The International Journal of Psychosocial Rehabilitation

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

University of Manitoba

Winnipeg, Manitoba

Canada R3T 2N2

 

Phone: (204) 474-8643

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 United States, arthritis is the most common cause of disability (National Center for Chronic Disease Prevention and Health Promotion, 2002). It is estimated that about 60 million Americans (almost 20 % of the population) are affected by arthritis, and that nearly 12 million experience activity limitations due to arthritis (National Center for Chronic Disease Prevention and Health Promotion, 2002). In Canada, Health Canada reported in 1996 that the overall prevalence of arthritis among Canadians was 21.1 % for women and 15.7 % for men (Reynolds, Chambers, Badlet, et al., 1992). Globally, arthritis has a world-wide distribution (Lawrence & Sebo, 1988). The prevalence of arthritis is greater among older individuals. In US, the National Center for Health Statistics reported that in 1997 over 36 % of the elderly aged 65 or above was diagnosed with some form of arthritis, while almost 50 % of people in their 70s and 80s have osteoarthritis (OA) [1](Stein, Griffin, & Brandt, 1996). According to 1996 Health Canada report, the prevalence of arthritis increased from 6.3 % for Canadians aged 16 to 74 to 51.2 % for those aged 75 and over (Reynolds et al., 1992).

 

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).

 

Purpose of Study

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.

 

Coping with Stress for Individuals with Arthritis

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, Hamilton, Potter, and Smith (1999) found that both the RA and OA patients showed greater clinical ratings of disease activity during a week of high stress than during a baseline, low-stress period.

 

            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, Caldwell, et al., 1996; Keefe et al., 1999; Rhee et al., 2000). For example, in Parker et al.’s (1995) study, persons with RA received a comprehensive cognitive-behavioral stress management protocol that incorporated a variety of components such as relaxation training; methods for identifying stressors and life goals; strategies for managing pain, mood, and interpersonal relationships; and specific strategies for managing stressors typical of RA. Recent studies have reported the effectiveness of novel stress management approaches including emotional disclosure (disclosing troubling thoughts and feelings about a traumatic experience; Smyth, Stone, Hurewitz, & Kaell, 1999) and the use of humour or laughter (Nakajima, Hirai, & Yoshino, 1999; Skevington & White, 1998) among arthritis patients.

 

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.

 

Methods

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.

 

Participant Recruitment and Focus Group Procedures

            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 Comments

Welcome and statements regarding the purpose of the study, focus group procedures, and ethical issues.

 

Opening Question

Please tell us a little bit about yourself.

 

Introductory Question

Stress 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 Questions

Is 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 Questions

What 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 Questions

All 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.

 

Results

Focus Group Participants

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 1 to 50 years). The perceived severity of arthritis (on a scale of 1 = mild to 5 = extremely severe) ranged from mild to extremely severe. Twelve (46 %) of the twenty-six participants rated medium severity (= 3), while six of the eight participants who rated 4 or 5 (extremely severe) were females. Perceptions of arthritis-related pain (on a scale of 1 = mild to 5 = extremely severe) ranged from 2 to 5. Of the five participants who rated their perceived pain as “extremely severe,” four were females.

 

Table 2. Summary for socio-demographic characteristics of the participants

 

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

 

 

 

 

 

Yearly Household Income:

 

 

 

 

  Above $100,000

0

2

0

0

  $90,001-100,000

0

0

0

1

  $80,001-90,000

1

0

0

0

  $70,001-80,000

0

1

0

1

  $60,001-70,000

0

0

0

0

  $50,001-60,000

0

2

1

0

  $40,001-50,000

0

0

0

0

  $30,001-40,000

0

1

0

2

  $20,001-30,000

2

1

0

0

  $10,001-20,000

5

0

1

0

  Below $10,000

0

0

0

1

  Missing

1

0

3

0

 

 

 

 

 

Race:

 

 

 

 

  Asian

0

0

0

1

  British

1

0

0

0

  Canadian

2

0

0

1

  Caucasian

4

6

5

3

  English

1

0

0

0

  W.A.S.P.

0

1

0

0

  Missing

1

0

0

0

 

 

 

 

 

Type of Arthritis:

 

 

 

 

  Osteoarthritis (OA)

6

6

2

3

  Rheumatoid Arthritis (RA)

2

1

2

2

  OA & RA

0

0

1

0

  Missing

1

0

0

0

 

 

 

 

 

Years Diagnosed with Arthritis:

 

 

 

 

  1

0

1

2

0

  1.5

1

0

0

0

  2

0

1

0

0

  3

1

1

0

1

  3.5

1

0

0

0

  4

2

0

0

0

  5

2

0

1

1

  6

0

0

0

1

  7

0

1

0

0

  8

1

1

0

0

  10

0

1

0

0

  15

0

0

0

1

  20

0

0

1

1

  30

0

1

0

0

  38

0

0

1

0

  50

1

0

0

0

 

 

 

 

 

Perceived Severity of Arthritis:

 

 

 

 

  1 = mild

0

1

0

0

  2

3

1

0

1

  3

4

4

1

3

  4

1

1

4

0

  5 = extremely severe

1

0

0

1

 

 

 

 

 

Perceptions of Arthritis-Related Pain:

 

 

 

 

  1 = mild

0

0

0

0

  2

2

2

0

2

  3

3

2

2

1

  4

2

2

1

1

  5 = extremely severe

2

0

2

1

  Missing

0

1

0

0

 

 

 

In the following section, the participants’ descriptions about meanings and sources of stress will be summarized, and then, key themes of coping with stress will be identified and described according to gender-based analyses.

 

Meanings and Sources of Stress

When asked what stress meant to participants, their responses appeared to suggest that stress is a reflection of their lives. For one female with arthritis, stress means “just getting through the day,” while one male with arthritis emphasized, “stress in my opinion is the biggest factor” in his life. That male described stress as “all a package,” referring to the effect of stress on his “physical and mental well-being,” his entire “body,” “diet,” and “lack of exercise.” For another female, stress means “get[ting] teary and tired,” and another male noted, when “I’m stressed out, I don’t seem to be able to concentrate like I normally can.” For one man, stress means “unknown.”“Most stressful situations are just the unknown. It doesn’t matter how difficult the problem is; it’s the unknown that makes it stress. Once you get a handle on things, stress goes away.”

