Relationship Between Coping Strategies and Health-Related Quality of Life Especially in Young Asthma Patients

Chapter 1

Introduction

There is an association between coping techniques and health related dimension of quality of life in sufferers of chronic illnesses (Martz & Livneh, 2007). The current study interrogates whether coping strategies and health related quality of life are related in patients of chronic diseases. A chronic illness is a disease that covers a huge unexpected time span of the life of the patients (Taylor, 2006).

The current research targets the patients of asthma that is a chronic illness and studies the coping strategies that are adapted by the patients to get used to with the changes brought about in life by the ailment. It also studies the type of coping mechanisms and their effect on the health-related quality of life of the asthma patients. The study investigates the nature of relationship between coping strategies and health-related quality of life especially in young asthma patients.

• Asthma

Asthma is an ailment of respiratory framework particularly influencing the lungs which in turns have impact on the breathing of the individual. Asthma is an ailment that is portrayed by discontinuous wheezing because of an allergen or aggravation. Wheezing is an indication of asthma however is by all account not the only symptomatic quality of asthma patients, but actually, if it happens because of interaction with an activating agent known as an allergen or irritant then it can be seen as an indicator of asthma (Clark, 2011).

It is a respiratory disease which is indicated by the blockage of the air pathways. The people with asthma have a distinctive type of irritation making them more vulnerable to the microscopic particulates in the surroundings when compared with the ordinary people. A great number of the patients with asthma, have narrowed bronchial tubes through which when air passes it makes a sharp, high pitched sound called as wheezing. It is audible while breathing in, but it is louder and clearer while breathing out (Localzo & Barnes, 2010).

• Symptoms of Asthma

The indicators of asthma that assist in the perception, description and interpretation of asthma are repetitive wheeze, feeling of constriction in the chest, shortness of breath and cough. These symptoms are most awful in the morning and evening time. Typically, these signs are not produced automatically but an activating agent is needed for these symptoms to appear (National Asthma Council, 2002).

• Prevalence of Asthma

Asthma is the most widely recognized long duration disease globally and presently a total number of 300 million individuals are influenced by this ailment. An increment in the pervasiveness of asthma has been seen in the established nations in the last three decades, however now the proportion appears to settle and has stopped on a rate of 10-12% of the grown-ups are influenced by asthma and the rate in youngsters is somewhat more than the grown-ups with 15% of the kids confronting the issue of asthma. On the other hand, in developing nations this proportion is relatively low than the occurrence (Localzo & Barnes, 2010).

In childhood, twice is the percentage of boys influenced by asthma when contrasted with the proportion of girls experiencing the ailment. Anyhow, this proportion diminishes with the progress of time and gets equal as the asthmatic people achieve adulthood. The people are similarly influenced by asthma in the adulthood without any sex segregation (Rees, Kanabar, & Pattani, 2010).

1.4. Causes of Asthma

The triggering factors of asthma may include allergens, exercise, irritants or viral infections. In some conditions, stress may also play a vital role to trigger the symptoms of asthma. A few of the etiological factors having a significant role in the initiation of this disease are being described briefly as follows:

1.4.1. Atopy

Atopy is an inclination towards exhibiting specific allergic susceptibility responses. Atopy may have a genetic role, in spite of the fact that interaction with the allergen should occur before the hyper reactive response can be exhibited. The name “atopy” was proposed by Coca and Cooke in 1923 (Cocoa & Cooke, 1923; Ring, Przybilla, & Ruzicka, 2006).

Numerous doctors and researchers utilize the expression “atopy” for any IgE-mediated response (even those that are suitable and corresponding to the antigen), however numerous child specialists hold “atopy” for a hereditarily intervened inclination to an elevated IgE response (Pawankar, Holgate, & Rosenwasser, 2009).

Atopy may persist in 40–50% of the people in rich nations, with just an extent of atopic people getting to be asthmatic. Atopy is produced by the hereditarily decided generation of a particular IgE antibody, with numerous patients demonstrating a family history of allergic ailments. It is a main consideration for asthma; the people who are non-atopic are less prone towards creating asthma in comparison to the atopic individuals (Localzo & Barnes, 2010).

1.4.2. Allergens

An allergen is a type of antigen that produces abnormally vigorous immune response in which the immune system fights off a perceived threat that would otherwise be harmless to the body. Such reactions are called as allergies. In technical terms, an allergen is an antigen capable of stimulating a type-I hypersensitivity reaction in atopic individuals through Immunoglobulin E (IgE) responses (Goldsby & Richards, 2012).

Allergens are found in the atmosphere and enter the lungs with oxygen; these allergens are often comprised of animals’ skin or hair, dust bug, mold, pollen particles particularly in the season of spring when fertilization is occurring with the full speed. The dander, which is dead skin and hair that fall off the animals’ body, pee and salivation of the warm-blooded creatures have such particular proteins which may be the cause to bring out allergic responses in individuals (Fanta, Carter, Steib, & Haver, 2007).

There are different sorts of allergens which are known to produce various sorts of allergic responses in the people. These may be inhaled allergens which are the cause of producing allergies after they are breathed in with the air, for example, pollen or dust particles. They might be the consequence of contact with any sort of bug, for example, honey bees or mosquitoes and so on. A few individuals show an additional allergic response towards specific kind of medications and may need to face life endangering situations as a result of their use, like pain killers. A few individuals have a tendency to show contact allergy towards substances like latex, house hold toxins, e.g., paints and newsprint (Prescatore, 2003).

1.4.3. Infections

Infection is the procedure in which the tissues of the body of a living being are invaded by illness causing factors, they multiply and maximize their number in the body. Accordingly, they face the resistance of the human immune system which is intended to battle and safeguard the body from outside attackers called infectious agents. Particularly the attack of a living organism’s body tissues via infection causing factors, their increment and the response of host tissues to these organisms and the poisons they create is called as infection (Fanta, Carter, Steib, & Haver, 2007).

There is an unpredictable kind of connection among asthma and infections. Infections are known for the speeding up of the indications of asthma and basic asthma can bring about more infections. Despite the fact that, the procedure of asthma has been constantly researched and argued over a quite a quite long duration of about a hundred years yet at the same time there is space for extra effort on this subject to totally examine all parts of the ailment. So that it can be managed right away with no issue (Martin & Sutherland, 2010).

1.4.4. Genetic Predisposition

A genetic predisposition is an inherited threat of getting an ailment or a condition. Being genetically susceptible does not imply that a man has that ailment, but rather it implies that one is most probably in the risk of falling prey to that ailment. Mostly, first degree relatives have the best hereditary inclination to the ailment which is transferred and keeps passing on in families, like, cancer or as for this situation, asthma (Eldrige, 2015).

The familial connection and a high level of similarity for asthma in identical twins demonstrate a hereditary inclination towards the ailment; however, it is not yet clear that the genes inheriting asthma are the same responsible for atopy or are different ones. It now appears to be possible that various genes might likewise play a role for asthma particularly, and expanding proof proposes that the seriousness of asthma is additionally hereditarily decided (Localzo & Barnes, 2010).

1.4.5. Hygiene Hypothesis

In medical terms, the hygiene hypothesis is a theory which expresses that an absence of initial childhood introduction to infectious organisms, advantageous microorganisms (e.g. gut flora or pro biotic), and parasites raises vulnerability to allergic maladies by restraining the normal progress of the immune system. Specifically, the absence of presentation is thought to prompt problems in the strengthening of immune resilience. The hygiene hypothesis has additionally been known as the “biome depletion theory” and the “lost friends theory” (Parker, 2010).

The hygiene hypothesis plays a role of a clarification for the expanding rates of asthma prevalence. As per this hypothesis, a lot of importance on cleanliness and utilizing the inoculation & anti-biotic agents inhibits the complete advancement of regular immune system particularly in kids. At the point when an immune system is not permitted to deliver Th1 cells as a result of introduction to the microorganisms, has a tendency to create Th2 cells, that are allergy producing, makes the individual more vulnerable towards production of asthmatic indications (Clark, 2011).

1.4.6. Role of Exercise

Another intriguing element among the triggers of asthma is exercise or work out. Over numerous previous years it has been noticed that a few types of work out are more stimulating for the people with asthma putting them at danger of the invasion than alternate activities. Among the exercises that are additionally provoking for asthma symptoms are ice-hockey and skiing are all the more difficult when contrasted with swimming for the patients of asthma. For those patients who had a routine of walking or running, reported that the seriousness of the symptoms evoked after these exercises changed along with weather (Fanta, Carter, Steib, & Haver, 2007).

Exercise is regularly utilized as a screening element within asthma patients whose stimulators are obscure. The non-asthmatic people do not have a tendency to show chest blockage or bronchoconstriction on exercise; but, they do show bronchodialation while exercising or work out. A test known as an exercise test is utilized in the affluent nations. An exercise test may comprise of baseline peak flow measurement then six minutes of supervised energetic work out. Exercise may consist up of walking or running that is trailed by peak flow measurements for around 30 minutes later (Rees, Kanaber, & Pattani, 2010).

1.4.7. Air Pollution

Air pollution is characterized as a mixture of solid particles and gases in the environment. Waste products from automobiles, toxin dumps from industries, dust, smoke, pollen particles and spores of molds found in the atmosphere are the reason for air pollution. A portion of the air contaminators are poisonous and if they enter the lungs may elevate the vulnerability to various ailments. Individuals with heart or lung issues like asthma, aged grown-ups and above all kids have the most susceptibility of exhibiting health problems and issues due to air pollution (Environmental Protection Agency, 2015).

