Abstract
Objective
Health-related quality of life (HRQOL) is an important outcome for patients living with chronic kidney disease (CKD), and it is necessary to better understand potential gender and racial differences as well as predictors associated with reduced HRQOL so effective interventions can be developed.
Methods
Participants included 182 patients with CKD who were administered a battery of questions that included the Medical Outcomes Study-Short Form 36; Perceived Stress Scale, and the Brief COPE. Demographic and disease specific information was abstracted from the patients’ medical record.
Results
No differences by race were observed with regard to stress, quality of life or coping with the exception that minority patients reported use of religious coping more often (p=0.001) and had higher levels of energy when compared to non-minority CKD patients (p=0.27). Women with CKD tended to use self-distraction (p=0.002), positive reframing (p=0.035), venting (p=0.024), and religious coping (p=0<0.001) more often than men. No significant differences in perceived stress or domains of quality of life were observed between men and women with CKD. A link between coping strategies and HRQOL was observed in women (p=0.001–0.02) but not men. Perceived stress was associated with poorer quality of life for men (p=0.017–<0.001) and women (p=0.001–<0.001), but more domains of men’s quality of life were affected by perceived stress when compared to women.
Conclusions
The findings of the study suggest that the wider range of coping strategies used by women may be associated with buffering the link between perceived stress and quality of life. Men with CKD may benefit from interventions that not only reduce stress but also facilitate the use of a broader range of coping strategies to reduce stress and improve quality of life.
Keywords: health-related quality of life, gender, chronic kidney disease, stress, coping
Living with chronic kidney disease (CKD) can impact the quality of many aspects of a person’s life (Abdel-Kader et al., 2009). There is no singular definition of the concept of health-related quality of life (HRQOL); however, most agree that it is a multi-dimensional construct that consists of an individual’s perceptions of their functioning in a number of areas, including physical, psychological, and social well-being (Valderrabano et al., 2001). Health-related quality of life is an important outcome to consider in patients living with CKD, regardless of whether or not they are on dialysis or awaiting transplantation (Abdel-Kader et al., 2009). Individuals with CKD have been found to have poorer HRQOL than the general population (Perlman et al., 2005). Poor HRQOL has been found to be associated with increased rates of hospitalization and mortality for patients on dialysis (Lopes et al., 2003; Mapes et al., 2004). Since poor HRQOL is associated with adverse health outcomes, it is important to understand potential predictors and mediating factors associated with HRQOL in this population in order to develop targeted and effective interventions to improve HRQOL.
The daily management of chronic kidney disease may require dietary/fluid restrictions, dialysis, and managing other co-morbid chronic conditions. The many tasks involved in managing CKD combined with the possible psychosocial effects of these tasks could potentially cause high levels of perceived stress. For example, higher levels of perceived stress have been found to be associated with poorer HRQOL in other populations such as renal transplant recipients (White et al., 1990). This finding suggests that perceived stress may be a potentially important factor to consider when attempting to improve upon HRQOL of patients with CKD. Lazarus and Folkman’s Transactional Theory of Stress and Coping, states that the relationship between a person and his or her environment is transactional in nature, and two factors (appraisal of the stressor and coping) mediate this relationship (Lazarus & Folkman, 1987). Based on this theory, this study examines the association of stress and coping with HRQOL.
Coping refers to how a person manages the demands that are placed upon them as a result of how an event is evaluated (Lazarus & Folkman, 1984). Some coping styles are considered to be adaptive (active coping, planning, use of emotional support, use of instrumental support, positive reframing, religion, humor, and acceptance), whereas others are considered to be maladaptive if used long term (venting, denial, substance use, behavioral disengagement, self-distraction, and self-blame) (Lunsford et al., 2006). For example, Yeh and Chou (2007) found that many different types of coping strategies are used during times of greater perceived stress in patients with renal disease on hemodialysis, but they did not examine gender differences (Yeh & Chou, 2007). Gender differences in coping are important, however, because they have been found in a variety of non-CKD samples and can have important implications for the way women and men might cope differently with issues related to their CKD. For example, in a sample of primary care patients who were prescribed antidepressants, gender differences were identified in the relationship between beliefs about depression and coping styles. Women’s greater use of adaptive coping was related to the belief that a person has control over their depressive symptoms (Kelly et al., 2007). Similarly, in a sample of psychology undergraduates, women tended to use more emotion-focused coping and men tended to use more problem-focused coping in response to a stressful situation (Ptacek et al., 1994). Although there seem to be gender differences in coping styles among other populations, little is known about coping and gender in CKD patients and how it is related to perceived stress and HRQOL.