 

Many participants equated stress with arthritis-related problems or issues such as “taking longer to do things” (female), “the inability to do things the way you used to” (female), the effect of “weather” (male), “delay, frustration, and short temper” (male).  One female pointed out, “there’s been a lot of changes in my life since I was diagnosed” with arthritis. One male summarized, “the main thing is anything to do with arthritis.”

 

With respect to negative and/or positive aspects of stress, two men and one woman with arthritis did not think stress could be positive at all—“not very comfortable, feel depressed” (male), “get furious” (male), and “you fly off the handle really quick” (female). Many participants described how stress negatively affects their cognitive functioning and behavior—“frustration” due to physical inability (female); “can’t sleep” (male);  “forgetful” (male); “you don’t think clearly when you’re under stress” (female); “stress makes me forgetful, what I’m doing, where you’ve put things, what you have to do” (female).

 

On the other hand, many individuals (particularly, women) with arthritis agreed that stress could be positive. It could be considered as “a motivator” (male); something that “push[es] you to overcome the difficulties” (male), “pushes you out instead of staying in” (female), or “make[s] you be more aware of yourself, aware of things that are going on around you” (female). “If you stop and think and realize that you’re under stress and you analyze what’s made it that way, then you can make some changes that are positive” (female).“It [stress] makes you change. I had to learn how to do things differently” (female).  Other positive aspects of stress raised by females include: “it [stress] helps you get things accomplished,” and boosting “self-confidence” once “getting things done.”

 

When asked to identify main causes or sources of stress, the majority of the participants agreed that living with arthritis is a major stressor, particularly combined with the aging process, as summarized by one female—“As you get older, between age and arthritis you can’t do the things that you used to do. That bothers me more than anything.” Arthritis-related “pain in back and hips and in knees … bother” them (female & male), while many indicated that they are “limited and restricted” because of arthritis. Living with arthritis was considered “a nuisance” (male), and made some males “inconvenient” and even “very awkward.” Some women and men were “forced to leave a job that [one] loved very much,” and others were “worried” about the fact that “it’s not going to get better” (female)—“I know there’s no cure… I’m incapacitated to some extent and with no hope” (male).

 

In contrast to these typical views, one female suggested a different point of view—“I don’t think that the arthritis itself causes me the stress. It’s when I take on too much, I expect too much of myself and I think that’s it.”

 

The next most common source of stress mentioned was family issues/problems. Note that the average age of all the respondents was about 65 years and most were retired, yet many were still troubled by family matters (e.g., “worrying about my children,” “illness in the family”)—“I have 3 kids still at home… There’s always that mix going on about how far you’re going to help them” (female). Many men felt out of control over their families (“the family can create a lot of stress because you can’t lots of times control them”), while one male lamented the lack of understanding about his pain in his family.

 

“At work you can make a decision and change it but at home you can’t necessarily convince your kids you should be doing this” (male).

 

“My family, they don’t understand my situation. Seems to them I’m only joking because I always say that I have pain here. But they don’t feel what I’m feeling this way.  There’s nothing visible for the people.  ‘You look OK.’  They don’t know what you’re feeling inside” (male).

 

Other causes/sources of stress discussed include financial (“lack of money … money is always a stressor,” male) and job-related matters (e.g., “a bad situation at work where there’s a lot of favouritism and nepotism,” female; “you have to get this building in operation and everybody’s leaning on your shoulder,” male).

 

“First problem, it was the money. I don’t have any income as of now.  I tried for disability, but they deny.  They said it’s not severe and it’s not prolonged.  I said in the letter, ‘Did you tell me this was not severe?  Can you feel what I feel?’ ” (male).

 

Furthermore, some participants raised loneliness (e.g., “living alone,” female), “too many obligations” (female), and “dealing with difficult people” (female) as other sources of stress.

 

“I’m suffering from stress from being lonely, my relationship breakdowns and stuff like that.  I suppose I’m suffering more stress from loneliness than I am from arthritis” (male).

 

“I guess the major cause is too many obligations, feeling like you have to take on everything that somebody asks you to do or you think you need to do. You have to learn to say ‘No,’ which is hard because I’ve always looking after everybody” (female).

 

In the next section, by comparing descriptions of coping with stress for women and men with arthritis, results of gender-based analyses are provided. The focus group data yielded a number of stress-coping strategies that were common to both women and men, while others were unique to one informant group or the other. In this section, common themes are presented first with a description of the gender-specific themes to follow.

 

Common Stress-Coping Methods for Middle-Aged and Older Women and Men with Arthritis

Eight common themes of coping with stress emerged from the focus group data: (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.

 

Keeping active and busy. Many female and male participants described the importance of keeping oneself busy and active as a means of coping with stress. Examples included being involved in group or individual activities, just going out, “volunteer work,” and “doing something every day”—“Being interested in something, being active, keeping busy, and enjoying something” (male). These help to “keep my mind off of things” (female) or “keep your mind occupied” (male).

 

“I do handicrafts.  I do Meals on Wheels when they need me. I play bridge, and I continue to go to our seniors group as often as I can. That’s keeping busy” (female).

 

“I lead a very active life. I’m quite involved in two senior’s groups in our area and the bridge group at church. I aquacize a couple of times a week, so I keep fairly busy” (male).

 

 “I try to go out just about every day, whether it’s just grocery shopping, or I’ll meet a friend for lunch. [Moderator; How does that relieve your stress?] I think just going out and being with other people, not even necessarily talking to them, but realizing that you’re part of this whole universe, you’re not isolated.  That helps me” (female).

 

“I’m involved with my church. And, I read and I find that I do things to keep me busy, whether it’s going out for lunch with my friends or playing bridge or whatever.  So I try to keep as active as I can” (female).

 

“You have to keep busy and not sit around and think about whatever stresses there might be around you. It certainly helps to get your mind off of it by doing something. Doesn’t have to be an awful lot, just meet someone for lunch, for example. You gotta go somewhere and do something, you just can’t sit there” (male).

 

Exercise/Physical activity. A number of female and male participants purposefully engaged in some form of exercise or physical activity in order to cope with stress. They suggested that the use of exercise/physical activity for this purpose generates other related benefits such as: enhancing self-esteem, relaxation, facilitating a good night’s sleep, feeling good, health benefits, social benefits (e.g., not feeling isolated), pain relief, and taking mind off of problems.

 

“I do get on my bicycle downstairs and I try pedal that, and I start at 5 minutes and then I go up to 15 minutes a day and keep myself going. I feel proud of myself when I get off it because I managed to do it” (female).