No doubt, air pollutants like SO2 (sulfur dioxide), O3 (ozone) and fuel particles can be the reason of starting asthma symptoms, however it is vague that they have any affluent part in the generation and prompting of the symptoms. It implies that they definitely play the part of initiators of asthma yet they are not the reason or triggering component of asthma. A lot of the latest proof debates against the fact that air pollution has any essential part in asthma in light of the fact that asthma is not any more predominant in urban communities with huge number of vehicle pollution when contrasted with the small towns or valleys that still have a high pervasiveness rate of asthma (Localzo & Barnes, 2010).

1.4.8. Occupational Factors

Occupational Asthma is a sort of asthma that is particularly portrayed by variant air passage blockage, hypersensitivity of airflow passages and infection of air sections particularly because of introduction to the substances found at an individual’s work environment and not outside it (Bernstein, Bernstein, Chang-Teung, & Malo, 2013;Tarlo, Balmes, & Balkissoon, 2008; Tarlo & Lemiere, 2014).

Occupational elements producing asthma are generally common and may have an impact on up to 10% of youthful grown-ups. Laterally, more than 200 inducing substances have been identified. Chemicals like toluene diisocyanate and trimellitic anhydride can be the reason of triggering symptoms without atopy. Individuals may need to face allergens additionally while at work like in lab agents there may be animal allergens and fungal amylase utilized for fermentation of wheat flour by bakers (Localzo & Barnes, 2010).

Occupational asthma might also be known as work related asthma. It is characterized as an asthmatics’ air pathways’ reactions towards dust particles, vapors, exhaust and gases that are present in the working environment. The individual has to deal with these segments daily. It is the extreme condition of preexisting symptoms. It is specifically because of the interaction between the person with such symptoms that may be known to have a part in the impelling and activation of the ailment (Clarke, 2011).

1.4.9. Stress

It can be characterized as a physical or emotional strain that may be nicely endured by the body resulting in proficient working or badly endured which usually brings about some type of fatigue. Negative stress, that is additionally known as distress is thought to be a significant stimulator of asthma (Navarra, 2003).

Stress and asthma have an associated history together. There had been a period in the recent past when stress was believed to be completely or absolutely the reason for asthma. In 1970s, asthma invasions were dealt by relaxation of the patient. Stress can be an activating element for asthma. It is found from the medical experiments that an upsetting circumstance can bring about the minor narrowing of the air ducts in patients with asthma and early treatment with medication can stop that reaction (Fanta, Carter, Steib, & Haver, 2007)

Numerous individuals with asthma are known to report that their asthmatic symptoms turn out to be more awful while experiencing stress. It is a known reality that psychological components have a part in the shrinking of bronchioles that are the minute particles of the lungs. In any case, a few patients have reported contradictory aftereffects of decrease in the seriousness of their illness on confronting intense stress like death of a loved one (Localzo & Barnes, 2010).

1.5. Types of Asthma

There are different types of asthma based on the factors that are the cause of asthma induction in the individuals. All of the types cannot be explained here but a few of them are being described in the text as follows:

• 1.5.1. Childhood Asthma

Asthma is believed to be the most widely recognized persistent disease influencing kids and if it is left uncontrolled, it may have worst impacts on the quality of life of the person. Most of the kids have the customary symptom of wheezing; however few of them do not exhibit this symptom. Cough is frequently neglected in kids and is thought to be common and non-threatening, yet it ought not to be done so as it might be a symptom of asthma. Cough that appears regularly during the evening is a typical symptom of asthma. Such kids could not sleep during the night and as a result face trouble in focusing on studies in the school (Clarke, 2011).

Asthma exhibits an extraordinary variety of symptoms when found in kids in comparison to grown-ups. Alterations are obvious apparently and seriousness in kids and after a passage of time in grown up people. This alteration can be disturbing, if the persons strive to use the grown-up control strategies for the kids. However, it can be illuminating additionally as though the basic reasons are examined it can be useful in managing asthma at all ages (Silverman, 2002).

• 1.5.2. Nocturnal Asthma

The sort of asthma in which the symptoms appear during night, from 12 to 8 a.m. is named as nocturnal asthma. It is triggered by the stimulants at home, for example, dust and animal hair or excretion. It may show up at an early hour in the night but is usually overlooked until gets extreme during night and the individual needs to get up because of abnormal respiration. The symptoms may appear sometimes or as often throughout the week, having symptoms like the daytime asthma. Hence, making the differential screening very problematic. A piece of the data gives the thought that it is the type of the symptoms that are ignored when appearing at daytime reappear in the night (Diette, Markson, & Skinner, 2000).

There is a proceeded and continued debate concerning the reality that whether nocturnal asthma is a separated kind of asthma or not. Some of the evidence gives the view that it is the unaddressed type of the symptoms appearing at daytime which show up again around the hours of night (Diette, Markson, & Skinner, 2000). As indicated by the most recent US dictations, nocturnal asthma is one of the four principle symptoms of asthma that need to be dealt with while treating asthma (Clarke, 2011).

• 1.5.3. Exercise induced Asthma

It is also known as exercise induced bronchospasm. It is a jargon which is utilized for the explanation of the symptoms of asthma that show up when the individual exercises or work outs. It is particularly characterized as intense, brief shrinkage of air ducts as a result of exercise or workout. It is still unapproved that it is a symptom or a different kind of asthma. Some 50%-90% of asthmatics are those with hyper reactivity towards exercise (Rundell & Jenkinson, 2002).

If not controlled, asthma can constrain the tasks of the asthmatics. Patients with asthma need to care about their symptoms routine wise so that it would be dealt totally or decrease in their symptoms when not exercising (National Heart, Lung and Blood Institute, 2007). There is information that reports about 10% of the people with this particular sort of asthma do not tend to produce the symptoms of some other kind of asthma. The differential screening of the people with this specific sort of asthma is truly challenging. They would be reporting cough, problematic respiration, painful ribcage or blockage with or without wheezing (Hurwitz, Argyros, & Roach, 1995).

• 1.5.4. Asthma during Pregnancy

Asthma does not oppose pregnancy. Nonetheless, an expecting lady who has symptoms of asthma which are not effectively controlled is at danger of symptoms getting extreme for both herself and her infant. The data also reports about the changes in the severity of the symptoms in pregnancy; however the proportion of information is equally distributed. Around 33% of the ladies, report the severity of their symptoms, for 33% of the other ladies pregnancy turns into a reason for diminishing the severity of the illness and for the remaining 33% there is no variation at all in their asthmatic symptoms because of pregnancy (Schatz, et.al, 1988; Scatz, 1999; Demessie, Breckenridge, & Rhoads, 1998).

In case the asthma of mother is not appropriately managed, it can have worst consequences for the health of the infant and may finally bring about an increment in the casualties of the infant quickly after been born, birth before expected time and decreased weight at the time of birth which is an indication that the infant is not born healthy and may need to battle in the advancing period because of diverse variety of diseases in the life (Schatz, 1999; Demessie, Breckenridge, & Rhoads, 1998). An asthmatic pregnant lady ought to frequently visit the doctor for subsequent checkups to restrict the symptoms so that any difficulty may be kept away after labor, which incorporates danger to life of both the mother and the child (National Heart, Lung and Blood Institute, 2007; Demessie, Breckenridge, & Rhoads, 1998).

• 1.5.5. Treatment-Resistant Asthma

This word is used for the explanation of the state of those asthmatic people who do not have the ability to react towards the corticosteroids treatment utilized for the control of the symptoms of the ailment. Among all the asthmatic people a collective rate of 5-10% of the patients are the individuals who do not react to the medicines consumed for the remedy of the ailment (Ito, Chung, & Adcock, 2006).

This circumstance can be found in any asthmatic case, yet most frequently it has been seen in those people who are confronting the symptoms at the intense levels of seriousness (Wenzel, 2006). Formerly, it was accepted that this counteraction is directly due to some flaw in the person’s response towards the corticosteroids that restrains the anti-microbial results of the medications. However, the series of studies have shown that there are various parts and procedures of steroid restriction. Likewise, it has been recommended that a few of the patients with asthma who are unaffected by the treatment have alterations in the kind of infection regarding their asthma, because of alterations in the response to the activity of corticosteroids (Barnes, Adcock, & Ito, 2005).

• 1.5.6. Aspirin-Induced Asthma

As indicated by the estimations from various series of studies, just about 21% of grown-ups and 5% of kids with asthma have been found to show speeding up of their symptoms because of painkillers and other non steroidal and anti-biotic medications (National Heart and Lung Blood Institute, 2007). There are various names that are being utilized for the portrayal of this circumstance, specifically, aspirin sensitive asthma (ASA), aspirin induced asthma (AIA) and aspirin exacerbated respiratory disease (AERD). The intensity of the ailment is believed to boost up with the progression of time, with the progress of the age of the patient, the illness likewise gets serious (Spector, Wangard, & Farr, 1979).

