Affleck et al., 1999; Keefe et al., 2001), (c) spiritual coping (Keefe et al., 2001), (d) optimism (Affleck, Tennen, & Apter, 2001), (e) positive thinking (Ravicz, 2000), (f) mood-regulation (Hamilton, 2001), and (g) exercise/physical activity (Focht, Ewing, Gauvin, & Rejeski, 2002).
It is important to emphasize that there is evidence to
suggest the
effectiveness of psychosocial or cognitive-behavioral interventions for
arthritis (e.g., Keefe et al., 1990; Keefe,
As noted earlier, qualitative methodologies have rarely been used in arthritis coping research (Keefe et al., 2002). To represent such a rare study, Romer (2000) used a qualitative approach to explore the stress-coping process of older women with OA. Her content analysis suggested that the stressors associated with OA involved a wide range of physical, psychological, and social aspects of life, while pain, disability, and dependence on others were identified as major stressors. The majority of the participants appraised living with OA as stressful in terms of both actual loss and potential loss in the future. Consequently, living with OA evoked negative emotions such as anger, frustration, discouragement, fear, and helplessness. In order to manage the stressors, the respondents used a variety of problem-focused and emotion-focused (palliative) coping strategies.
Although it has been given only scant attention in arthritis and coping research, the experience of positive and meaningful life events such as leisure pursuits appears to function as a means of coping with stress for persons with arthritis. In their study of individuals with RA and OA, Zautra, Burleson, Matt, Roth, and Burrows (1994) found that persons who experienced greater numbers of positive events felt less depressed than persons who experienced smaller numbers of positive events. Folkman and Moskowitz (2000a) emphasized that meaningful positive events such as leisure may act as “breathers” from stress, “sustainers” of coping effort, and “restorers” for persons who suffer from serious chronic illnesses such as arthritis.
In summary, the current literature suggests that the use of coping strategies seems important for people living with arthritis in effectively managing stress. Although a variety of resources or strategies have been identified or shown to act as a means of coping with stress, it is not entirely clear how or in what ways these individuals deal with stress from their points of views. Better understanding their insights into the specific ways in which they manage stress is essential not only to theoretical development, but also to rehabilitation and intervention purposes. Therefore, it is important to conduct an in-depth study to directly examine how or in what ways people with arthritis cope with stress from their perspectives. Furthermore, given that there has been very limited evidence for the contribution of leisure to stress-coping despite its potential, it is also important to examine such contribution.
In order to explore the meaning and experience involving the use of stress-coping strategies for middle-aged and older women and men with arthritis, the present study adopted a qualitative method. Specifically, this study used focus groups segmented by participants’ gender. It has been shown that focus groups are an effective method to obtain in-depth information about a concept or issue and to describe and explain people’s experiences in practical and efficient ways (Madriz, 2000; Krueger, 1994; Krueger & Casey, 2000). Rather than being predetermined or controlled by hypotheses and existing measures of stress-coping (which are often criticized as based on male normative standards), the use of a qualitative method such as focus groups provides an opportunity to better understand people’s perspectives about their experiences and meanings of stress-coping. Openness and flexibility in discovery expressed by actual words of individuals are strengths of such methods. Furthermore, because focus group discussions bring forward people’s experiences and offer a social context for meaning-making, they more readily allow for an analysis of gender (Madriz, 2000).
As an analytical framework, phenomenology was adopted in this study. A phenomenological perspective focuses on “what people experience and how they interpret the world” (Patton, 1990, p. 70). Also, Schutz (1970) suggested that phenomenology focuses on the ways in which members of society experience everyday lives and “how the social world is made meaningful” (Gubrium & Holstein, 2000, p. 489). In the present exploratory study, the focus was on describing and interpreting the meanings involving the use and experience of stress-coping among middle-aged and older women and men with arthritis and, then, looking at similarities and differences in their experiences and meanings that could be attributed to gender.