 

“Exercise.  It really helps relax you; you sleep a lot better.  My husband and I usually go out for walks late at night before bedtime. It does make you feel a lot better. [Moderator: So you do that to cope with stress?] Yeah, we do it consciously” (female).

 

“I go to the Wellness, there are light weight machines, treadmill a little. I work out at least 3 times a week for a good hour. I tough this out, then shower and that makes a difference.” (male)

 

“I take physical activity classes a few times a week. You’re with other people with arthritis and you talk to them and you don’t feel as isolated.  And you’re helping your body by doing range of motion exercises.  One class is on the land, one is in the water, and in-between I do skating. And I go swimming still.  There are changes that take place in your body when you do physical activity. You feel more endorphins and there’s a different pain relief.  You feel physically better health” (female).

 

“I do exercise.  When you exercise you have a lot of flexibility, you can move.  So your joint will move around.  It’s good to move” (male).

 

“I have a dog that needs me to walk it.  I love him so I take him.  When I took a course on arthritis, this is one of the things they say, that you should walk. I know I would sit if I didn’t have him to make me go for walks, so he is a plus” (female).

 

Educational: Gaining knowledge about arthritis

Another common theme shared by female and male participants was educating oneself or gaining knowledge about arthritis—“knowledge is the biggest asset of all” (male).

 

“Reading about what is happening to you and getting a better understanding of your osteoarthritis or your rheumatoid arthritis, or your cataract surgery, or whatever.  Just having the knowledge of what is happening and knowing which road you have to go to deal with it.  That alleviates a lot of it. Not knowing is stressful, but once you know, you feel more in control. I think you have to know what kind of problem you have.  Find out what kind of arthritis you have, talk to your doctors, and then you can deal with that. Education is so important” (female).

 

“Talking to other people with arthritis so you don’t feel alone. You know other people have similar problems and that opens your eyes and makes you more aware” (female).

 

Socialization/social support/friendship. Many female and male participants agreed that socialization with and gaining support from friends and family members are important to effectively cope with stress—e.g., “Quite often if you join a group, you’re with people who have the same problems and this does help” (female).

 

“I like being in the groups and sharing. I facilitate the suicide grief group at the Y as a leader.  And I’ve also been with Compassionate Friends for bereaved parents. Now I’ve joined the arthritis support group.  It’s being with other people who have your life experiences that you can share” (female).

 

“I found it positive once I joined groups and shared the experiences and methods that were being used to try and rectify the problem.  It did become positive in that sense, because we attempted as a group first of all to take control, and secondly to find ways and means, individually, to do things to rectify our situation, which I’ve been doing for the past 20 years” (male).

 

“I have 5 children and 10 grandchildren and I like to spend time with them. I try to get involved with them in different stuff at home and talk to them about the family, because I want them to have the history of my family which I think is very important. And I take them in the summer to ball games and stuff like that and they enjoy that” (male).

 

“I’m very lucky because I have my daughter and her husband live just 8 houses down from us and their youngest is 9.  She comes over for breakfast every morning and then comes after school, so I look forward to that. [Moderator; Right, she keeps you on the ball.] She sure does.  And then I have grandchildren that are involved with water polo and I like to go watch their games and their competitions” (female).

 

Spiritual coping

Another common theme of stress-coping shared by some female and male participants was the use of spiritual or religious aspects—e.g., “my association with the church. Spiritual and associating with people, just to think of something else for a while” (male).

 

“Every morning I just pray that I’ll get through the day. I try to do contemplation on a regular basis” (female).

 

“Well, something I do, that’s been a part of my life in the last 3 years, is my hour with Oprah.  Takes me into a whole new world, a positive, spiritual, all those good things.  And that is my time, I don’t feel anything, I’m really happy.  It’s just a beautiful time” (female).

 

“I like Reverend Schuler on Sunday—Church service from Crystal City.  I think he’s a great speaker. That’s my hour to do just what I want. I find it a lot easier than going out to church” (female).

 

“I would take out any one of my Wayne Dwyer tapes and I’d go to my bedroom where it’s quiet and I would listen to his tapes and meditate. That’s what I’d do when I feel it’s just getting too much.  So I find that quiet time” (female).

 

Acceptance/Acknowledging stress. Some female and male participants raised acceptance of one’s conditions and/or abilities, or acknowledging (rather than ignoring) the fact that they are experiencing stress as a way of dealing with stress:

 

 “If things have piled up on me and I get irritable, settle back and take it easy. Take your time and don’t accept anything more than what you think you can accomplish in a day. I think it has made me slow down and accept that I’m not as young as I used to be, and I can’t do the things that I used to be able to do” (female).

 

“Recognizing that I have stress and then just giving myself permission to say, ‘This is what it is.’  Once I recognized that I feel that way, pacing myself and then I can read, or I can get out and walk, I can do whatever and then I feel better. Just acknowledging and then doing whatever activities that make me feel better” (female).

 

“I try to analyze what exactly is causing this stress and if I can do something about it I will. If not, I accept it and take it the way it comes” (male).

 

Helping others: Altruistic benefits. Several female and male participants suggested that helping others, for example, through volunteering activities (e.g., “I do a lot of volunteering work at nursing homes,” male), helps them cope with stress:

 

“I volunteer with other seniors in Canada.  I find that helps me a lot because you always see somebody that’s worse than you are. You can share experiences and it helps you at the same time. I want to continue doing for as long as I can” (male).

 

“Confident in what I was doing.  For the last 14 years I’ve been working at the Christmas Cheer Board for two months every year and I thought last year, ‘No I can’t do it.’  But I went in and I worked right through it” (female).

 

“Being with groups—I can help these people because I have a life experience that I never ever wanted but now that I have it. Just to be there and a shoulder for them to lean on. When they say, ‘Thank you for being there,’ it’s a good feeling too.  You know you can help them. You just have to be there to let them know they can survive” (female).

 

Leisure as a means of coping with stress. Most female and male participants agreed that leisure plays an important role in helping them cope with stress (e.g., giving “enjoyment” and “pleasure,” giving “the balance,” “it’s my time,” stress reduction, feeling better physically and emotionally):

 

“Leisure is very important because it gives me the balance. You have a goal of each day you’re gonna do so much.  But in that day I always set aside time for me, it’s my time.  I choose times every day for me. I have a soft-bounce trampoline. And it’s so good.  It’s my form of exercising, that’s my pleasure” (female).

 

“I think there’s definitely a link in the relationship between leisure activities and stress reduction” (male).

 

“The more leisure you do, the better you feel. Less stress, emotionally and physically better” (female).