Because of the threat of Reye’s disorder, children and teenagers should not consume painkiller or medications that have painkillers as a part for influenza like symptoms or chickenpox without considering the recommendation of the specialist. As it has been demonstrated by a couple of kids so the parents need to consult the specialist before giving painkillers to their asthmatic kids.  Aspirin hyper responsiveness is characterized as continued, usually extreme, attack of asthma, mostly occurring with rhinorrhea, nasal blockage, aggravation in conjunctiva, reddish colored head and neck which shows up after a few minutes or around 1-2 hours of consuming the painkiller (Szczeklik & Sanak, 2000)

Doctors must inquire the grown-up asthmatics about the past history when painkiller consumption caused the chest congestion. Likewise, such grown-up patients who have intense following asthma or nasal polyps ought to be aided about the threat that goes side by side with the utilization of these medications (National Heart, Lung and Blood Institute, 2007). The utilization of aspirin test is not suggested with the aim of screening of ASA due to the fact that it is connected with an expanded threat of life endangering results (Nizankowska, Bestynska-Krypel, Cmiel, & Szczeklik, 2000). The usual consumption of painkillers is known to restrict disease, diminish upper air passage mucosal congestion and decelerate the procedure of nasal polyp creation. In case of the treatment of irresponsiveness gives positive results, the patient is subjected to normal application of aspirin treatment (Simon, 2004).

An individual may have to face many problems during the course of one’s life especially those suffering from a chronic illness like asthma which has long lasting effects on the life of the sufferer. So, if the individual wants to live a better life he or she may have to learn better coping with the encountered problem.

1.6. Coping

There are several descriptions of coping that have been narrated by different famous public figures. The most precise and generally utilized definition is the one proposed by Richard Lazarus and Susan Folkman. As per this definition, coping is a procedure through which individuals attempt to control the apparent changes between the needs and opportunities they evaluate in a disturbing situation (Lazarus & Folkman, 1984).

White (1974) viewed coping as adjustment under comparatively challenging circumstance. As per him, coping attempts are infrequently decided and are in view of prolonged settlement routines or procedures under troublesome and testing circumstances. Potentially, the most effective worker on the subject of coping, Richard Lazarus, presented coping as constantly changing ideas and processes to control particular extrinsic and intrinsic needs that are analyzed as allegation or expanding the convenience of the individuals (Lazarus & Folkman, 1984).

1.6.1. Coping Strategies

The methods or ways that are used to adapt or get used to of the various changes occurring at different stages of life are called as coping strategies or some has also named these as functions of coping. According to Lazarus and colleagues, coping serves two basic functions (Lazarus, 1999; Lazarus & Folkman, 1984). These two functions are:

• It can either alter the problem that is causing stress.
• It can regulate the reaction exhibited towards the problem.

1.6.1.1. Emotion-focused Coping Strategies

These kind of coping techniques are based on controlling the emotional response towards the stressing circumstance. Individuals can standardize their emotional responses through behavioral and cognitive strategies or systems. Behavioral methodologies are those including activities which are aimed to normalize the evoked procedures, e.g., individuals regularly ask help about the conflicts with loved ones. A few individuals simply enjoy diverting actions, e.g., sitting in front of the TV or playing games. This methodology is basically seen in the ladies with breast cancer (Taylor, 1983).

1.6.1.2. Problem-focused Coping Strategies

It is based on reducing the demands of a troubling condition or expanding the opportunities to control it. There are numerous illustrations of problem focused coping in our everyday routine life. e.g., quitting a pressurizing employment, requesting mental or therapeutic help. Individuals are expected to utilize problem focused coping techniques when they believe that their chances or the needs are alternative (Lazarus & Folkman, 1984).

1.6.2. Theoretical Framework of Coping

1.6.2.1. Model of Coping by Lazarus (1983)

Lazarus proposed two types of theories to explain the process of coping. These types are:

1.Trait-oriented versus state-oriented Coping

2. Micro-analytic versus macro-analytic Coping (Krohne & Rodgner, 1982).

• Trait-oriented Strategy

The trait-oriented strategy focuses the early recognition of a person’s availability and extent of coping.

• State-oriented Strategy

The state-oriented technique centers the genuine coping of a man and the outcome one receives by using these coping styles or strategies.

• Micro-analytic Strategy

This methodology investigates a great variation of specific and objective coping techniques.

• Macro-analytic Strategy

This methodology is brought together by real speculative adapting systems.

1.6.2.2. Transactional Model of Coping

This model of coping is a scheme to analyze the procedures of coping with pressurizing experiences. Distressing incidents are gestured as individual-habitat changes. These transformations rely on the effect of the external stressor. This is initially regulated by the individual’s evaluation of the stressor and then on the communal and artistic opportunities within his or her ability to avail (Lazarus & Cohen, 1977; Antonovsky & Kats, 1967; Cohen, 1984).

At the point when subjected to tension an individual inspects the demand of the circumstance (primary appraisal). Primary Appraisal is a person’s choice about the significance of an episode to be pressurizing, positive, controllable, troublesome or irrelevant. After, one encounters a stressor, secondary appraisal is conducted. It is an examination of people’s adapting opportunities and decisions. Secondary appraisal manages what an individual can do of the circumstance. Certain coping tries, that are done for the conformity of the issue lead to aftereffects of the coping procedure (Cohen, 1984).

If an individual can learn to cope better with the encountered problem, then it may result in an improvement in the quality of life of the individual.

1.7. Quality of Life

Quality of Life is characterized as a man’s mental impression of the material truth of the features of the world (Rapley, 2003). Another explanation of the quality of life that is generally used is the one given by the world health organization panel of the quality of life is as per the following:

The views of an individual about their position in life owing to the traditions and normative systems in which they reside and in connection to their objectives, desires and concern consolidating in a intricate manner the individual’s physical health, mental state, level of freedom, social connections, individual faiths and their association with a vital part of their surrounding (WHO, 1999)

1.7.1. Dimensions of Quality of Life

The term quality of life is a very broad term with a vast range of meanings in it. It is impossible to describe all the dimensions of the term quality of life, but a few of these are being described in the following text:

• 1.7.1.1. Health-related dimension of Quality of life

Anna Bowling, one of the predecessors of health related quality of life in United Kingdom, gave the accompanying definition in her book, Measuring Disease: A Review of Disease-Specific Quality of Life Measurement Scales characterizes health related quality of life as:

Health-related quality of life is the highest levels of physical role, working of the body along with relations and ideas of health, fitness, life satisfaction and prosperity. It ought to additionally incorporate a few investigation of the level of satisfaction of patient with the treatment, outcomes and health condition with upcoming strategies. This definition incorporates the parts of the individual and the fair somatic wellbeing that is about feeling healthy and perfect; the genuine physical fitness to do the parts in the community (Bowling, 1995).

Moving from personal to aggregate level of health related quality of life, it is centered on ceasing the transferable ailments, using vaccination and immunization, environmental health measures like bug restraint, edibles’ purity, health information and health improvement. A few investigators have argued regarding a fit society or a sound nation additionally is the one characterized by overall bonding (Wilkinson, 1996; Kawachi, Kennedy, Lochner, & Prothrow-Stith, 1997; Kennelly, O’Shea, & Garvey, 2003).

• 1.7.1.2. International Dimension of Quality of Life

Quality of Life is an essential point in the worldwide advancement as it allows the development to be seen on a more extensive scale when contrasted with the level of life. In the theory of advancement, distinctive ideas addressing, what involves the wanted diversity for a particular community and the various methods that quality of life is portrayed by organizations therefore structures how these organizations work for the collective development of quality of life. Organizations, for instance, World Bank proclaim a reason for “working for a world with no impoverishment” (The World Bank, 2010).

With impoverishment portrayed as an absence of necessary human needs, involving, profession, water, garments, ability to adjust, access to being prepared, treatment administrations or trade. Impoverishment is determined as low quality of life. With the help of this depiction, the World Bank satisfies the necessities to improve quality of life by most recent and free means, with the clear purpose of diminishing impoverishment and to help the individuals to control the price of high quality of life (The World Bank, 2009).

Different foundations, however, can also work towards better worldwide quality of life with a minutely varying definition and essentially distinctive procedures. A great deal of NGOs do not focus to reduce the poverty on a national and worldwide level, yet attempt to improve the quality of life for both people and masses. A case can be scholarship projects that give monetarily help to exceptional people. In spite of the fact that a great number of organizations of this type may even debate about rooting out poverty, the techniques are outstandingly distinctive (Spiegel & Huish, 2010).

The quality of life is improved by struggle of both NGOs and also government. Global health can procure more political existence if governments somehow managed to combine features of human security into global action scheme. Stressing persons’ principal rights of health, roof, food and freedom coordinates clear inter-provincial problems negatively influencing current society and may bring about more prominent activities and results. Isolation of global health concerns into global strategy preserved by ways that are made by overextended parts of safety and mutual agreement (Phillips, 2006).

• 1.7.1.3. Social Dimension of Quality of Life

Psychologists, sociologists and social gerontologists of United States of America led the vast majority of the experimental studies on the theme of quality of life in studies that attempted to compute well-being, satisfaction or joy and what individuals wanted to say when using the words ‘the great life’ explained as psychological fitness, recognized quality of life, behavioral appropriateness, favorable environment. Andrews (1974) opposed that quality of life is the cutoff point to which contentment and happiness have been achieved. Quality of life had been proposed as a effective response to an individual’s action, condition and moral values (Andrews & Withey, 1976), as the distinction among required and genuine circumstances (Krupinski, 1980), progress of the people and/or their surroundings (Bubolz, Schatz, Ray, Swatz, & Brad, 1980).

Overall, quality of life studies in gerontology stretch out side by side, studies on constructive maturing and rotate around feelings of limitation, social associations and the standard of environmental settings (Day, 1991), on mental fitness, intellectual strength, societal capacity and result, individual hold, satisfaction with life and drive to work (Baltes & Baltes, 1990). Essentially, quality of life is still used to propose the old thought of the ‘betterment of life’ (Zautra & Goodhart, 1979). It can likewise be seen in the terms of disparity between reality, the origination of reality and prospects (Calman, 1984; Presant, 1984).

