The Relationship Between Quality of Life and Coping Strategies in Hospitalized Patients with COVID-19

authors:

avatar Navid Mirzakhani Araghi ORCID 1 , avatar Shafagh Saei ORCID 2 , * , avatar Mehdi Alizadeh Zarei ORCID 3 , avatar Parvin Dibajnia ORCID 1 , avatar Leila Angooti Oshnari ORCID 4

Department of Occupational Therapy, School of Rehabilitation, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Department of Occupational Therapy, Rehabilitation Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
Department of Occupational Therapy, School of Rehabilitation, Iran University of Medical Sciences, Tehran, Iran
Department of Occupational Therapy, Shohada_e_Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Middle East Journal of Rehabilitation and Health Studies: Vol.9, issue 2; e118587
published online: April 20, 2022
article type: Research Article
received: August 12, 2021
revised: March 5, 2022
accepted: March 9, 2022
DOI: https://doi.org/10.5812/mejrh-118587

how to cite: Mirzakhani Araghi N, Saei S, Alizadeh Zarei M, Dibajnia P, Angooti Oshnari L. The Relationship Between Quality of Life and Coping Strategies in Hospitalized Patients with COVID-19. Middle East J Rehabil Health Stud. 2022;9(2):e118587. https://doi.org/10.5812/mejrh-118587.

Abstract

Background:

The COVID-19 pandemic may have destructive effects on patients’ mental health and quality of life (QoL).

Objectives:

This study aimed to assess the relationship between QoL and coping strategies in hospitalized patients with COVID-19.

Methods:

This cross sectional descriptive-analytical study was performed at Imam Reza Hospital in Tabriz City for 2 months. Seventy hospitalized patients with COVID-19 were recruited by convenience sampling. The patients completed the adapted version of the World Health Organization Quality of Life Scale Brief Version (WHOQOL-BREF) and the Coping Strategies Questionnaire (CSQ). We indicated a critical value of 60 as the optimal cut-off point to assess perceived QoL. Also, low, moderate, and high coping strategies are dedicated to 0 - 66, 66 - 110, and > 110, respectively. Data were analyzed using the Pearson correlation coefficient in SPSS version 21.

Results:

Seventy patients were enrolled, including 35 males and 35 females with a mean age of 39.69 ± 11.31 years. QoL’s social and physical dimensions had the highest and lowest mean scores (65.18 ± 18.99 and 41.40 ± 17.22, respectively). The results showed that 3 out of 5 dimensions had a mean score of < 60. Regarding CSQ, the mean scores of problem- and emotional-oriented coping strategies were 87.27 ± 15.45 and 85.05 ± 12.47, respectively. Most participants had moderate problem- and emotional-oriented coping strategies (85.5% and 92.8%, respectively).

Conclusions:

The current study showed that the QoL score was less than 60 in most of the QoL dimensions in COVID-19 patients. Moreover, most of the participants used coping strategies moderately. Therefore, it is recommended to perform further studies to compare the impact of coping strategies on QoL in patients and the control group.

1. Background

COVID-19 is a new, genetically modified, highly contagious virus from the coronavirus family called SARS-CoV-2 (1). It spread rapidly throughout the world and infected almost all countries in a short period (2). This disease may endanger the mental health status of people (3-5) due to superstitions and misinformation about this pandemic, travel bans, and executive instructions for passengers’ quarantine (6, 7). It may considerably affect patients’ quality of life (QoL) (8). Because QoL, with its various dimensions, aids clinicians in determining problems influencing people’s everyday life (9).

Previous studies on patients with COVID-19 in China during the spread of the disease have reported a high prevalence of several psychological disorders, including anxiety, fear, depression, emotional changes, insomnia, and posttraumatic stress disorder (PTSD) in these patients (10, 11). In patients with COVID-19, PTSD is one of the most important psychological disorders that can damage their mental health (12).