 

With respect to specific leisure activities, female and male participants mentioned “reading,” playing music (“I play violin—I forget about everything,” male), doing puzzles, and camping. These activities help them keep their mind off problems or stressors (e.g., pain), have time for oneself, or feel relaxed.

 

“I like to read books. You get away from yourself.  You’re not thinking about anything else. Reading is my biggest one” (male).

 

“I read. If you get involved in a book, you forget about your pain” (female).

 

“I play the piano and fight with the cat. When my life seems to be going into a vicious circle, I’ll sit down and I’ll play some music, or I sit down and play with the cat. Just to stop the world from spinning around” (female).

 

“Playing the piano is something I do just for myself” (female).

 

“I do the crosswords, that really relaxes me” (male).

 

“I like to do crosswords, that’s what I love to do. It keeps my mind from getting the senile old age. It’s a good activity for my mind—just gets me out of thinking about things I can’t do” (female).

 

“We go camping in the summer and I find it really relaxing” (female).

 

Furthermore, some participants suggested that leisure travel helped them cope with or reduce their stress. Specifically, described were: taking one’s mind off toward outward, being “out in nature,” “see[ing] things in a different perspective which reduces stress,” getting away from responsibilities and stressors, leisure travel as “relaxing” and a way of “feel[ing] refreshed,” and visiting one’s homeland. One man noted that he “didn’t feel [his] arthritis” during his Costa Rica trip, while another man pointed out that visiting his homeland, Philippines, “reduce[d] the pain of [his] arthritis” and “stresses” “because of the weather” and after “chat[ting] with all the people I know.”

 

“Twice a year, usually in the spring and the fall, I pack up my husband in the truck and we go away somewhere—we’ve been all over. [Moderator; How does that relieve your stress, going on these trips?] You’re seeing something different, you’re doing something different, and I think it does take your mind off it.  For me it would be a stress reliever” (female).

 

“If we go on any kind of travelling, it’s usually a day trip.  [Moderator; How does that reduce your stress?] They do.  I can forget about my day job.  And it’s nice, you just disappear and you don’t have anything to do for a few hours. I like we get away from yourself” (male).

 

On the other hand, other respondents found travel difficult because of their physical restrictions and their need for extra preparations. For some, money was an issue—they could not afford to travel (most of these respondents, particularly females, had very low incomes); however, a couple of participants mentioned that “I’d love to travel if I had the money to see the world, to see different places.” Interestingly, these comments about constraints associated with travel were raised only by female participants.

“You have to prepare a lot. At least I have to think, how much walking?  Is this gonna be uphill?  Downhill?  What happens if I have to take my glucosamine and chondroitin. There’s all sorts of logistical things you have to think about.  But other than that, it can be relaxing, but just a little extra preparation time is required to think things out” (female).

 

Stress-Coping Methods Unique to Middle-Aged and Older Women with Arthritis

 

Besides the above common themes of stress-coping strategies for both women and men with arthritis, other strategies were identified only by either women or men.

Positive attitude and thinking/Positive changes in life. Several female participants, not male participants, suggested the role of having a positive attitude and thinking as an important way of dealing with stress—e.g., “I try to have a positive attitude and try to find some joy in each day, whether it’s just a small thing” (female). One woman indicated that “just remember[ing] all these impossible things that I’ve overcome” helps her gain confidence and feel “stronger.”

“Stress. You just seem to flow out of it, if you apply the positive thinking.  The power of positive thinking, for me, works, in spite of many types of illnesses that I’ve been given.  So taking a positive approach to a stress situation that is negative. You can get good stress out of it” (female).

 

“I’ve just got to push myself, starting off the day with trying to have a more positive attitude and try to do something each day, saying ‘Get out there and do it, never mind.’ Maybe it’s getting up and riding that bike for 5 minutes. Getting out of the suite and keeping in touch with people would be good for me” (female).

 

A couple of females emphasized the power of having a positive attitude to take control over one’s life and make positive lifestyle changes:

“When I was diagnosed with rheumatoid arthritis 38 years ago, my little boy was not quite 2 and I just had a new baby, and I was seeing an internal medicine specialist for my arthritis.  And he told me, ‘You’re just going to have to think about yourself and get a maid and what-have-you to look after your family, your house.’ And I thought, ‘No way.  I’m just going to take control of my arthritis, I’m not gonna let it take control of me.’  So I decided I was going to have a positive attitude. I find that’s what helps me with my stress” (female).

 

“I’m still at the stage where I haven’t really accepted the fact that I have osteoarthritis, because I don’t believe it.  I believe that I can reverse it and change it if I change my lifestyle, which I’ve done in the last 2 or 3 years—change the way I look at things mentally, physically, change my diet—a healthier way of living. Because that’s really what has caused where I’m at.  Initially you have the doctor’s support, you have the medication, but ultimately you have to do it on your own and only I can change what I have in my knees with whatever medication, along with exercise and changing your entire lifestyle, so that you have better health results. I don’t want to wear the label that I have arthritis” (female).

 

Female-specific leisure activities as a means of coping with stress. Specific leisure activities discussed only by females included: “cooking and baking,” “keeping a journal,” “painting,” “drawing,” “making cards,” and “Christmas decorations.”

“Cooking and baking. That’s one thing that does make me feel good. [Moderator; Sure. You would consider that a leisure activity?] It is in a way, yeah, because I’d rather do that than housework” (female).

 

“Yes, I guess it [leisure] does.  I’m keeping a journal. You just get a lot of things off your chest, what you’re feeling, how you’re feeling.  It’s like as if you were talking to somebody and it’s just like a burden shared is a burden lessened” (female).

 

Other female-specific coping strategies. Other stress-coping strategies mentioned only by females included: pacing oneself, the use of “humour,” prioritizing (“budget[ing] my time to do things that I really want to do”), and doing nothing.

 

“Pace myself because if I do too much, then … That’s what I’m learning to do, spread it out. [Moderator; How does that reduce your stress, like pacing yourself?] Not dwelling on myself.  Well I feel better physically and emotionally” (female).

 

“Try and have some laughs during your life every day, whether it’s a TV show video or a phone. There’s always one particular friend that no matter what’s on your mind they always make you laugh.  Phone that friend.  Then when I’m really stuck, I have a lot of cartoon books. Herman always makes me laugh” (female).

 

“When I quit work one of the things I did is, a lot of prioritizing.  And, let go of a lot of stuff because you can’t save the world.  I think I am less stressed now than I used to be” (female).