• 1.7.1.4. Philosophical Dimension of Quality of Life

Moving next to each other with this research is the historical interrogation of the happiness beginning from the commitments of initial Greek rationalists to present day logic and sociology (Morgan, 1934; Mason, & Faulkberry, 1978; Andrews, 1981). Bentham (1983) presented the measurement of health and its examination which, he explained, as ‘the difference in quality between the aggregate of a wide range of joys and all of the agonies of each type which a man has to face while a particular course of time’. Three diverse philosophical propositions of ‘the good life’ are: (1) the hedonist, that takes last welfare for the individuals to experience the particular purposeful (2) preference satisfaction, that depicts the pleasant life as the satisfaction of the persons’ wishes and need and (3) the ideal, that contains a part of a ‘good life’ that comprises of the completion of certain conventional beliefs. (Brock, 1993; Scanlon, 1993).

1.7.2. Theoretical Framework of Health-related Quality of Life

            The theoretical framework of health-related quality of life consists of different theories regarding health-related quality of life. A great number of theories have been proposed in accordance to explain the concept of health-related quality of life. Some of the theories have been described as follows:

In 1995, Wilson and Cleary displayed an argumentative model of health-related quality of life (Wilson & Cleary, 1995). This was helped by the necessity for a model which could be used to arrange healthcare methods so that the health-related quality of life of the patients could be made better, reporting the associations between producers and identifiers. This model was further extended by Ferrans (2005). This explored version points out five divisions of patient outcomes from biological plan through symptoms, working condition and usual health perspectives to aggregate quality of life, including a solitary way basic causal association (Ferrans, 2005).

Other than this the Wilson and Cleary (1995) model have been reprimanded due to the reason that it puts additional emphasis on the impact of what the writers recommend to as health-related elements on quality of life (Anderson & Burckhardt, 1999).

Summary

The discussed theoretical framework above shows the association between coping strategies and health-related quality of life specifically for the individuals with asthma symptoms. They are consistently tied together with general agreement that they are related to one another specifically with relevance to patients of asthma.

Chapter 2

Literature Review

A plenty of literature and previous work is available with relevance to the coping strategies and health-related quality of life. The most relevant and accurately related researches are being narrated in the text that follows.

Garro (2011) lead a study to check coping styles which were utilized by the parents to adapt the variations in their life resulted by the ailment of their kid, i.e., asthma. The sample included 26 parents whose kids were experiencing asthma. They were evaluated utilizing Coping Health Inventory for Parents (CHIP) to check the technique for coping utilized by them. The outcomes of the study demonstrated that parents by all possible means adapt to their kid’s asthma by attempting to comprehend the circumstance of their kid, enjoy various activities and creating a positive perspective.

Another explanatory study by Cameron and Wally (2015) analyzed psycho social coping in those suffering from long term, severe ailments. The research reported that long term, severe diseases are the main reason for deaths throughout the world. These ailments are generally, range from minor to life debilitating. Coping with these issues is very troublesome for the individual and in addition the family of the sufferer. Different sorts of coping styles including problem based coping, emotions based coping, separation, adjustment coping, meaning based coping, and association-based coping are discovered to be utilized by the patients and also by their relatives.

Coping depends on individual variations like capacity of sentimental control, observing data and sickness perception. The outcomes demonstrated that poor coping may bring about the physical health to get poor.

Tiggelmann, Monique, Schayck, Kleinjan, and Rutger (2014) evaluated the model of common sense in early teenagers experiencing asthma. It was a long duration study to examine the connection between illness perception, asthma control and sentimental issues with coping techniques utilized as a regulator for all the variables. Common Sense Model was utilized as a part of the study for the sample which comprised of 253 teenagers with an age range between 10 to 15 years. Illness perception was found to be linked with asthma control and sentimental issues. Most of the coping methods do not normalize connection between illness perception and results. Procedures intended to change illness perception in teenagers with asthma could diminish sentimental issues.

Barton, Clarke, Sulaiman, and Abramson (2003) analyzed coping as a regulator of psychosocial impediments to best management and control of asthma symptoms. Asthma patients tend to show poor medical adherence which in turn results in continuance in the appearance of the symptoms and prevent them from disappearing completely. The association between anxiety and depression, and adherence to the treatment could be accurately predicted with the help of coping strategies used. Different coping strategies are used by the patients with asthma to cope with their disease as compared to the healthy individuals as well as other chronic sufferers. Emotion-focused strategies, like denial, were found to be mostly used by the patients with poor medication adherence, those admitted to the hospital or by those who had suffered a fatal asthma attack. Techniques to improve coping strategies have been useful in reducing symptoms and psychological distress. The availability of coping resources to patients and/or their caregivers and the coping strategies that are used are likely to regulate the effect of psychosocial factors on the control of asthma.

Tiggelmann, Monique, Schayck, Kleinjan, and Rutger (2014) evaluated the model of common sense in early teenagers experiencing asthma. It was a long duration study to examine the connection between illness perception, asthma control and sentimental issues with coping techniques utilized as a regulator for all the variables. Common Sense Model was utilized as a part of the study for the sample which comprised of 253 teenagers with an age range between 10 to 15 years. Illness perception was found to be linked with asthma control and sentimental issues. Most of the coping methods do not normalize association between illness perception and results. Procedures intended to change illness perception in teenagers with asthma could diminish sentimental issues.

Farr (1999) led an exploratory study to check the coping styles utilized by those people experiencing asthma. The patients of asthma may utilize such coping methods which would prove catastrophic to them over the long run. It was found that there are stunning resemblance in the coping styles of those suffering from asthma, and additionally those fighting tumor of any sort. It was observed that the patients of asthma additionally have a tendency to show negative coping styles of rejection, outrage, barter and depression.

Mosnaim, Sharp, Grammer, and Kohrman (2004) investigated coping with asthma in African Americans through a focus group research. African Americans experience the long term and severe illnesses like asthma. Thus, this study was led with the motive to understand and clarify the method through which non-medical components aid the guardians or parents of the sufferers to adapt to the illness of their kids, additionally, the adults experiencing asthma. The sample comprised of two groups with ten members each, elder than 18 years old. The information was examined through debate and their responses were recorded. The outcomes showed that to both of the groups, asthma was a source of stress putting them at danger. Thus, the individual feels needier of the support of the family or the guardians.

Mosnaim et.al (2006) directed a study to check coping in settled Hispanics. It was also a focus group study. The study investigated the people’s point of views of their part to look after their asthmatic kid, contrasting the families’ caring styles of the kid, indication of the difficulties arising while taking care of the kid and check specific coping needs of the low pay Hispanic families with an asthmatic kid. Five focus groups were made with low-salary, foreigner, Spanish-speaking Hispanic grown-ups looking after an asthmatic kid, having community health specialists, parents and grandparents, also including ladies with asthma. Voice recorded focus groups were given interpreted verbatim in Spanish, forward interpretation in English, and reverse interpretation in Spanish. Results highlighted the lack of asthma self-controlled techniques, uncertainty in screening, and the utilization of society pharmaceutical as components that ought to be thought about while planning techniques to enhance asthma results in this threatened group of people.

Northup and Weaner (1984) led an exploratory study to investigate the association between hospitalization and capacity to adapt the variations followed by asthma in the life of a person. The sample comprised of 51 hospitalized and 51 non-hospitalized people influenced by asthma. As per the outcomes, hospitalization demonstrated a solid association with intensity of asthma furthermore the variations in life because of asthma. A fractional relation was found with failure to cope with asthma by the individual whereas hospitalization did not demonstrate an association with changes because of different reasons not due to asthma.

Cortina et.al (2011) directed a study to check the connection between single nucleotide polymorphisms in candidate genes associated with different asthma appearance and health-related quality of life (HRQoL). A cross sectional study was directed at a kids’ health care centre in 275 school going youngsters and their caretakers were given a scale to evaluate their quality of life. Genes related with asthma can be related with health-related quality of life somehow free of the working of their lungs.

Leander, Cronqvist, Janson, Uddenfeldt, and Rask-Anderson (2008) reported that health-related quality of life had been contemplated continuously utilized as a measure for the result of asthma, however the consequences for health related quality of life are not known so surely. It was directed to check whether quality of life instruments could anticipate the start of asthma. An sample of 290 subjects who had exhibited asthma indications, were surveyed utilizing spirometry, allergy testing and a survey Gothenburg Quality of Life.

The outcomes demonstrated that the members who exhibited asthma symptoms additionally indicated, mostly, the indications of sleep hindrance, aching rib cage, depression, issue while resting and slightest experienced muscle contraction who did not exhibited asthma (p<0.05). People with low health-related quality of life were discovered to be liable towards falling prey to asthma.

Another research by Sundberg, Palmqvist, Tusater, and Toren (2008) was conducted with the reason to check health-related quality of life, after presenting an intervention strategy in youthful grown-ups with asthma. It was a repeated measure research study, as the sample was examined both previously as well as after the presentation of the intervention. The outcomes demonstrated that female sex and low forced expiratory volume in one second (fev1), both declined between and after follow u. An association was found between low forced expiratory volume in one second (fev1) and female sex. Complain of asthma was reported more by females in comparison with males.