Although previous research has examined the types of coping strategies used by patients under stress, the current study is unique because little is known about how the association between stress, coping, and HRQOL varies in men and women with CKD. For example, Johnson and colleagues found that women reported poorer quality of life ratings than men before kidney transplantation (Johnson et al., 1998). However, little is known about how perceived stress and coping styles may impact HRQOL in this population. Thus, the objective of the present study is twofold: (a) examine the association of stress and coping on HRQOL, and (b) identify any gender or racial differences that may exist in those associations.
Methods
Participants
Participants were 182 patients with CKD who were participating in a larger prospective cohort study at the University of Pittsburgh Medical Center. The aims of the study were to investigate memory, sleep, stress, coping, and HRQOL in patients with advanced CKD. Participants were approached patients during their routine CKD clinic visit, dialysis clinic visit, or their initial evaluation at a kidney transplantation clinic between March 2004 and October 2007. Patients were excluded if they were less than 18 years old or greater than 90 years old or had any of the following conditions: craniofacial abnormalities, active malignancy, treated sleep apnea, active infection, active coronary artery disease (unstable angina or myocardial infarction within the last 6 months), advanced cirrhosis, advanced dementia, active alcohol abuse, history of head injury, or refractory psychiatric disease (a psychiatric illness that would it potentially dangerous to participate in a sleep study) as ascertained by medical records and confirmed in interview. We also excluded patients with an unsafe home environment from the study because sleep technicians conducted the sleep study in the participants’ homes.
Three hundred six patients were screened for study participation between March 2004 and October 2008. Of these, nine met exclusion criteria and 79 withdrew consent prior to completing the cognitive assessment. Of the remaining 218 patients, 26 did not complete the polysomnography measures (6 because of time constraints or loss of interest, 7 because of noncompliance, 5 because of poor patient health, 1 due to kidney transplantation prior to protocol initiation, 5 due to patient death, 4 because of inability to tolerate polysomnography as required for the parent study). Of the remaining 192 patients, 10 had missing coping data and were excluded from our analysis.
Procedures
The University of Pittsburgh Institutional Review Board approved this study and all participants provided signed informed consent. The baseline data collection session included a brief standardized health interview and questionnaire, assessment of current medication use, and blood pressure and anthropometric measurements. Age, sex, race, education, and employment status were self-reported. We obtained a history of physician-diagnosed medical illnesses, previous surgical treatments, or medical procedures from the health interview. Additionally, we abstracted standard serum laboratory tests, current and previous hemodialysis access, and current and previous kidney transplantation status from the medical record.
Instruments
Perceived stress was assessed using the four-item Perceived Stress Scale (PSS) (Cohen et al., 1983). The PSS asks participants to rate how often they have had certain thoughts or feelings over the past week (e.g., “In the last week, how often have you felt that you were unable to control the important things in your life?”). Participants rate each item on a five-point Likert scale (0=never, 1=almost never, 2=sometimes, 3=fairly often, 4=very often). Two positive items are reverse scored, and the sum of the four items is calculated to get an overall PSS score ranging from 0 to 16. This scale has adequate internal consistency, test-retest reliability, and construct validity (Cohen et al., 1983).
Coping style was assessed using the Brief COPE (Carver, 1997). This 28-item measure assesses 14 subscales reflecting styles of coping: active coping, planning, positive reframing, acceptance, humor, religion, using emotional support, using instrumental support (e.g., providing transportation to appointments, preparing meals for the patient), self-distraction, denial, venting, substance use, behavioral disengagement, and self-blame. “I have been using alcohol and other drugs to help me get through it,” is an example of an item from the substance abuse scale. Participants rate each statement on a four-point Likert scale (1 = I usually don’t do this as all, 2 = I usually do this a little bit, 3 = I usually do this a medium amount, 4 = I usually do this a lot). The subscales of the Brief COPE have adequate internal consistency (Cronbach’s α = .50 – .90) (Carver, 1997). Eight of these subscales are considered to be adaptive coping styles (active coping, planning, use of emotional support, use of instrumental support, positive reframing, religion, humor, and acceptance) and six of these subscales are considered maladaptive coping styles (venting, denial, substance use, behavioral disengagement, self-distraction, and self-blame) (Lunsford et al., 2006). The adaptive coping score was calculated by taking the mean of all items in the eight adaptive coping subscales, and the maladaptive coping score was calculated by taking the mean of all items in the six maladaptive coping styles. This measure has been found to have acceptable internal consistency (Carver, 1997).
Health-related quality of life was assessed using the 36-item Health Survey (SF-36) (Ware & Sherbourne, 1992). The SF-36 assesses eight domains of health status, including physical functioning, role limitations due to physical health, role limitations due to emotional problems, energy, emotional wellbeing, social functioning, pain, and general health. The SF-36 is widely used, and it has been found to have adequate internal consistency (McHorney et al., 1994) and validity (McHorney et al., 1993).