 

“Giving myself permission sometimes to sit and do nothing, which took quite a while. Sometimes you start feeling guilty if you’re not doing anything” (female).

 

Stress-Coping Methods Unique to Middle-Aged and Older Men with Arthritis

 

Not thinking about stress. Several men, not women, talked about “not thinking about” stress as a way of coping with stress:

“I go to bed and clear my mind. I just say I’m not going to think about that” (male).

 

“I think when I feel stress you have to think about it. ‘Oh, God it’s hurting.  Jesus I wish I didn’t have arthritis.’ It’s almost like a self-hypnosis.  You don’t think about stress.  And when you don’t think about it, it’s not there!”  (male).

 

Comparing oneself with less fortunate people. As a mental approach, several men seemed to purposefully compare themselves with less fortunate people; they “wouldn’t trade places” with less fortunate people—“Thinking how lucky you are compared with other people.”

“What helps my stress probably is, you know there are thousands of millions of people on the face of the earth with whom I wouldn’t trade places. When things get really bad, ‘Gee, I’m glad I’m not in a bloody cave in Afghanistan, or in a mud slide, or tornado’ ” (male).

 

“I just got back from Cuba.  And talking of people that are less fortunate than we are, Cubans. Living under a Communist regime is not the biggest blessing in the world.  It’s a beautiful country, but very poor people. Would you rather be in Cuba without any arthritis, or would you rather be a Canadian with arthritis?  No, I’d rather be here with arthritis. I try to deal with my arthritis here” (male).

 

Other male-specific coping strategies. Other stress-coping strategies pointed out by men included: asking “Do I care?,” and having “a nice cigar and a nice glass of wine” alongside one’s “fireplace”—“it feels good” and “relaxing.”

“When you find something that really bugs you, I like to think, ‘Well, will anybody care about this in 100 years?’  If I get home and the laundry is not done and the house isn’t done, maybe my wife’s had a bad day.  Don’t let it worry me any more.  The big thing is, ‘Do I care?’ ” (male).

 

Finally, there appeared to be male-specific leisure activities that can be used as a means of coping with stress. Specifically, several men talked about sport spectating—e.g., “season tickets” to football games (i.e., “the Bombers”) and watching professional sports on TV (e.g., “NFL football”).

 

Discussion

Our analyses of focus group data, which contain in-depth and extensive descriptions about stress and stress-coping from the perspectives of our participants, suggest not only that stress is prevalent in lives of middle-aged and older women and men with arthritis, but also that they use a variety of coping strategies to deal with stress in their lives. For some, stress means “just getting through the day” or “all a package” in one’s life; for others, stress means “unknown” or “get[ting] teary and tired.” Although stress is considered primarily negative (e.g., “not very comfortable,” “feel depressed,” “get furious,” “frustration,” “can’t sleep,”  “forgetful”), the participants (particularly females) identified the possibility that stress could be positive (e.g., “a motivator,” “push you to overcome the difficulties,” “make you be more aware,” “help you get things accomplished”). For the majority of the participants, a primary source of stress is, in fact, arthritis-related problems or issues such as “pain,” “limited and restricted” physically and behaviorally, “taking longer to do things,” “the inability to do things the way you used to,” and “no hope.” Many agreed that the aging process exacerbates or aggravates the challenges or problems with arthritis. The other major sources of stress described were family issues/problems, financial stressors, job-related matters, and loneliness.

 

Coping strategies discussed by the participants represent a wide range of behavioral and psychosocial approaches to manage stress. As described in the results section, the specific common themes of stress-coping strategies identified appear distinct in focus and uniqueness. However, from a broader and more holistic perspective, it seems possible to conceptualize overarching themes that cut across these specific themes. Despite the differences in the focus of each specific theme, the focus group data appear to suggest the existence of overarching themes that tie these themes together to broadly or holistically conceptualize core meanings of stress-coping for middle-aged and older women and men with arthritis.

 

Overarching Themes of Stress-Coping for Middle-Aged and Older Women and Men with Arthritis

 

Leading an active life. One such overarching theme is leading an active life. This theme is concerned with all aspects of life including: physical, psychological/cognitive, emotional, social, and spiritual involvements in life. Examples from physical activity illustrate many of these aspects, including social (“You’re part of this whole universe, you’re not isolated.”), physical (“There are changes that take place in your body when you do physical activity. You feel physically better health.”), and psychological such as the enhancement of self-esteem (“Feeling so good about it, feeling so proud”), relaxation (“It helps relax you.”), and peacefulness (“Going for a walk” facilitates “peace and tranquility.”). In their recent review paper, Hurley, Mitchell, and Walsh (2003) concluded that for persons with arthritis “the psychological benefits of exercise are as important as physiological improvements” (p. 138). They identified coping with arthritis as a key factor of “psychosocial sequelae of OA” (p. 139) gained from exercise.

 

      In addition, many participants were conscious of gaining knowledge about arthritis (i.e., cognitive)—“Just having the knowledge of what is happening and knowing which road you have to go to deal with it.” Also, a number of participants extensively discussed the importance of leading an active social life—“Talking to other people with arthritis so you don’t feel alone.” One woman described another benefit of leading an active social life—“Going out, you just sort of become part of the whole universe.” Also, some participants talked about the role of spirituality in effectively coping with stress (i.e., leading an active life spiritually)—“Spiritual, contemplation, pray.” Also, accepting one’s conditions and acknowledging stress are considered an element of leading an active life. It appears important to accurately acknowledge one’s conditions and abilities and to realize that life is stressful in order to make appropriate choices to lead one’s life to right directions.  One female summarized this point, “Recognizing that I have stress and then just giving myself permission to say, ‘This is what it is.’ Once I recognized that I feel that way, pacing myself and then doing whatever activities that make me feel better.”

 

Furthermore, helping others such as being involved in volunteer activities (i.e., altruistic) is considered one important aspect of leading an active life. For example, one man suggested, “I lead a very active life. I’m quite involved in two senior’s groups in our area, and I do a lot of volunteering work at nursing homes.” It was described that being involved in volunteer activities to help others facilitate one’s confidence and a good feeling. One woman pointed out that “working at the Christmas Cheer Board” helps her feel “confident.” 