Stahl et.al (2002) reported a study done to assess the health related quality of life (HRQOL) across various countries and the relationship among HRQOL and indicators of asthma. AQLQ and clinical indications were utilized with the goal of investigation. The outcomes demonstrated a significant distinction among all the nations included in the study. The consistency of relationships between the two measures proved the validity of the interpretations which were utilized in the study for analysis. Variations were found in the standard values of the various nations. Cultural, sex and financial contrasts clarified the distinctions in the study sufficiently.

Another research by Ferreira, Brito, and Ferreira (2009) reported a research done with the purpose to measure the health related quality of life in those individuals suffering from asthma. Moreover, the distinction of socio demographic traits by non-disease-specific health related quality of life was also interrogated. Young, single, employed, highly educated, highly paid males belonging to urban areas reported high levels of utility. The results were as expected, the patients with severe disease reported low utility levels as compared to those with mild form of the disease. The measures used in the study were preference-based and they discriminated the patients according to the socio-demographic factors as well.

A long term study by Wang, Wang, Wang, and Hui Zhang (2007) compared the quality of life of adolescents with asthma or epilepsy. These individuals were analyzed using Medical Outcome Study 36-Item Short-Form (MOS F-36) to analyze quality of life (QOL). The results showed that there were no significant differences between the medical traits of the individual with asthma or epilepsy. The results of the study presented the following facts: (i) for both the individuals with epilepsy and asthma showed significant difference between healthy individuals and those with any of the disease (ii) the quality of life of patients with asthma was better than epileptic individuals (iii) the individuals with asthma had better emotional and mental health as compared to the patients with epilepsy.

A research by Engles and Monique (2011) which was conducted to compare the quality of life in asthma patients with role of personality, coping strategies used by the patients and the symptoms most reported by the patients. This research was done with the purpose to check those specific personality traits which were linked with high quality of life and also those with low quality of life. Individuals who were extroverts had high quality of life whereas those who were introverts had low quality of life; moreover the individuals who exhibited agreeableness had positive results on QOL. The coping techniques, positive reevaluation and hidden asthma fully regulated the connection between QOL and agreeableness. The results predicted the relationship between personality and QOL in asthma patients.

A similar research by Hesselink et.al (2004) states that adequate psychosocial coping abilities and a proper coping method can have positive effect on the quality of life in chronic illness’ patients. The aim of the study was the analysis of the connection between psychosocial coping assets and coping process with HRQOL separately for asthma and chronic obstructive pulmonary disease (COPD). The results gave the idea that psychosocial coping techniques and coping methods have a separate association with health-related quality of life (HRQOL) in patients with asthma, as well as a separate link between health-related quality of life and coping strategies in patients with chronic obstructive pulmonary disease (COPD).

Another research by Wilson et.al (2011) reports that the study was conducted with the aim to recommend such perfect tools which could accurately report the perceived effect of asthma on the quality of life of the sufferer. Total seventeen tools were used in this analytical study, eleven developed for use with adults and rest of the six was designed to be used while working with the children. None of the seventeen tools met the criteria of a perfect tool which match the desired traits of the researchers. It was concluded from the results of this research that until the development of a the instrument which meet up the criteria of the desired tool all the other tools could be used as supplemental (standardized and used specifically according to the objectives of the specific study) or emerging (requiring validation as well as standardization).

Homer, Brown, and Walker (2011) surveyed the impact of asthma on the quality of life of school going kids. 183 school going kids from the country zones were subjected to an exploratory examination to check the connection between demographic elements like, reaction to asthma and their quality of life (QOL). Coping recurrence, asthma seriousness and race anticipated asthma related quality of life (AQoL). Asthma seriousness is inversely related with asthma related quality of life (AQLQ).

Luskin et.al (2014) directed a study to check the effect of intensity of asthma and asthma triggers on asthma related quality of life experiencing serious or hard to treat asthma. Asthma related quality of life was surveyed utilizing mini- AQLQ self reported questionnaire, asthma triggers were gathered toward the starting and after every year. It was a longitudinal study containing term of around three years. The outcomes demonstrated that if the asthma activating and intensifying components were evaded it will result in diminishing the scores of mini- AQLQ. It additionally showed a betterment in the QOL of the patients with asthma.

Mullaso, Roppollo, and Rabaglietti (2014) led a study to check the part of individual characteristics and physical frailty on health-related quality of life (HRQoL). It was a cross sectional study in Italian group of aged grown-ups. The sample comprised of 250 individuals with, 74-80 years of age. HRQoL was evaluated utilizing SF-36, mental capacities were checked utilizing Mental Component Summary (MCS) and physical capacities through Physical Component Summary (PCS). Results illuminated the part of individual qualities and single weight of the five components of physical frailty on health-related quality of life.

Indigenous Researches

A lot of work has been done on the topic of coping strategies among different individuals, and quality of life of patients with different diseases and disorders but there is no collective work on the topic of health related quality of life and coping strategies.

An examination via Ismail and Mehmood (1997) led an exploration study to check situational coping and coping qualities of Pakistani students facing an upsetting circumstance. The COPE inventory was utilized to check the coping reactions inside a group of 33 graduated students who were attempting to adapt a particular troubling circumstance, i.e., their exams. Their dispositional coping method was acquired two days before the start of their examination. Dispositional coping was discovered to be a strong indicator of situational coping style. Significant relationship was reported among problem focused coping style before the exam and emotion focused coping after the exam. A significant relationship was additionally found between certainty level and problem focused coping.

A research by Kathleen (2009) done to interrogate the psychological wellbeing, quality of life and coping strategies in cardiac patients. It was hypothesized that all these three variables are correlated with one another, also that these variables would show significant gender differences. The results suggested that there is a significant relationship among Psychological Wellbeing, Quality of Life and Coping Strategies. Significant gender differences were also reported between male and female genders. The subscales of coping strategies also exhibited significant gender differences for both the genders in cardiac patients.

Another research by Ali (2009) assessed the correlation among Depression, Social Support and Quality of Life in those individuals suffering from chronic kidney failure. A significant relationship between depression, social support and quality of life in individuals suffering from chronic renal failure was found. Gender differences were also hypothesized to be present among the three variables. The results confirmed the relationship between the variables and also reported that the nature of the relation between the variables is negative.

Khan (2009) conducted a study for the investigation of the variances in stressful events, perceived social support and coping strategies in females suffering from acute myocardial infarction (AMI) and control group. Significant differences were hypothesized in stressful events, perceived social support and coping strategies in female sufferers and control group. The results confirmed both the hypotheses that the variables are correlated with each other and also that the nature of the relation is positive. Stressful events and coping are positively correlated also that the social support and coping are positively correlated with each other.

Chaudhary (2009) investigated the presence of gender differences in coping techniques those used by patients of blood cancer. It was hypothesized that there are gender differences in coping techniques used by those fighting with blood cancer. Female patients reported to use more coping as compared to the male patients with blood cancer. It was proved by the results that males tend to use problem focused coping as compared to females who are found to be more inclined towards using emotion focused coping. The results also proved the theory that females are more vulnerable to stress as compared to males.

Rasul (2008) conducted a study to investigate the gender differences in perceived quality of life of clients of obsessive compulsive disorder. The sample consisted of 60 clients, 30 males and 30 females from different hospitals of Lahore. The sample was assessed using Urdu versions of WHOQOL scale by world health organization (WHO, 1996). The results showed that there were significant differences in quality of life in OCD clients. It was also indicated that OCD clients perceived differently all the domains of quality of life.

Saher (2008) conducted a research to explore the relation between optimism and quality of life in the students of university of the Punjab. A sample of about 240 students, 120 males and 120 females, from different departments of the university was included in the study. A self constructed local scale of optimism was designed as per the guidelines of the optimism test by Seligman (2002) and WHOQOL-BREF (1996) for the assessment of quality of life. The results showed that optimism was found to be significantly and positively correlated to quality of life.

Saif (2008) examined the relationship between social support and coping strategies in acute myocardial infarction patients. The sample consisted of 36 patients, 18 males and 18 females were subjected to Social Support Scale (2001) and COPE scale (1989) for the assessment of the sample. The results indicated that social support and coping strategies were positively correlated in myocardial infarction patients.

Shami (2008) conducted a study to examine gender differences in self-determination and quality of life of physically disabled young individuals. A sample of 60 physically disabled young individuals was recruited for assessment. Self Determination Scale and WHO QOL Scale were used for the assessment purpose. Results revealed that physically disabled individuals’ quality of life and self-determination level is very low. No gender differences were there on the domains of quality of life and self-determination; moreover, there was no relationship between self-determination and quality of life of physically disabled individuals.

Javed (2008) conducted an exploratory study to know the relationship between quality of life and life satisfaction in patients of breast cancer. The sample consisted of 60 female patients from INMOL hospital of Lahore. The assessment scales included Functional Assessment of Cancer Therapy-Breast (FACT-B) version 4 and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORT QLQ-C30) version 3. The results showed that there was a significant relation between quality of life and satisfaction of life.

Gulraiz (2008) carried out a research that investigated the effect of optimism on coping strategies in patients with Diabetes. The sample consisted of 50 patients with an age range of 45-60 years of age, 22 males and 28 females. The Life Orientation Test-Revised (LOT-R), Gratitude Questionnaire-6 (GQ-6), Adult Hope Scale (AHS), Satisfaction with Life Scale, Subjective Happiness Scale (SHS), Santa Clara Strength of Religious Faith Questionnaire and Coping Strategies Questionnaire (CSQ) were used for the assessment of the effect of optimism on coping strategies. The results revealed that life satisfaction is affected by coping strategies in diabetics.