Participants represented a sample of individuals who had attended an arthritis self-management program [2] offered in a western Canadian city. Two approaches were used to recruit participants. First, one research team member (the second author of the paper) attended a meeting of the program, and explained the purpose and procedure of the study both orally and by distributing a handout. Confidentiality and anonymity of information to be collected were explained to potential participants, as well. Those individuals who were interested voluntarily signed up for a focus group session. Second, a list of individuals who had attended the arthritis self-management program was obtained from the program coordinator only for the research purpose. A research assistant called each individual to explain the nature and procedure of the study and ethical issues, and some people voluntarily agreed to participate in a focus group session. The criteria for being participants included: (a) individuals had been diagnosed to have some form of arthritis, and (b) the individuals were 40 years of age or above. [3}Attention was also paid to ensuring that both women and men were recruited to participate. Twenty-six individuals who met the above criteria and agreed to participate engaged in one of the three focus groups: (a) women only group (9 women), (b) men only group (7 men), and (c) mixed gender group (5 women and 5 men).
Each focus group session took place at a focus group facility of a local research firm. An experienced professional moderator facilitated all of the focus groups. The moderator followed a focus group questioning route (Krueger & Casey, 2000) developed by the research team and guided by the research objectives. The questioning route outlined opening comments about the topic of stress, introductory questions to engage the participants in the topic, transition questions related to evaluations of stress, key questions on the causes of stress and coping strategies, and ending questions to summarize the discussions and confirm main points (see Table 1). At the conclusion of each focus group, the participants completed an exit questionnaire to provide socio-demographic background information. They were thanked for their time and contribution to the focus group and each was given a $50 honorarium. Each focus group lasted about 90 minutes as planned. The research assistant transcribed verbatim the conversations of the focus groups. For the mixed gender group, the voices of females were noted as (f), and the voices of males were identified as (m) in the transcriptions.
Table 1. Outline of focus group questioning route and protocol |
Opening CommentsWelcome and statements regarding the purpose of the study, focus group procedures, and ethical issues. Opening QuestionPlease tell us a little bit about yourself. Introductory QuestionStress is something you hear a lot about these days because many people feel stressed. When thinking about your daily life, what does stress mean to you? Transition QuestionsIs stress a negative factor in your life? If so explain how it is negative. Is stress a positive factor in your life? If so in what ways it is positive. Sub-probe: What is it about stress that makes it good or bad? Key QuestionsWhat are the things that make you stressed? Sub-probe: (a) Would you say it is primarily one thing that causes you stress or is it a number of different things added together? (b) What about any health concerns you may have? (c) Anything else that makes you feel stressed? What are the ways or things that you do or use to help you deal with stress in your daily life? Sub-probe: (a) What are your typical ways of coping with stress in your life? (b) What role, if any, does leisure play in helping you deal with stress? (c) Would your thoughts change if you were thinking about vacations and/or holidays (alone and/or with other people)? Ending QuestionsAll things considered, what would you say is the major cause of stress in your life? Of all the ways of dealing with stress that we’ve talked about tonight, which have you found to be most useful or effective in your life? |
Data Analysis Procedure
Phenomenological data analysis was conducted. The principal researcher (i.e., the first author of this paper) and the other researcher (i.e., the second author of the paper) individually identified statements, separately for women and men with arthritis, and listed every significant statement relevant to the phenomenon (i.e., “horizonalization” of the data). Each statement was treated as having equal value (Moustakas, 1994). In the next step, these statements were then grouped or clustered into themes or meaning units, separately for women and men, by removing repetitive and overlapping statements (Creswell, 1998). These meaning units were formulated by reflectively reading and re-reading the full transcripts to ensure that the significant statements were consistent with the original context. The researchers individually engaged in this process to assess whether anything was not accounted for in the clusters of common themes, and to ensure that the proposed clusters did not include interpretations that exceeded the original context of the data (Riemen, 1986). This process resulted in a refinement of the theme clusters, which were then referred back to the original descriptions for further validation.