 

      The role that leisure plays in helping persons with arthritis cope with stress should not be undervalued. In the focus groups, this role of leisure was extensively and often enthusiastically described by many participants. Their descriptions suggested that the constructive use of leisure is not only effective in dealing with stress, but it is also an important component of leading an active life for them. For example, one male noted, “I think there’s definitely a link in the relationship between leisure activities and stress reduction,” while one female indicated, “Leisure is very important because it gives me the balance.” For her, “leisure is pleasure, so I choose times every day for me.” Another female concurred, “I think you have to have some enjoyment in life.  So you try to pick the things that you’d like to do.” One woman emphasized benefits of leisure with respect to stress reduction and physical and emotional health—“The more leisure you do, the better you feel. Less stress, emotionally and physically better.”

 

      Another benefit of leisure discussed was palliative coping through leisure (i.e., a form of a time-out from stressful everyday lives; Iwasaki & Mannell, 2000; Iwasaki, Mannell, Smale, Butcher, 2002 & in press). Speaking of reading, one female mentioned, “If you get involved in a book, you forget about your pain,” while the importance of playing a musical instrument was raised by one man, “I play violin—I forget about everything.” Likewise, one female pointed out, “I play the piano. Just to stop the world from spinning around.” For her, “playing the piano is something I do just for myself.” Talking about cross-words puzzles, another woman suggested, “It’s a good activity for my mind. Just gets me out of thinking about things I can’t do.” Also, participants described that leisure helps them keep their minds off of problems and feel relaxed. For example, one man mentioned, “I just love to go for a walk. It takes my mind off any problems and gets my mind off. And I go anywhere on the river and go fishing. I find it very relaxing.” One female talked about a “nice relaxing bath” as a means of coping with stress, while another female noted, “I do jigsaw puzzles that help to relax.”

 

      In addition, some participants suggested that leisure travel is a means of coping with or reducing stress. As described in the results section, stress-coping benefits of leisure travel mentioned include: taking one’s mind off toward “outward,” being “out in nature,” “seeing things in a different perspective,” “getting away” from responsibilities and stressors, and relaxation. However, it must be pointed out that other participants (particularly, women) felt travel difficult and restricted due to their health problems or concerns.

 

      In summary, regardless of the type of activity that middle-aged and older persons with arthritis engage in for various purposes, one overarching theme of coping with stress appears to be leading an active life. As human beings, individuals with arthritis seem to value the importance of pursuing their lives in a meaningful way. Their behavioral involvements in life, as well as their social, educational, psychological, spiritual, and altruistic involvements, help them gain important meanings in the pursuit of their lives, by affirming the significance and preciousness of living. Thus, their lives as a whole seem to be multi-dimensional and multifaceted rather than one-dimensional. The eight common themes of stress-coping identified represent or illustrate some of the important activities or pursuits that help persons with arthritis generate meanings in their lives. Persons with arthritis, at least, in the present sample, seem to be trying to ascertain the meanings of living with arthritis within their life-world, by actively affirming its implications for self, relationships, lived space and time, embodiment, personal projects, as well as the way in which these sufferers employ the various relevant discourses surrounding these conditions.

 

      In the past, of various coping methods, problem-focused or confrontive coping strategies were found to be most frequently used and perceived to be most effective among individuals with arthritis (Bendtsen & Horquist, 1994; Mahat, 1997; Katz, 1998). A recent comprehensive review of the literature concerning the influence of stress factors on onset and course of rheumatic diseases including RA supported this notion (Hermann, Scholmerich, & Straub, 2000). More recently, in their longitudinal study on older adults with RA, Melanson and Downe-Wamboldt (2003) found that the majority, at all three time periods, most frequently used confrontive coping, and palliative coping (e.g., doing things to take one’s mind off of stress) and fatalistic (e.g., just putting up with it) or supportant coping (e.g., talking to people, spiritual coping) being second and third. The present findings, however, lent support for a much broader notion of leading an active life as an overarching theme of coping that encompasses multi-dimensional and multifaceted ways in which middle-aged and older adults actively deal with stress. Problem-focused or confrontive coping strategies were, of course, contained within this theme; however, descriptions by our participants emphasized that leading an active life provides them with an opportunity to gain important meanings of life (i.e., meaning-focused coping, Folkman & Moskowitz, 2000ab).

 

Perceived control over oneself and one’s life. Another overarching theme derived from the data is the perception of taking control over oneself and one’s life. The eight specific themes of stress-coping identified in the results section seem concerned, at least partly, with the importance of taking control. For example, speaking of the educational dimension of life, one female suggested, “Getting a better understanding of your arthritis. Once you know, you feel more in control. Education is so important” (emphasis added). Referring to the social dimension of life, one man mentioned, “I found it positive once I joined groups and shared the experiences and methods that were being used to try and rectify the problem… We attempted as a group first of all to take control, and secondly to find ways and means, individually, to do things to rectify our situation” (emphasis added). One’s determination and attitude toward taking control are, in fact, very important to effectively deal with stress associated with arthritis, as convincingly described by one female—in response to her doctor’s suggestion to be dependent on helpers, she replied, “No way. I’m just going to take control of my arthritis, I’m not gonna let it take control of me” (emphasis added). 

 

The notion of taking control over one’s life is relevant to other dimensions of life, as well. For example, keeping active and busy through exercise/physical activity is considered one way of taking control of one’s life since exercise provides an opportunity to take charge of one’s body and experience a sense of control over self. Similarly, through spiritual coping, one is able to take control of her/his life. Meditation and contemplation may allow a person to feel in control of self. Also, acknowledging stress (i.e., acceptance) is a way of appropriately finding out what is causing stress, which is part of taking control over one’s life. One male with arthritis suggested, “I try to analyze what exactly is causing this stress and if I can do something about it, I will.” Likewise, a sense of freedom and control is involved in volunteering activities to help others since such altruistic activities are, in definition, non-obligated, unlike paid employment. Finally, leisure pursuits provide an opportunity for persons with arthritis to experience a sense of control and freedom because leisure activities typically take place in free or non-obligated time. As described earlier, one female suggested, “Leisure is very important. I always set aside time for me, it’s my time. So that’s my pleasure.” 

 

 Indeed, feeling in control is a key aspect addressed in the concept of self-efficacy. There is growing evidence that increases in self-efficacy may be related to positive outcomes of psychosocial and educational interventions for persons with arthritis (Keefe et al., 1999; Lorig, Mazonson, & Holman, 1993; Smarr et al., 1997). Also, new guidelines for the management of acute and chronic pain in OA and RA incorporate building confidence in patients’ self-help abilities as an essential element of biomedical and psychosocial treatments (Simon et al., 2002).