Statistical Analyses
Descriptive statistics were calculated for participant characteristics, lab values, and questionnaire data, as well as to test the distribution of data. The data for the following outcomes were non-normally distributed: maladaptive coping (Brief COPE), physical functioning (SF-36), role limitations due to physical health (SF-36), role limitations due to emotional problems (SF-36), emotional wellbeing (SF-36), social functioning (SF-36), and pain (SF-36). Therefore Mann-Whitney U tests were conducted in order to examine between group differences. Between-group differences were examined using ANOVA as the perceived stress (PSS), energy subscale (SF-36), general health subscale (SF-36), and adaptive coping (Brief COPE) were found to be normally distributed. Bivariate correlations among study variables were also calculated to assess for multicollinearity. These analyses were performed using SPSS version 16.0.
Using EQS, a multi-group structural equation modeling (SEM) was performed on each health-related quality of life subscales (physical functioning, role limitation – physical, role limitation – emotional, energy, emotional wellbeing, social functioning, pain, and general health) to be predicted by adaptive and maladaptive coping, and perceived stress by sex (male, female). The model was estimated using the Expectation-Maximization Maximum Likelihood (EM-ML) (Jamshidian & Bentler, 1999) with the Yuan and Bentler (Yuan & Bentler, 2000) correction for non-normality data with missing data. The EM-ML method allows a model to be estimated without imputation and loss of subjects. The Yuan and Bentler correction is similar to Satorra and Bentler (vanEye & Clogg, 1994) with complete data. A saturated model was run within each gender, therefore, the overall statistic (i.e., model chi-square and fit indices) will not be reported.
Results
Participant Characteristics
Participants were 182 patients with chronic kidney disease. As described in Table 1, participants were, on average, 53 year of age. The majority of participants were male (64%), white (65%), married (59%), with at least a twelfth grade education (89%). The majority of participants (48%) were not on dialysis, 40% were on hemodialysis, and 12% were on peritoneal dialysis. While there were no gender differences in most demographic characteristics and health measures, (e.g., age, education level, type of dialysis), gender differences were found for race (p=.05) and Phosphorus level (p=.03).
Table 1.
Participant Characteristics
| Characteristic | Men (n=116) | Women (n=66) | Entire Sample |
|---|---|---|---|
| Age (mean, SD) | 53.6 ± 14.7 | 51.9 ± 14.3 | 53.0 ± 14.5 |
| Race (n, %)* | |||
| White | 83 (71.6) | 36 (54.5) | 119 (65.4) |
| Black | 28 (24.1) | 29 (43.9) | 57 (31.3) |
| Other | 5 (4.3) | 1 (1.5) | 6 (3.3) |
| Marital Status (n,%) | |||
| Married | 72 (63.2) | 34 (51.5) | 106 (58.9) |
| Widowed | 0 | 4 (6.1) | 4 (2.2) |
| Divorced | 15 (13.2) | 9 (13.6) | 24 (13.2) |
| Separated | 4 (3.5) | 5 (7.6) | 9 (5.0) |
| Never Married | 23 (20.2) | 14 (21.2) | 37 (20.6) |
| Education (n,%) | |||
| Less than 12th grade education | 13 (11.4) | 5 (7.6) | 18 (10.0) |
| Grade 12 or high school graduate | 29 (25.4) | 25 (37.9) | 54 (30.0) |
| Some college | 25 (21.9) | 19 (28.8) | 44 (24.4) |
| College graduate | 24 (21.1) | 11 (16.7) | 35 (19.4) |
| One or more years post college | 23 (20.2) | 6 (9.1S) | 29 (16.1) |
| BMI (mean, SD) | 27.5 ± 4.9 | 28. 6 ± 6.3 | 27.9 ± 5.4 |
| Dialysis Type (n, %) | |||
| Hemodialysis | 48 (41.4) | 25 (37.9) | 73 (40.1) |
| Peritoneal Dialysis | 7 (6.0) | 15 (22.7) | 22 (12.1) |
| None | 61 (52.6) | 26 (39.4) | 87 (47.8) |
| Lab Values (mean, SD) | |||
| Serum calcium (mg/dl) | 9.0 ± .8 | 9. 1 ± .7 | 9.1 ± .8 |
| Serum phosphorus (mg/dl)* | 5.0 ± 1.4 | 6.0 ± 4.2 | 5.3 ± 2.8 |
| Potassium (mmol/L) | 4.7 ± .76 | 4.8 ± .6 | 4.7 ± .7 |
| Serum creatinine (mg/dl) | 6.5 ± 3.5 | 7.5 ± 4.4 | 6.8 ± 3.9 |
| Albumin (g/dl) | 3.9 ± .55 | 3.8 ± .58 | 3.9 ± .6 |
| Blood urea nitrogen (mg/dl) | 55.6 ± 20.3 | 52.6 ± 20.8 | 54.6 ± 20.7 |
| Glucose level (mg/dl) | 127.1 ± 64.2 | 113.7 ± 39.5 | 122.4 ± 57.1 |
p>.05
There were no gender differences found in perceived stress, or health-related quality of life. However, there were gender differences in the use of maladaptive and adaptive coping strategies such that women had higher mean ranks of both what may be considered maladaptive (Mann Whitney U = 2109.50, p=.02, mean = 1.59 vs. 1.43) and adaptive (F(1,154)=5.40, p=.02, mean = 2.57 vs. 2.32) coping strategies than men. The only significant race difference was that minority participants rated the energy/fatigue subscale of the SF-36 higher than non-minority participants (F(1,171)=5.00, p=.03, mean = 43.76 vs. 51.50) and the use of religious coping [F(1,165)=11.99, p=0.001]. The only significant difference between those on dialysis and those not receiving dialysis was that those not on dialysis rated their physical functioning scale of the SF-36 higher than those on dialysis (F(1,169)=7.78, p<.01, mean=68.31 vs. 57.78).