Ejaz (2008) examined Gender Differences in Quality of Life, Satisfaction with Life and Depression in hospitalized heart patients. The sample consisted of 80 cardiac patients from different hospitals of Lahore. WHOQOL scale, Beck Depression Inventory II (BDI-II) and Satisfaction with Life Scale were used. Results revealed that hospitalized cardiac patients’ quality of life and satisfaction with life is very low and indicated higher level of depression. No gender differences were there in quality of life and significant relationship was found between quality of life, satisfaction with life and depression level in hospitalized cardiac patients.

Saleem (2009) investigated coping strategies in different types of diabetics with relevance to gender, age and education. A survey was conducted to get a sample of 100 diabetics, 50 males and 50 females, from different hospitals of Lahore. COPE-BRIEF (Urdu) version was used for the assessment of coping strategies in diabetics. Males tend to use problem focused coping more and emotion focused coping are more used by females. There was no relationship of age and education with coping strategies in diabetic patients.

Zaman (2009) conducted a research to investigate anxiety and coping strategies in relation to daily hassles among university students. Sample consisted of 100 students, 50 males and 50 females, from different departments of the University of the Punjab. State Trait Anxiety (STAI) and Coping Strategies Questionnaire (CSQ) were used to assess coping strategies. The results showed that there was a significant relationship between the two variables. Results also suggested that daily hassles and anxiety are positively related and no significant gender differences were found in anxiety.

Zaman (2009) carried out a study to examine general anxiety experienced by students and coping strategies used. A sample of 100 students (50 males and 50 females; age range between 19-27 years) was selected from different departments of “Faculty of Life Sciences” University of the Punjab. State Trait Anxiety Inventory (STAI) (Spielberger, 1980) and Coping Strategies Questionnaire (CSQ) (Kausar, 2004) were used for assessment purpose. A positive relationship was found to be there between anxiety and coping strategies. Students tend to use avoidance focused coping more.

Riaz (2009) explored the relationship among Optimism, Hope and use of Coping Strategies in male and female patients with Chronic Obstructive Pulmonary Disease (COPD) patients. The sample consisted of 25 males and 25 females, from different hospitals of Lahore. Life Orientation Test (LOT) (Scheier & Carver, 1985), Herth Hope Index (Herth, 1992) and COPE Inventory (Carver, Scheier & Weintraub, 1989) were used for the assessment of the sample. The results suggested there is a significant relation between optimism, hope and coping strategies.

Shabbir (2009) investigated the effect of thalassemia on the quality of life adolescents as reported by the mothers of the children with thalassemia Quality of Questionnaire (EORTC QLQ) O30 (Aaronson et.al, 1993) was used for the assessment of thee sample. The results indicated that the impact of thalassemia is greater on females from rural background and nuclear family system as compared to males from urban background and joint family system.

Rationale of the study

            A chronic disease like asthma has long lasting effects on the life of the sufferer. So, the rationale of the present study was to check the effect of asthma on the quality of life of the affected individual and the coping strategies used by them as a result to improve the quality of life. The study also analyzes the nature of relationship between coping strategies and health-related quality of life in patients with asthma.

Objectives of the study

The objectives of the present study are:

• To check the presence of the relationship between coping strategies and health-related quality of life of the asthmatic patients.
• To check the type and nature of the relationship between coping strategies and health-related quality of life of the asthma patients.
• To confirm whether there is a positive and direct relationship between the coping strategies and health-related quality of life of the asthmatic patients.

Hypotheses

• There is likely to be a relationship between the coping strategies and health related quality of life in patients with asthma.

• Coping strategies are likely to predict health related quality of life in patients with asthma.
• There are likely to be gender differences between coping strategies and health-related quality of life in patients with asthma.
• There are likely to be differences between coping strategies and health-related quality of life on the basis of family system in patients with asthma.
• There are likely to be differences between coping strategies and health-related quality of life on the basis of family background in patients with asthma.

Chapter 3

Method

3.1. Research Design

It was a correlational study to check the existence and type of relationship between the health related quality of life and coping strategies in asthmatic patients. The design of the study was within group design.

3.2. Sampling strategy

            Purposive sampling strategy was used for the data collection as the data was collected only from the patients of asthma.

3.3. Sample

            The sample of the study consisted of 60 asthmatic patients. These patients were belonging to a specific age group, i.e. 17 to 25 years of age. Though asthma can occur at any stage of life but children, adolescent and young adults are more prone and vulnerable to it. (Localzo & Barnes, 2010).

3.4. Inclusion Criteria

While taking the sample following criteria was kept in mind:

• Only those individuals were added in the sample that could read and write.
• Only those individuals were added in the study suffering from asthma.
• Only those individuals were added in the study falling in the specified age range.

3.5. Exclusion Criteria

The individuals with the following criteria were avoided from adding into the sample:

• Those individuals were not added in the study who were illiterate.
• Healthy individuals, i.e., who were not suffering from asthma were not added in the study.
• Individuals with any other disease than asthma were not added in the study.

3.6. Demographic Characteristics of the Sample

The demographics of the sample are described in the table below:

Table 3.1

Demographic Characteristics of the Sample (n=60)

Characteristics	M(SD)	f(%)
Age	21.17 (24.50)	–                                         –
Gender
Boys	–                                         –	29 34.5%
Girls	–                                         –	31 36.9%
Parents
None	–                                         –	21 25%
Only Father	–                                         –	5 6%
Only Mother	–                                         –	13 15.5%
Both	–                                         –	21 25.0%
Siblings
0-3	–                                         –	15 36.0%
4-7	–                                         –	36 42.9%
8-13	–                                         –	9 10.8%
Birth Order
1-3	–                                         –	38 45.2%
4-6	–                                         –	16 19.1%
7-9	–                                         –	5 7.2%
9-13	–                                         –	1 2.4%
Education
5	–                                         –	23 27.4%
8	–                                         –	8 9.5%
10	–                                         –	16 19%
12	–                                    –	8 9.5%
14	–                                         –	4 4.8%
16	–                                         –	1 1.2%
Occupational Status
Unemployed	–                                         –	38 54.8%
Employed	–                                         –	22 45.2%
Religion
Muslim	–                                          –	59 70.2%
Non-Muslim	–                                          –	1 1.2%
Origin of Language
Urdu	–                                          –	2 2.4%
Punjabi	–                                          –	49 58.3%
Other	–                                          –	9 10.7%
Family System
Joint	–                                          –	24 28.6%
Nuclear	–                                          –	36 42.9%
Family Background
Rural	–                                       –	36 42.9%
Urban	–                                       –	24 28.6%
Per Month Family Income (Rs.)
10,000 and Below	–                                         –	35 40.6%
12,000-20,000	–                                    –	10 13.1%
25,000-35,000	–                                    –	5 6.0%
40,000-50,000	–                                    –	4 4.8%
51,000 and above	–                                    –	6 10.8%
Number of Dependents
0-5	–                                          –	18 21.5%
6-12	–                                          –	40 42.8%
25-30	–                                          –	2 2.4%
Satisfaction with Family Income
Yes	–                                           –	33 39.3%
No	–                                           –	27 32.1%
Duration of Asthma affected life
1-5 years	–                                           –	41 48.8%
6-10 years	–                                           –	13 15.6%
13-17 years	–                                           –	16 7.2%
Age of Onset
4-14	–                                           –	11 13.2%
15-20	–                                           –	34 40.5%
21-25	–                                           –	15 17.9%
Reason of Asthma
Hereditary	–                                           –	19 22.6%
Non-hereditary	–                                           –	41 48.8%

3.7. Measures

Coping Strategies Questionnaire (CSQ, Kausar, 2004) and Asthma Quality of Life Questionnaire (AQLQ, Juniper, 1991) were used to assess study variables.

• 3.7.1 Coping Strategies Questionnaire (CSQ) (Kausar, 2004)

            It consists of 62 items and is developed for Pakistani population. The respondent has to indicate on a 5-point likert scale ranging from “not applicable” to “mostly” indicating degree to which a strategy is used. The questionnaire has four subscales that assess four types of coping, namely as active-practical coping, active-distractive coping, avoidance-focused coping and religious focused coping.

Active practical coping subscale consists of 16 items analyzing practical strategies and to find out practical solutions such as “consult experts for the problem”. Active-distractive coping subscale consists of 9 items covering strategies like “made myself busy in meeting with people”, “going out with friends”. Avoidance-focused coping strategies, with 24 items, included strategies like “wish to forget what happened”, “started avoiding others”. Religious focused coping strategy, having 13 items, included items like “prayed to God”.

            The scale consisted of four subscales, described above. The alpha reliability of all the subscales was found to be good for the present study. The α-reliability of active practical coping subscale was found to be .79 for the present study. The α-reliability of active distracting coping subscale was found to be .62. For the other two subscales, naming, avoidance and religious focused coping it turned out to be .76 and .80 respectively.

• 3.7.2. Asthma Quality of Life Questionnaire (AQLQ) (Juniper, 1991)

There are 32 questions in the AQLQ and they are in 4 domains (activity limitation, symptoms, emotional function and environmental stimuli). The Activity Limitation domain contains 5 ‘patient-specific’ questions, e.g., “how limited have you been during the last two weeks in strenuous activities like, running upstairs”. This allows patients to select 5 activities that moved from strenuous to work related tasks. The Symptoms domain consists of 12 items regarding the severity of the symptoms of the patients, e.g., “how much discomfort or distress have you felt during the last two weeks due to symptoms like chest tightness?” The next domain, i.e., Emotional Functioning 5 items, like, “How much of the time during the last two weeks did you feel concerned about having asthma?” The last domain which is Environmental Stimuli, comprises of items, like, “how much of the time during the last two weeks did you experience asthma symptoms as a result of being exposed cigarette smoke?”