The principal researcher carefully reviewed the common theme clusters and summary statements that were individually developed in the previous steps. Consistencies between the two researchers’ analyses were retained as overall themes. The principal researcher dealt with divergent analytical aspects by either incorporating some of them into similar themes, or identifying the others as new themes. As a result of this process, the principal researcher constructed an overall and integrated description of the essences (or “essentials”) of the phenomenon, separately for women and men. This synthesis contained the “bones” of the phenomenon (Patton, 1990).
As a final check on the analyses, the two researchers communicated to confirm that the analysis was appropriately carried out and that the results were consistent with and accurately reflected the focus group data, as well as made a final revision on overall and integrated descriptions of the phenomenon. Finally, the participants were sent a summary of the analyses for their assessment. Those participants who returned their evaluation forms (sixteen, 61.5 %, of the 26 participants) unanimously verified that the descriptions were consistent with the views they expressed during the focus groups and their perspectives on stress and stress-coping.
A record of responses to the
participant
exit questionnaire is presented in Table 2 for each of the three
groups: female
only, male only, and mixed-gender groups.
Table 2 is
provided for descriptive and background purposes only. Participants
ranged in
age from 42 to 78 (mean = 64.2). Of the seven participants who
completed a
university degree, six were males. Nineteen (73 %) of the twenty-six
participants
were retired. Of the seven participants who indicated that their yearly
household income was below $20,000, six were females. Regarding race,
eighteen
(69 %) of the twenty-six participants identified themselves as
Caucasian. As
for the type of arthritis, seventeen participants (65 %) were diagnosed
to have
osteoarthritis (OA), while seven participants (27 %) had rheumatoid
arthritis
(RA). One participant was diagnosed to have both OA and RA, and one
person did
not indicate the type of arthritis. The participants represented a wide
range
of time of been diagnosed with arthritis (from
|
|
Female Only Group |
Male Only Group |
Mixed Gender Group |
|
|
|
|
|
Females |
Males |
|
Age: 40-44 |
0 |
0 |
1 |
1 |
|
45-49 |
1 |
0 |
0 |
0 |
|
50-54 |
1 |
0 |
0 |
0 |
|
55-59 |
1 |
2 |
0 |
1 |
|
60-64 |
2 |
0 |
1 |
0 |
|
65-69 |
0 |
3 |
3 |
1 |
|
70-74 |
3 |
2 |
0 |
1 |
|
75-79 |
1 |
0 |
0 |
1 |
|
|
|
|
|
|
|
Highest Level of
Education: |
|
|
|
|
|
Graduate
degree |
0 |
1 |
0 |
0 |
|
Bachelor
degree |
1 |
2 |
0 |
3 |
|
Some
degree (R.N., R.I.A.) |
1 |
2 |
1 |
1 |
|
Business/trade
certificate |
0 |
1 |
1 |
0 |
|
Teaching
certificate |
0 |
0 |
1 |
0 |
|
Grade
12 & some post-secondary education |
0 |
0 |
1 |
0 |
|
Grade
12 |
4 |
1 |
0 |
1 |
|
Less
than grade 12 |
3 |
0 |
1 |
0 |
|
|
|
|
|
|
|
Marital Status: |
|
|
|
|
|
Married |
3 |
5 |
2 |
4 |
|
Single |
1 |
0 |
1 |
0 |
|
Divorced
or separated |
1 |
2 |
2 |
1 |
|
Widowed |
4 |
0 |
0 |
0 |
|
|
|
|
|
|
|
Occupational Status: |
|
|
|
|
|
Retired |
6 |
6 |
4 |
3 |
|
Unemployed |
0 |
1 |
0 |
0 |
|
Household
worker |
1 |
0 |
0 |
0 |
|
Employed,
full-time (35 hrs or more/wk) |
2 |
0 |
0 |
2 |
|
Employed,
casually (less than 10 hrs/wk) |
0 |
0 |
1 |
0 |