In stressful situations, people use various coping strategies. They can be classified into 8 subscales: confrontive coping, distancing, self-controlling, seeking social support, accepting responsibility, escape-avoidance, planful problem solving, and positive reappraisal subscales (13). Emotion- and problem-focused strategies are the 2 main coping mechanisms in these situations. The emotion-focused strategies attempt to regulate the emotional consequences of a traumatic event by controlling overwhelming emotions. Problem-focused strategies include activities and responses to remove or alter the source of stress, such as applying cognitive and problem-solving skills. Typically, when people can deal with stressful situations, they use problem-oriented coping strategies, and if they cannot change the case, they might cope with emotion-focused responses (13, 14). Studies have demonstrated individual differences in coping with stress and the association of various coping techniques with health and QoL (15). Determining an appropriate coping strategy is essential to better manage COVID-19 and implement necessary interventions and public health policies; accordingly, we performed this study during the COVID-19 pandemic. In a previous study, during the COVID-19 pandemic, financial security and optimism about the disease increase one’s chances of coping well, while having pre-existing medical conditions and sleeping more than before reduces one’s chances of coping well. They recommended considering their results in planning mental health and public health intervention/policy (16). Earlier studies also suggested that the effectiveness of coping strategies was context-specific and could affect health planning (17, 18).

2. Objectives

According to the importance of COVID-19 as a new concept for medical caregivers, its probable consequences on patient’s mental health/QoL, and based on the importance of assessing the use of diverse methods (such as coping strategies), the present study aimed to assess thoroughly the possible relationship between the QoL of patients with COVID-19 and coping strategies adopted by them.

3. Methods

3.1. Study Design

This cross-sectional study was performed at Imam Reza Hospital in Tabriz City for 2 months, from May 2020 to June 2020. As the Imam Reza Educational Hospital is the primary referral center for patients with COVID-19 in East Azerbaijan, it was chosen to conduct this study. A sample of 70 hospitalized patients with COVID-19 was selected by convenience sampling and based on the following inclusion criteria: (1) COVID-19 patients with a consciousness higher than 12 on the Glasgow scale and (2) the definitive diagnosis of COVID-19 based on the patient’s medical history. Patients were excluded from the study if they refused to complete the questionnaires or if their level of consciousness was below 12 on the Glasgow scale.

3.2. Data Collection Tool and Technique

After obtaining informed consent, the World Health Organization Quality of Life Scale Brief Version (‎WHOQOL-BREF) and the Coping Strategies Questionnaire (CSQ) were completed, and the demographic characteristics were recorded, including age, sex, education, job, and marital status by patients under the supervision of the researcher.

3.2.1. WHOQOL-BREF

WHOQOL-BREF has 26 items. Each item is rated on a 5-point Likert scale where 1 indicates the lowest negative perceptions and 5 reveals the highest positive perceptions. The score ranges from 26 to 130. To describe the result thoroughly, there is a critical value of 60 as the optimal cut-off point for assessing perceived QoL and satisfaction with health. The first question evaluates QoL in general; this question is called the Single Item Score (SIS), and the second question considers health condition satisfaction. The other 24 questions are grouped into 4 dimensions, including psychological (6 items), social (3 items), environmental (8 items), and physical (7 items) questions (19). In Iran, the validity and reliability of this questionnaire were reported by Taghavi et al. (2014). They mentioned the Cronbach alpha values of ≥ 0.7 in all dimensions (20).

3.2.2. CSQ

In its original version, CSQ consists of 66 items assessing patients’ self-rated use of cognitive and behavioral strategies to cope with daily stress. Problem-oriented coping types consist of seeking social support, accepting responsibility, planful problem solving, and positive reappraisal. Emotional-oriented coping types consist of confrontive coping, distancing, self-controlling, and escape avoidance. Each item in the questionnaire is scored from 0 (I did not use it at all) to 3 (I use it a lot) based on a 4-point Likert scale. Each subscale has a maximum score of 36 and a minimum score of 0. Low, moderate, and high coping strategies are dedicated to 0 - 66, 66 - 110, and > 110, respectively (21). In Iran, the validity and reliability of this questionnaire were reported by Rostami et al (2013). The Cronbach alpha ratio ranged from 0.61 to 0.79, and the test-retest reliability for 4 weeks was 0.59 - 0.8 (22).