The response scales also vary for each of the subscale, e.g., for the activity limitation the response options are like, 1= totally limited, 2= extremely limited, 3= very limited, 4= moderate limitation, 5= some limitation, 6= a little limitation and 7= not at all limited. The response scale for symptoms is assessed like, 1= a very great deal, 2= a great deal, 3= a good deal, 4= moderate amount, 5= some, 6= very little and 7= none. The last two subscales, i.e., emotional functioning and environmental stimuli items are judged on the similar scale, i.e., 1= all of the time, 2= most of the time, 3= a good bit of the time, 4= some of the time, 5= a little of the time, 6= hardly any of the time and 7= none of the time. Patients were asked to respond to each of the 32 questions on a 7-point scale (7 = not impaired at all – 1 = severely impaired). The overall AQLQ score is the mean of all 32 responses and the individual domain scores are the means of the items in those domains.

The α-reliability for each subscale was calculated separately. The α-reliability for the activity limitation subscale was calculated to be .86 for the activity limitation subscale, for symptoms subscale it was found to be .95 and for emotional functioning and environmental stimuli, it was .83 and .85 respectively.

3.8. Procedure

First of all, proper permission from the authors of the scales being used in the study for the assessment of the sample, i.e., Asthma Quality of Life Questionnaire (AQLQ) by Juniper (1991) to study quality of life in patients with asthma and Coping Strategies Questionnaire (CSQ) by Kausar (2004) to study the coping strategies being used by patients to cope with the disease and improve quality of life was obtained.  An authority letter from the director of the Institute of the Applied Psychology, University of the Punjab for data collection was signed from the medical superintendents, i.e., M.S. of the three well known hospitals of Lahore. After getting the permission for data collection from the respective heads the participants of the study were approached from three government hospitals. Ghulab Devi Chest hospital, Jinnah hospital and General Hospital of Lahore, were the hospitals whose heads allowed to collect data from the patients in their hospital. Informed consent was taken before including the individuals in the study, the purpose of the study was made clear to them and they were informed about their right of quitting the research and walk away. Their data confidentiality was ensured. Then they were given the questionnaire for the assessment and evaluation. After they were done, the filled questionnaires were taken back from them and once again confidentiality was ensured.

3.9. Ethical considerations

There were some ethical considerations that were kept into the mind, that are as follows:

• The scale was used after taking permission from the author, for its use and reproduction.
• Participants were not forced for the participation; they were free in this regard.
• Informed consent was taken.
• Confidentiality was ensured.
• They were given the right of quitting the research anytime they like.
• The data was not collected from the hospital whose head did not allow the data collection from their hospital.

Chapter 4

Results

It was hypothesized that there is likely to be a relationship between coping strategies and health-related quality of life in patients with asthma.  Coping strategies were assessed using the Coping Strategies Questionnaire (CSQ) by Kausar (2004) and Health related quality of life in patients with asthma was assessed using Asthma Quality of Life Questionnaire (AQLQ) by Juniper (1991). It was also hypothesized that coping strategies are likely to predict health-related quality of life significantly in patients with asthma. Moreover, it was hypothesized that there are likely to significant differences in patients with asthma on the basis of gender, family background and family system.

The data was analyzed using the SPSS v16 software. The relationship between the variables was analyzed using the analysis of correlation.

Table 4.1

Relationship between Coping Strategies and Health-Related Quality of Life

Sr. no	Variables	1	2	3	4	5	6	7	8
1.	Activity Limitation		.84**	.87**	.62**	.24	.36**	-.14	-.03
2.	Symptoms			.88**	.29*	.34**	.48**	-.20	-.02
3.	Emotional Functioning				.50**	.24	.36**	-.26*	-.05
4.	Environmental Stimulus					-.07	-.05	-.06	.01
5.	Active Focused Coping						.55**	.07	.42**
6.	Active Distracting Coping							-.13	.02
7.	Avoidance Focused Coping								.40**
8.	Religious Focused Coping

**p<0.01,*p<0.05

The results showed that if active distracting coping increases activity limitation also increases, e.g., increased smoking can limit physical activity. Active practical coping is negatively related with symptoms. Active practical coping results in less distress caused by symptoms. If active distracting coping increases, then the severity of the symptoms gets less distressing. Emotional functioning improves if active distracting coping is used.

If avoidance focused coping is used, it decreases emotional functioning. The results also revealed that there is no relationship between religious coping with any quality of life subscale. Only active practical coping predicts quality of life significantly.

Table 4.2

Coping Strategies as predictors of Health related Quality of Life in Patients with Asthma.

Variables	β	95% CI
Active Practical Coping	.12	-.22-.46
Active Distracting Coping	.32	.02-.58
Avoidance Focused Coping	-.16	-.51-.13
Religious Focused Coping	-.02	-.28-.24
R2	.20
F	3.36**
Δ R2	.20
Δ F	3.36**

Note. β=standardized Co-efficient, CI= Confidence Interval, R²= R square, F= level of significance, ΔR²= R² change, ΔF= F change and **p<.01.

The results of regression analysis showed that the model of coping strategies predicted health related quality of life significantly. 20% of the variability in health related quality of life was accounted for by coping strategies. Active distracting coping was the strongest predictor of health related quality of life, i.e., β= .32. The assumption of multi-collinearity was fulfilled. All the tolerance values were greater than .2.

Table 4.3

Gender differences in Coping Strategies and Health related Quality of Life among Patients with Asthma

	Males		Females				95% CI		Cohen’s d
Variables	M	(SD)	M	(SD)	t	p	LL	UL
Active Practical Coping	8.03	.88	7.45	.84	2.64	.01	.14	1.03	.67
Active Distracting Coping	6.63	1.08	6.06	.83	2.28	.03	.07	1.06	.59
Avoidance Focused Coping	7.00	.76	7.06	.78	-.48	.63	-.49	.30	-.08
Religious Focused Coping	8.06	.81	8.11	1.26	-.15	.88	-.59	.51	-.05
Activity Limitation	2.13	1.01	1.80	.73	1.45	.16	-.13	.78	.37
Symptoms	2.54	1.28	1.95	.87	2.07	.04	.02	1.14	.54
Emotional Functioning	2.75	1.28	2.54	.95	1.06	.29	-.27	.89	.27
Environmental Stimuli	1.25	.69	1.51	1.08	-1.09	.28	-.73	.21	-.29

Note. CI=confidence interval, UL=upper limit and LL=lower limit.

Equal variances were assumed and there is a difference in active practical coping among male and female patients of asthma. Equal variances were assumed and there is a difference in active distracting coping among male and female patients with asthma. Equal variances were assumed and there is no difference in avoidance focused coping among male and female patients with asthma. Equal variances were not assumed and there is no difference in religious focused coping among male and female patients with asthma.

Table 4.4

Differences on the basis of Family System in Coping Strategies among Patients with Asthma

	Joint		Nuclear				95% CI		Cohen’s d
Variables	M	(SD)	M	(SD)	t	p	LL	UL
Active Practical Coping	7.68	.93	7.76	.90	-.34	.74	-.56	.40	-.09
Active Distracting Coping	6.30	.91	6.36	1.05	-.26	.80	-.60	.46	-.06
Avoidance Focused Coping	6.97	.73	7.07	.79	-.53	.60	-.51	.30	-.13
Religious Focused Coping	8.24	1.27	7.99	.89	.92	.36	-.30	.82	.23
Activity Limitation	2.14	1.12	1.84	.67	1.30	.20	-.16	.76	.33
Symptoms	2.33	1.22	2.18	1.05	.50	.62	-.44	.74	.13
Emotional Functioning	2.70	1.31	2.52	.99	.60	.55	-.42	.77	.16
Environmental Stimuli	1.66	1.25	1.20	.54	1.93	.06	-.01	.93	.48

Note.  CI=confidence interval, UL=upper limit and LL=lower limit.

            Equal variances were assumed and no difference was found on the basis of family system in active practical coping among patients of asthma. Equal variances were assumed and no difference was found on the basis of family system in active distracting coping among patients of asthma. Equal variances assumed and no difference was found in avoidance focused coping on the basis of family system in patients with asthma. Equal variances were assumed and no difference was found on the basis of family system in religious focused coping among patients of asthma.

Table 4.5

Differences on the basis of Family Background in Coping Strategies among Patients with Asthma

	Rural		Urban				95% CI		Cohen’s d
Variables	M	(SD)	M	(SD)	t	p	LL	UL
Active Practical Coping	7.47	.89	8.12	.80	-2.89	.00	-1.09	-.20	-.77
Active Distracting Coping	6.02	.96	6.81	.85	-3.29	.00	-1.28	-.31	-.87
Avoidance Focused Coping	7.24	.78	6.72	.62	2.73	.00	.14	.91	.74
Religious Focused Coping	8.18	1.19	7.95	.82	.84	.40	-.32	.79	.23
Activity Limitation	1.80	.85	2.20	.89	-1.76	.08	-.86	.06	-.46
Symptoms	1.86	.99	2.82	1.07	-3.58	.00	-1.50	-.42	-.93
Emotional Functioning	2.27	1.12	3.08	.96	-2.88	.00	-1.36	-.25	-.35
Environmental Stimuli	1.47	1.04	1.25	.69	.92	.36	-.26	.71	.25

Note. CI=confidence interval, UL=upper limit and LL=lower limit.