 

Gender-Specific Stress-Coping Strategies for Middle-Aged and Older Persons with Arthritis

             Although the present study identified various specific themes of stress-coping common for middle-aged and older women and men with arthritis, as well as two overarching themes of stress-coping, focus group data appeared to suggest that there were also gender-specific stress-coping strategies. For example, the use of positive attitude and thinking or positive changes in life was discussed only by females, not by males. Also, pacing oneself, the use of humour, prioritizing, and doing nothing were described only by women, not by men. In contrast, not thinking about stress, comparing oneself with less fortunate people, and asking “Do I care?” were raised only by males, not by females.

 

            These gender differences in stress-coping strategies may be explained by the differences in gender-specific life circumstances faced by middle-aged and older women and men with arthritis, and by social and cultural factors such as the differences in socialization processes, expectations, attitudes, and identities between women and men (e.g., gender role orientations). Specifically for older persons with arthritis, Knotek’s (2001) study of RA inpatients provided evidence that female (as opposed to male) patients were more substantially affected by the lasting effect of pain in showing a steeper increase of anxiety, anger, and depressive symptoms. An important finding of Knotek’s study directly relevant to gender differences in domestic or household responsibilities is that fatigue, worry, and relationship stress in home and family settings due to the lasting of pain were more strongly exhibited by female patients than by male counterparts. Possibly because of extra responsibilities or burdens in home, family, or domestic settings more substantially experienced by women than by men, along with economic/financial disadvantages (as shown in the present study) [4], stress and pain (both physical and psychological/emotional) may be more severe and draining for females than for males with arthritis. There has been evidence to demonstrate the salience of gender in understanding pain and disability associated with arthritis—women with arthritis are more likely to experience greater levels of pain and physical disability and show more pain behavior than male counterparts (Affleck et al., 1999; Keefe et al., 2000; Keefe et al., 2001). Similarly, the present study appeared to show that women reported higher levels of perceived severity of arthritis and arthritis-related pain than did men. Specifically, six of the eight participants who rated 4 or 5 (extremely severe) in their perceived severity of arthritis were females, while four of the five participants who rated their perceived pain as “extremely severe” were females.

 

            Thus, it may be assumed that women with arthritis not only are faced with a wider range of stressors including family/domestic and economic/financial stressors than men with arthritis, [5] but they also appear more susceptive or reactive to the exposure to stress either associated or not specifically associated with arthritis than do male counterparts. This assumption does not mean that lives of men with arthritis are not stressful. Rather, it highlights the importance of giving attention to possible gender differences in: (a) the nature, sources/causes, and appraisals of stress between women and men with arthritis; (b) specific life circumstances (specifically, home, family, or domestic settings) faced by women and men; and (c) social and cultural factors such as the differences in socialization processes, expectations, and attitudes/identities between women and men (e.g., gender role orientations). As an example shown in the present study, unlike men with arthritis, many women with arthritis seemed to feel obligated or pressured to “take on everything,” partly because women are expected to do so:

 

“I guess the major cause is too many obligations, feeling like you have to take on everything that somebody asks you to do or you think you need to do. You have to learn to say ‘No,’ which is hard because I’ve always looking after everybody” (female).

 

Consequently, because of potential gender differences in the nature, sources/causes, and appraisals of stress, stress-coping strategies used by women with arthritis may somewhat differ than ones used by men with arthritis. For example, as shown in the present study, the use of positive attitude and thinking or positive changes in life may be more critical for women with arthritis than for their male counterparts partly due to the need to deal with the stressful nature of their lives, and the need to reconcile their susceptivity to stress.  [6] Supporting this idea concerning positive attitude and thinking, Ravicz (2000) showed that replacing negative thinking with positive thinking is a key factor for effective coping among women with chronic illnesses in order not to deplete the immune system, and to lead a more balanced life. Similarly, pacing oneself, journalizing, the use of humour, prioritizing, and doing nothing may play a more essential role in managing such needs for women with arthritis than for their male counterparts. For example, novel stress management approaches such as emotional disclosure (e.g., through journalizing; Smyth et al., 1999) and the use of humour or laughter (Nakajima et al., 1999; Skevington & White, 1998) recently advocated by an increasing number of researchers, may be more helpful and effective for women with arthritis than for men with arthritis.

 

In contrast, male-specific stress-coping strategies identified in the present study (i.e., not thinking about stress, comparing oneself with less fortunate people, and asking “Do I care?”) appear to reflect men’s attempt/intention to maintain or restore their self-esteem. Although maintaining self-esteem is important for any individuals to maintain good health and well-being, men may have a stronger desire for the maintenance of self-esteem than for women (Anderson, 1997; Wearing, 1998). Feeling good about oneself (i.e., self-esteem) seems to be one of the most essential and highly valued goals for many men. Although women also value such a goal, many women seem to more frequently and extensively show care for others than do men—Well-being of significant others appears equally important as their own well-being for many women. Because of gender differences in the socialization process and expectations, many women tend to show more concern and care for others. Sometimes, some women might be concerned with others’ needs first rather than their own needs. That is, some women might feel guilty when they try to focus on self. Consistent with this notion, one female in the present study pointed out, “Sometimes you start feeling guilty if you’re not doing anything.” These ideas are related to the social construction of gender roles (Anderson, 1997; Henderson, Bialeschki, Shaw, & Freysinger, 1996).

 

Furthermore, the present study identified some gender-specific leisure activities as a means of coping with stress. Specifically, cooking/baking, journalizing, paining, drawing, making cards, and Christmas decorations were mentioned only by women, whereas men talked about sport spectating (either live or watching professional sports on TV). There appear to be gender differences in preferences for type of leisure activities as a way of coping with stress.

 

Implications of Findings

             The findings of the present study support the importance of providing multi-dimensional and comprehensive, behavioral and psychosocial interventions for middle-aged and older persons with arthritis, as recommended in the recent literature (see Keefe et al., 2002 for a review). Given the use of a participant-centred qualitative methodology in this study, perspectives of our participants themselves were truly incorporated in the analyses of the data and interpretations of the findings. Broadly, it appears important and useful to give attention to the two overarching themes of stress-coping identified (i.e., leading an active life and taking control of one’s life) in intervention programs for middle-aged and older individuals with arthritis. More specifically, the eight specific themes of stress-coping derived from the focus group data seem to provide some of the key clues or insights into the process of how intervention programs help and facilitate middle-aged and older persons with arthritis to lead an active life and take control of their lives. These themes deal with various factors/dimensions that can potentially be incorporated into interventions including: behavioral, social, educational, psychological, spiritual, and altruistic. These multidimensional factors appear to represent key elements of comprehensive, behavioral and psychosocial interventions or treatments for middle-aged and older individuals with arthritis.