3.3. Ethical Considerations

Before the commencement of the study, ethical approval was obtained from the Ethics Committee of Shahid Beheshti Medical University (code: IR.SBMU.RETECH.REC.1399.674). Online informed consent was obtained from all the participants prior to their participation in this study.

3.4. Statistical Analysis

The variables were described according to the type of variables (quantitative or qualitative) using descriptive statistics (mean, SD, frequency, and percentage). The Pearson correlation test analyzed the relationship between QoL dimensions and coping strategies. All analyzes were performed using SPSS version 21 (SPSS Inc, Chicago, Ill, USA). P values less than 0.05 were considered statistically significant.

4. Results

In this study, 70 patients were enrolled, including 35 males and 35 females with a mean age of 39.69 ± 11.31 years (ranging from 20 to 68 years). Among these patients, most of them (66.3%) were married, had a university degree (76.3%), and were employed (80%). Regarding the duration of hospitalization, 54.3% were hospitalized for 0 - 10 days. The detailed demographic characteristics of the participants are presented in Table 1.

Table 1.

Demographic Characteristics of Hospitalized Patients with COVID-19

VariablesValues a
Age (y)39.69 ± 11.31
Sex
Male35 (50)
Female35 (50)
Marital status
Single19 (27.4)
Married47 (66.3)
Widow4 (6.3)
Education level
Elementary4 (5.6)
High school13 (18.1)
University degree53 (76.3)
Employment status
Unemployed/housewife12 (17.7)
Retired2 (2.9)
Employed56 (80)
Duration of hospitalization (days)
0 - 1038 (54.3)
10 - 2025 (35.7)
20 - 307 (10)

a Values are expressed as mean ± SD and No. (%).

The results showed that in WHOQOL-BREF, the social dimension had the highest mean score, and the physical dimension had the lowest mean score (65.18 ± 18.99 and 41.40 ± 17.22, respectively). It showed that the social and psychological dimensions had the optimal cut-off point for assessing perceived QoL and satisfaction with health-but the physical, environmental, and general health did not.

In terms of CSQ, the mean scores of problem- and emotional-oriented coping strategies were 87.27 ± 15.45 and 85.05 ± 12.47, respectively. Therefore, patients mostly had higher levels of the problem-oriented coping strategy. The results showed that most participants had moderate problem- and emotional-oriented coping strategies (85.5% and 92.8%, respectively; Table 2).

Table 2.

The Mean Scores on Quality-of-Life Dimensions and Coping Strategies

VariablesMeanStd. Deviation
QoL dimensions
Physical41.407917.22972
Psychological63.587015.37010
Social65.188218.99838
Environmental53.630517.72387
General health 43.571421.36031
The total score of emotional-oriented coping strategy 85.058012.47336
Emotional-oriented coping strategy subscales
Confrontive coping14.57143.16947
Distancing 14.00003.00979
Self-controlling18.27143.30534
Escape-avoidance19.08704.65498
The total score of problem-oriented coping strategy87.275415.45095
Problem-oriented coping strategy
Accepting responsibility 10.04292.71034
Seeking social support 17.60003.97602
Panful problem solving 16.24293.54039
Positive reappraisal19.77144.31100

In addition, there was a direct and significant relationship between physical and general health dimensions of QoL with the problem-oriented coping strategy (r = 0.340, P = 0.005 and r = 0.271, P = 0.025, respectively; Table 3).

Table 3.

The Relationship Between Quality-of-Life Dimensions and Coping Strategies

QoLCoping Strategies
Problem-Oriented Coping StrategyEmotional-Oriented Coping Strategy
rPrP
Physical0.340 a0.005-0.0190.881
Psychological0.0950.4390.0200.869
Social0.0550.676-0.0330.798
Environmental0.0460.714-0.2370.054
General health0.271 b0.025-0.0890.465

aCorrelation is significant at the 0.01 level.

bCorrelation is significant at the 0.05 level.