Equal variances were assumed in active practical coping among patients of asthma and there is a difference in coping on the basis of family background in patients with asthma.  Equal variances were assumed and difference was found on the basis of family background in active distracting coping among patients of asthma. Equal variances assumed and difference was found in avoidance focused coping on the basis of family system in patients with asthma. Equal variances were assumed and no difference was found on the basis of family system in religious focused coping among patients of asthma.

Chapter 5

Discussion

The present study was aimed to investigate the relationship between coping strategies and health related quality of life in the patients of asthma. It was also purported to check the nature of the relationship between the two variables, i.e., whether it was a positive and direct relationship which means upon increasing one variable other variable also increases automatically or the other variable decreases on increasing the other variable. It was hypothesized that there is a likely to be a relationship between coping strategies and health related quality of life in patients with asthma. It was also hypothesized that coping strategies are likely to predict health-related quality of life significantly in patients with asthma. Moreover, it was hypothesized that there are likely to significant differences in patients with asthma on the basis of gender, family background and family system.

The findings of the study confirmed the hypothesis that there is a relation between coping strategies and health related quality of life in young patients with asthma. Moreover, significant differences were found on the basis of gender and family background. No differences were found on family system in coping strategies by patients of asthma. Boys were found to use more active practical and active distracting coping whereas girls used more avoidance focused. Religious focused coping was found to be equally used by both genders. No differences were found on any type of coping on the basis of family system among patients of asthma. Moreover, differences were found to be there on the basis of family background. Urban community was found to use more active practical and active distracting coping as compared to rural which showed more inclination towards avoidance focused coping. Religious focused coping was found to be used equally by both the communities. The results of some similar studies are being discussed in the following text:

Garro (2011) showed that the parents of the sufferers of asthma mostly tend to cope with the disease of their children by using the problem focused coping strategies or techniques. These techniques include gaining knowledge and understanding of the encountered problem which in this case is asthma, so that they are able to deal with it by themselves and can educate their child also to decrease the impact of asthma on their lives.

In Pakistan, there is a lack of knowledge regarding the coping techniques to deal with the encountered problem which is asthma in this case. This is the cause that the sufferers have a decreased or low quality of life due to their asthma. The individuals should be imparted knowledge about their problem and the techniques which may prove to be helpful in dealing with the problem so that they may improve their quality of life by effective coping accordingly.

Cameron and Wally (2005) lead a study to interrogate the psychosocial coping in the patients of chronic illnesses, i.e., ailments affecting a long period of time of the sufferers’ life.  There are various types of coping used by the individuals, like, emotion focused coping, problem focused coping, disengagement, accommodative coping, relationship focused coping and meaning focused coping were found to be most extensively used by the individuals to cope with the changes in life due to the chronic illnesses not only by the patients but also by their family members. According to the results, poor coping may cause a visible decrease in the physical health of the individuals.

When looking at the situation in Pakistan, it is seen that people tend to show a greater inclination towards using emotion focused coping as compared to any other type of coping described above. Females use more emotion focused coping as compared to men who use problem focused coping than the women. This may sometimes cause their illness to get poorer because of the stress caused by negative emotions.

Another research by Barton, Clarke, Sulaiman and Abramson (2003) reported coping to be a regulator of psychosocial barriers for the normal functioning of lungs and asthma symptoms. Asthma patients exhibit poor ability to follow medical treatment and using medications regularly which results in prolonged prevalence of their symptoms. There are different types of coping methods to deal with the changes in life due to the disease. These types include problem-focused coping, emotion-focused coping, disengagement, accommodative coping, meaning-focused coping and relationship-focused coping which are most commonly used by the patients and family members of affected individuals of asthma. The results showed that patients who had poor medical adherence tend to use emotion-focused coping more as compared to the individuals with better medical adherence.

The situation of the patients of asthma is also not different in Pakistan. The patients, who have poor medical adherence, use more coping strategies to regulate their emotions as compared to the individuals with better medication adherence or those who had been hospitalized for the treatment and management of their symptoms. By teaching more effective types of coping like problem-focused coping, the symptoms can be reduced similarly in the patients of asthma belonging to Pakistan.

Leander, Cronqvist, Janson, Uddenfeldt and Rask-Anderson (2008) lead a study to check that whether the quality of life tools could forecast the triggering of asthma. The sample was analyzed using Gothenburg Quality of Life Questionnaire. According to the results, the asthmatic patients also showed the symptoms of hyposomnia, chest pain, depression, inability to relax and convulsions as compared to those individuals who did not developed the symptoms of asthma. Moreover, individuals with low health-related quality of life face more risk of asthma.

The sufferers of asthma in Pakistan also tend to show a decreased health-related quality of life because of the lack of health facilities to tackle with the disease effectively. The health-related quality of life of the patients can be improved by providing them better health care facilities so that they may enjoy healthy and normal life while effectively controlling their asthma symptoms.

Farr (1999) conducted a study to explore and check the coping methods adapted by patients of asthma. The study says that asthma patients may use such coping techniques which would cause their symptoms to become more problematic for them. The results found stunning similarities in the coping of asthma patients and the sufferers of cardiac failure. Negative coping styles of denial, anger, bargaining and depression were most exhibited by them.

Similarly, in Pakistan the patients use emotion focused coping strategies like denial instead of problem focused coping like using regular medical adherence to control the symptoms of asthma and treat the disease completely by using medication along with safety measures.

Another research study by Wodka and Barakat (2006) done to explore the relationship between coping and family support in college students suffering from chronic illnesses. Chronic illness or experimental group showed more anxiety and depressive symptoms as compared to the positive life event or control group. On comparison of the study with the situation in Pakistan, a little bit of similarity is reflected.

The individual who falls prey to a long term ailment tends to develop problematic psychological symptoms of anxiety, worry, tension, sadness or depression. It is also seen that the individuals who receive an adequate source of support from their friends and family show more effective and efficient coping with the symptoms of the disease as compared to those who are deprived of this support.

The education of health is purported to provide such information and skills which help them to cope effectively with the symptoms in daily life. It also helps in better motivation of the patients. On investigation of the link between coping and illness, it is necessary to focus on both illness as well as treatment. Moreover, the connection between patient, his environment and the society should also be kept into consideration (Deenan & Klip, 1993).

Recently, the domain of health psychology is gaining much popularity in Pakistan which is aimed to develop awareness of those psychological factors which may provide basis for the development of the symptoms of various physical diseases. It has been introduced as a separate field and education is being imparted in different famous universities of Pakistan. Also, the individuals are being trained to tackle the psychological factors by themselves so that they would not become the cause of physical illnesses in them.

A research by Kathleen (2009) showed similar results to the present study. A significant relationship between quality of life and coping strategies was found between the patients suffering from cardiac illnesses. It was hypothesized that both the variables are significantly correlated with one another.

Another research Ali (2009) checked the relationship between social support, depression and quality of life in patients with chronic kidney failure. A significant relationship was found to be present between the three variables. The results confirmed that there is a relation between these variables and the nature of the relationship is negative or inverse, i.e., on increasing one the other decrease automatically.

Zaman (2009) conducted a research which had the similar results as of this research. A significant relationship between the two variables was reported to be present. The result also suggested that daily hassles and anxiety are positively related and there are no gender differences in anxiety.

5.1. Conclusion

            The present age is the age of machinery. Every field has been mechanized; this has helped to save time no doubt, but at the same time has caused a rapid increase in the pollution which is resulting in different health issues including respiratory diseases along with skin problems. The greenery is being removed to get clear land for cultivation and for new industries, which is increasing pollution with a increase in temperature and decrease in fresh air full of oxygen causing an increase in problem of lungs like asthma or COPD (chronic obstructive pulmonary disease.

The results of the present study show that active distracting coping and activity limitation are positively related to each other, i.e., if one is increased the other automatically increases. Active practical coping is negatively related to symptoms, by increasing active practical coping the symptoms become less distressing. Active distracting coping reduces the distress caused by symptoms, emotional functioning gets better by increasing active distracting coping. Avoidance focused coping decreases emotional functioning and no significant relationship was found between religious focused coping and any of the quality of life variables. Moreover, only active practical coping predicted asthma quality of life significantly.

5.2. Limitations

There were some limitations which affected the results. These limitations are as follows:

1. The data was collected only from the hospitals of Lahore. The sample was small, so the results could not be generalized on the other population of asthma patients in Pakistan.
2. The participants were unable to understand some of the items of one of the scale and it was quite difficult for the researcher to explain those items to them.
3. Time span was quite limited for the data collection as well as the whole research.
4. There were some cultural differences also which affected the results of the research.

5.3. Suggestions

Some of the suggestions are being listed in the following to remove the limitations described above. The limitations can be removed by taking some simple steps as follows:

1. A large scale study should be conducted including the sample from various cities of Pakistan to ensure generalization of the results.
2. The time span should be increased to acquire more sample.
3. Such tools should be developed which would be culture free and also tool translation should be avoided to ensure originality of the scale.

5.4. Implications

The study has some important implications which are as follows:

1. The findings of the study could be helpful in better understanding of the situation of asthma.
2. Such steps could be taken which would be helpful to decrease the prevalence of the disease.
3. The triggering factors of the disease could be reduced.
4. Better health facilities should be provided in the hospitals to the patients.

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