 

            These suggestions are consistent with recent literature on treatment programs for older persons with arthritis. For example, based on Seligman’s (1975, 1991) theory of learned helplessness, Nadal (2001) developed a treatment program for older individuals with arthritis. The goal of the program is to help those individuals develop a more optimistic explanatory style that will ameliorate depression. According to Seligman, learned helplessness occurs when a person believes that she/he has no control over certain events. The program incorporates both psychological treatment and a psycho-educational component, and focuses on patients’ behaviors and beliefs. It utilizes cognitive and behavioral techniques, stress management training, self-care, and psycho-educational instruction to ameliorate feelings of helplessness, hopelessness, and worthlessness. Evers et al.’s (2003) recent findings from their longitudinal study suggested the importance of psychosocial interventions for arthritis patients, as well.

 

Also, the literature suggests the importance of leading an active lifestyle for older individuals with chronic diseases including arthritis (e.g., Harman, Holliday, & Meydani, 1998). Given that, as demonstrated in our findings, the meanings for leaning an active life substantially vary among arthritis patients, it is important to involve patients in the development and implementation of approaches to coping with stress (Melanson & Downe-Wamboldt, 2003). This notion is consistent with recent chronic illness literature that recommends a shift in focus from a compliance model to a shared decision-making model (Thorne & Paterson, 2000).

 

From practical perspectives, the specific and overarching themes of stress-coping identified in the present study appear to highlight the importance of recognizing and using strengths and resilience of persons with arthritis. This idea is consistent with a recent growth in positive psychology. For example, an increasing number of scholars advocate that it is important to “accentuate the positive” rather than “eliminate the negative” (Berscheid, 2003, p. 44; Larsen, Hemenover, Norris, & Cacioppo, 2003, p. 218-219). Similarly, speaking of positive clinical psychology, Seligman and Peterson (2003) emphasized, “the best therapists do not merely heal damage; they help people identify and build their strengths” (p. 306). These notions seem significantly applicable to helping people with arthritis more effectively cope with stress.

 

Often, compared to the role of behavioral (such as exercise, nutrition), cognitive, and social aspects of life, the potential of leisure pursuits as a means of helping persons with chronic diseases lead an active lifestyle has been given little attention. However, recently, researchers have begun to emphasize the importance of leisure as a key component of active lifestyle. For example, Folkman and Moskowitz (2000b) suggested that in addition to exercising control over one’s disease, exercising control over other areas of one’s life (including leisure) is an important determinant of counteracting distress under adversity.

 

In their examination of leisure activities for RA patients, Wikstroem, Isacsson, and Jacobsson (2001) found that the patients had given up two-thirds of their leisure activities since the onset of the disease. This giving-up of leisure activities was associated significantly and positively with present disease activity, measured by pain and morning stiffness, as well as significantly and negatively with quality of life. The findings imply that the maintenance rather than the termination of leisure activities appears important to help persons with arthritis ameliorate disease activity and promote quality of life. In her study of older persons with arthritis aged 50 or above, Payne (1999) found that those arthritis patients with a larger leisure repertoire reported significantly greater levels of perceived physical health than those with a smaller leisure repertoire. This finding suggests the importance of engaging in a broader range of leisure activities than a narrower range of leisure activities to reduce the negative impact of disease severity and maintain good physical health. These recent studies briefly reviewed above emphasize the importance of recognizing leisure as one element of intervention or treatment programs for persons with arthritis.

 

However, the study findings should carefully be interpreted since the study sample represented individuals who were involved in an arthritis self-management program. It was likely that the responses and perspectives obtained from this sample might be somewhat influenced by their experiences in this program. Thus, generalizability of the findings should be further examined in future research. Nevertheless, the richness and extensiveness of data/information about stress and stress-coping described by the participants with the use of a systematic qualitative analysis is a major strength of the study.

 

Although the present study identified some gender differences in stress-coping strategies for middle-aged and older persons with arthritis, further research is needed to more directly examine such differences in order to suggest relevant gender-specific recommendations for arthritis treatments and interventions. Nonetheless, our suggestions noted earlier about gender differences seem useful and may provide some important insights into the process of gender-appropriate treatment or intervention programs. In future research, in addition to gender, it is necessary to take into account the diversity of society (e.g., race/ethnicity, social class, sexual orientations) in order to provide more effective (e.g., culturally appropriate) programs for persons with arthritis.

 

 

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 [1] Osteoarthritis (OA) and rheumatoid arthritis (RA) are “among the most common forms of arthritis, are chronic in nature, cannot be cured using current biomedical treatments, and can produce high levels of pain and disability. Although OA and RA are considered by laypeople to be primarily joint diseases, RA is perhaps better considered to be systematic because it can affect many organ systems of the body, with resultant potential for significant morbidity and mortality… OA is a degenerative disease that is the result of both mechanical and biological events affecting joint cartilage and underlying bone” (Keefe et al., 2002). In contrast to the prevalence of OA primarily among older people, RA can occur in young adults as well as older adults (National Center for Chronic Disease Prevention and Health Promotion, 2002).

 
[2] Because of the nature of a sample used, the study findings should carefully be interpreted, as cautioned in the discussion section later in this paper.


 [3] The original plan was to have participants with arthritis aged 50 years or above. However, because of the difficulty in locating and recruiting a sufficient number of those older individuals with arthritis, it was decided to lower the age limit of participants to 40. The use of 40 years of age as the cut-point was based on evidence that arthritis is relatively uncommon among individuals aged 40 or under (Felson, 1990). As a result, one person (aged 49) in the female only group, and one female (aged 42) and one male (aged 44) in the mixed group were in their 40s. All the participants in the male only group were aged 50 or above.

 

 [4] Of the seven participants who indicated that their yearly household income was below $20,000, six (86 %) were females.


 [5] Marital status of the participants might have influenced their descriptions of household responsibilities as a stressor. For females only 5 out of 14 (36 %) were married, while for males 9 out of 12 (75 %) were married. Most male participants thus had the benefit of having spouses share responsibilities for household work., while most females did not.

 

[6]  Interestingly, as shown earlier in the section of Meanings and Sources of Stress, in the present study older females with arthritis more extensively discussed positive aspects of stress than did their male counterparts.

 


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