5. Discussion

This study showed that QoL’s social and physical dimensions had the highest and lowest mean scores, respectively. Besides, most participants had moderate problem- and emotional-oriented coping strategies. It was noted that a higher level of the problem-oriented coping strategy was used than the emotional strategy. It is noteworthy that there was a direct and significant relationship between the score of the physical dimension and the total score of QoL with the problem-oriented coping strategy.

Since assessing QoL is essential due to the long-term lockdown and isolation during the outbreak of COVID-19, recent Chinese investigations have been performed using psychometric instruments (such as Short Form-18(SF-18) (23) and utility instruments (such as EQ-5D-3L) (24). The current study showed that the QoL score was less than 60 out of 100 in 3 main dimensions (possibly due to COVID-19), which was consistent with a previous study (24). Mucci et al. also revealed that the outbreak of COVID-19 had negative impacts on QoL in the general population (25). However, Chen et al., who assessed QoL in China, showed that most of the enterprise workers (93.8%) had a perfect score of 1.000 for EQ-5D during the COVID-19 pandemic (26). These contradictory results may be due to different samples used in these studies. Hospitalized patients were assessed in the current study, but Chen et al. (26) assessed workers during the pandemic.

The current study showed that most of the patients used problem- and emotional-oriented coping strategies moderately, and a high level of using these strategies was noted in limited patients. In a previous study assessing the management of COVID-19-related perceived stress through coping strategies, the results showed that religion (76.3%), instrumental support (51.4%), and active strategies (51.2%) were the most commonly used coping strategies (27). However, a previous investigation on patients with disabilities and chronic diseases mentioned acceptance and self-distracting methods to cope with COVID-19-related perceived stress (28). Also, Altuntaş et al. reported social support as the most frequently used strategy in COVID-19 (29). These different results indicated the importance of considering coping strategies in this pandemic.

5.1. Limitations

This study has some limitations. First, it would be better if the authors could assess a control group from the general population along with hospitalized patients to compare results and show the possible impacts of COVID-19 on QoL and coping strategies. It is noteworthy that comparing the QoL and coping strategies of COVID-19 outpatients with hospitalized one could also be informative. In addition, the authors assessed all hospitalized patients in all age groups. As people’s increased age may affect coping strategies, it is recommended to consider different age groups separately in future studies.

5.2. Conclusions

The current study showed that the QoL score was less than 60 in most of the QoL dimensions in COVID-19. Moreover, most participants used coping strategies moderately, and a high level of using these strategies was noted in limited patients. Therefore, it is recommended to perform further studies to compare the impact of coping strategies on QoL in patients and control groups.

Acknowledgements

References

  • 1.

    Vandenberg O, Martiny D, Rochas O, van Belkum A, Kozlakidis Z. Considerations for diagnostic COVID-19 tests. Nat Rev Microbiol. 2021;19(3):171-83. [PubMed ID: 33057203]. [PubMed Central ID: PMC7556561]. https://doi.org/10.1038/s41579-020-00461-z.

  • 2.

    Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? Lancet. 2020;395(10231):1225-8. [PubMed ID: 32178769]. [PubMed Central ID: PMC7102589]. https://doi.org/10.1016/S0140-6736(20)30627-9.

  • 3.

    Bao Y, Sun Y, Meng S, Shi J, Lu L. 2019-nCoV epidemic: address mental health care to empower society. Lancet. 2020;395(10224):e37-8. [PubMed ID: 32043982]. [PubMed Central ID: PMC7133594]. https://doi.org/10.1016/S0140-6736(20)30309-3.

  • 4.

    Ryu S, Chun BC, Korean Society of Epidemiology -nCo VFT. An interim review of the epidemiological characteristics of 2019 novel coronavirus. Epidemiol Health. 2020;42. e2020006. [PubMed ID: 32023775]. [PubMed Central ID: PMC7011107]. https://doi.org/10.4178/epih.e2020006.

  • 5.

    Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al. Mental health care for medical staff in China during the COVID-19 outbreak. Lancet Psychiatry. 2020;7(4):e15-6. [PubMed ID: 32085839]. [PubMed Central ID: PMC7129426]. https://doi.org/10.1016/S2215-0366(20)30078-X.

  • 6.

    Liu X, Na RS, Bi ZQ. [Challenges to prevent and control the outbreak of COVID-19]. Zhonghua Liu Xing Bing Xue Za Zhi. 2020;41(7):994-7. Chinese. [PubMed ID: 32220275]. https://doi.org/10.3760/cma.j.cn112338-20200216-00108.

  • 7.

    Zhao S, Chen H. Modeling the epidemic dynamics and control of COVID-19 outbreak in China. Quant Biol. 2020:1-9. [PubMed ID: 32219006]. [PubMed Central ID: PMC7095099]. https://doi.org/10.1007/s40484-020-0199-0.

  • 8.

    Alinia C, Yaghmaei S, Abdullah FZ, Ahmadi A, Samadi N, Pourteimour S, et al. Correction to: The health-related quality of life in Iranian patients with COVID-19. BMC Infect Dis. 2021;21(1):538. [PubMed ID: 34098900]. [PubMed Central ID: PMC8182992]. https://doi.org/10.1186/s12879-021-06246-w.

  • 9.

    Fayers PM, Machin D. Quality of Life: Assessment, Analysis, and Interpretation. New York, NY: Wiley; 2000.

  • 10.

    Liu S, Yang L, Zhang C, Xiang YT, Liu Z, Hu S, et al. Online mental health services in China during the COVID-19 outbreak. Lancet Psychiatry. 2020;7(4):e17-8. [PubMed ID: 32085841]. [PubMed Central ID: PMC7129099]. https://doi.org/10.1016/S2215-0366(20)30077-8.

  • 11.

    Yao H, Chen JH, Xu YF. Patients with mental health disorders in the COVID-19 epidemic. Lancet Psychiatry. 2020;7(4). e21. [PubMed ID: 32199510]. [PubMed Central ID: PMC7269717]. https://doi.org/10.1016/S2215-0366(20)30090-0.

  • 12.

    Bo HX, Li W, Yang Y, Wang Y, Zhang Q, Cheung T, et al. Posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with COVID-19 in China. Psychol Med. 2021;51(6):1052-3. [PubMed ID: 32216863]. [PubMed Central ID: PMC7200846]. https://doi.org/10.1017/S0033291720000999.

  • 13.

    Shinichi F, Faridhosseini F, Hajebi Khaniki S, Chalakinia N, Saadati Z, Tara F. Psychological symptoms and coping strategies of nurses caring for patients with COVID-19 pneumonia. J Fundam Mental Health. 2020;22(6):481-9.

  • 14.

    Babore A, Lombardi L, Viceconti ML, Pignataro S, Marino V, Crudele M, et al. Psychological effects of the COVID-2019 pandemic: Perceived stress and coping strategies among healthcare professionals. Psychiatry Res. 2020;293:113366. [PubMed ID: 32798932]. [PubMed Central ID: PMC7397939]. https://doi.org/10.1016/j.psychres.2020.113366.

  • 15.

    McFadden P, Ross J, Moriarty J, Mallett J, Schroder H, Ravalier J, et al. The Role of Coping in the Wellbeing and Work-Related Quality of Life of UK Health and Social Care Workers during COVID-19. Int J Environ Res Public Health. 2021;18(2). [PubMed ID: 33477880]. [PubMed Central ID: PMC7832874]. https://doi.org/10.3390/ijerph18020815.

  • 16.

    Iddi S, Obiri-Yeboah D, Aboh IK, Quansah R, Owusu SA, Enyan NIE, et al. Coping strategies adapted by Ghanaians during the COVID-19 crisis and lockdown: A population-based study. PLoS One. 2021;16(6). e0253800. [PubMed ID: 34181679]. [PubMed Central ID: PMC8238213]. https://doi.org/10.1371/journal.pone.0253800.

  • 17.

    Park CL, Russell BS, Fendrich M, Finkelstein-Fox L, Hutchison M, Becker J. Americans' COVID-19 Stress, Coping, and Adherence to CDC Guidelines. J Gen Intern Med. 2020;35(8):2296-303. [PubMed ID: 32472486]. [PubMed Central ID: PMC7259430]. https://doi.org/10.1007/s11606-020-05898-9.

  • 18.

    Aldwin CM. Stress, coping, and development: An integrative perspective. Guilford Press; 2007.

  • 19.

    Skevington SM, Lotfy M, O'Connell KA, Whoqol Group. The World Health Organization's WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual Life Res. 2004;13(2):299-310. [PubMed ID: 15085902]. https://doi.org/10.1023/B:QURE.0000018486.91360.00.

  • 20.

    Taghavi SM, Mokarami H, Nazifi M, Choobineh A, Marioryad H, Kujerdi MF. The Influence of Socio-Demographic, Health and Work-Related Factors on Health-Related Quality of Life among Iranian Industrial Workers. Health. 2014;6(16):2250-60. https://doi.org/10.4236/health.2014.616261.

  • 21.

    Folkman S, Lazarus RS. If it changes it must be a process: study of emotion and coping during three stages of a college examination. J Pers Soc Psychol. 1985;48(1):150-70. [PubMed ID: 2980281]. https://doi.org/10.1037//0022-3514.48.1.150.

  • 22.

    Rostami AM, Ahadi H, Cheraghaligol H. [The Prediction of Coping Strategies Based on Personality Traits in Irritants Affiliates]. Res Addict. 2013;7(26):111-26. Persian.

  • 23.

    Qi M, Li P, Moyle W, Weeks B, Jones C. Physical Activity, Health-Related Quality of Life, and Stress among the Chinese Adult Population during the COVID-19 Pandemic. Int J Environ Res Public Health. 2020;17(18). [PubMed ID: 32906604]. [PubMed Central ID: PMC7558071]. https://doi.org/10.3390/ijerph17186494.

  • 24.

    Ping W, Zheng J, Niu X, Guo C, Zhang J, Yang H, et al. Evaluation of health-related quality of life using EQ-5D in China during the COVID-19 pandemic. PLoS One. 2020;15(6). e0234850. [PubMed ID: 32555642]. [PubMed Central ID: PMC7302485]. https://doi.org/10.1371/journal.pone.0234850.

  • 25.

    Mucci F, Mucci N, Diolaiuti F. Lockdown and Isolation: Psychological Aspects of Covid-19 Pandemic in the General Population. Clin Neuropsychiatry. 2020;17(2):63-4. [PubMed ID: 34908969]. [PubMed Central ID: PMC8629090]. https://doi.org/10.36131/CN20200205.

  • 26.

    Chen X, Xu Q, Lin H, Zhu J, Chen Y, Zhao Q, et al. Quality of life during the epidemic of COVID-19 and its associated factors among enterprise workers in East China. BMC Public Health. 2021;21(1):1370. [PubMed ID: 34246225]. [PubMed Central ID: PMC8271302]. https://doi.org/10.1186/s12889-021-11414-3.

  • 27.

    Girma A, Ayalew E, Mesafint G. Covid-19 Pandemic-Related Stress and Coping Strategies Among Adults with Chronic Disease in Southwest Ethiopia. Neuropsychiatr Dis Treat. 2021;17:1551-61. [PubMed ID: 34045857]. [PubMed Central ID: PMC8144169]. https://doi.org/10.2147/NDT.S308394.

  • 28.

    Umucu E, Lee B. Examining the impact of COVID-19 on stress and coping strategies in individuals with disabilities and chronic conditions. Rehabil Psychol. 2020;65(3):193-8. [PubMed ID: 32406739]. https://doi.org/10.1037/rep0000328.

  • 29.

    Altuntaş O, Tekeci Y. Effect of COVID 19 on perceived stress, coping skills, self-control and self-management skills. Res Sq. 2020:1-16.