Frequency of Use and Gender Differences on the COPE Subscale
The most frequent coping strategies for men and women in this sample were acceptance, activity, emotional support and planning. See Table 2. Gender differences were observed with females reporting more frequent use of self-distraction [F(1,167)=9.73, p=0.002]; positive reframing [F(1,165)=4.51, p=0.035]; use of religion [F(1,165)=18.047, p<0.001]; and venting [F(1,159)=5.18, p=0.024]. See Table 2.
Table 2.
Gender Differences of COPE Subscales
| COPE Subscale | Males | Females | Total | |||
|---|---|---|---|---|---|---|
| Mean | Standard Deviation |
Mean | Standard Deviation |
Mean | Standard Deviation |
|
| Acceptance | 5.49 | 2.99 | 6.03 | 1.67 | 5.89 | 1.79 |
| Active Coping | 5.81 | 1.86 | 5.44 | 1.70 | 5.23 | 1.94 |
| Mental Disengagement | 2.57 | 1.13 | 2.65 | 1.06 | 2.60 | 1.10 |
| Denial | 2.45 | 0.96 | 2.62 | 0.99 | 2.51 | 0.98 |
| Emotional Support | 4.86 | 2.10 | 5.45 | 2.17 | 5.08 | 2.13 |
| Substance Use | 2.20 | 0.86 | 2.08 | 0.52 | 2.15 | 0.75 |
| Humor | 3.35 | 1.69 | 3.00 | 1.48 | 3.22 | 1.62 |
| Self-Distraction* | 3.64 | 1.61 | 4.49 | 1.88 | 3.95 | 1.76 |
| Planning | 5.02 | 2.06 | 5.61 | 1.86 | 5.24 | 2.0 |
| Positive Reframing* | 4.30 | 1.84 | 4.94 | 1.91 | 4.54 | 1.89 |
| Religion* | 4.31 | 2.42 | 5.93 | 2.27 | 4.91 | 2.49 |
| Venting of Emotions* | 3.42 | 1.40 | 3.98 | 1.69 | 3.63 | 1.54 |
| Instrumental Support | 4.34 | 1.87 | 4.92 | 1.93 | 4.56 | 1.91 |
| Self-Blame | 2.90 | 1.40 | 3.15 | 1.64 | 2.99 | 1.50 |
p<0.05 difference between males and females
Perceived Stress and Coping by Gender
The CKD patients were asked about stressors they experienced as part of the Brief COPE questionnaire. The majority of patients reported stress related to their disease (56.2%). The remaining stressors included issues related to family, finances, work, or loss of loved ones. See Table 3.
Table 3.
Types of Stressors reported by Patients on the COPE
| Stressors | N (%) |
|---|---|
| No Living donor available | 6 (5.7) |
| Kidney/Health Problems | 51 (50.5) |
| Work | 5 (5) |
| Family Health Problems | 6 (6.7) |
| Family Problems | 14 (13.3) |
| Psychological | 2 (2.5) |
| Financial | 7 (6.7) |
| Life stressors (buying home) | 7 (6.7) |
| Bereavement/Loss | 4 (3.8) |
Perceived stress was significantly and positively associated with maladaptive coping in both men and women (β = .454, p < .001; β = .355, p = .018). About 21% and 13% of variability in the maladaptive coping was explained by perceived stress for men and women, respectively. There was a significant, negative association between perceived stress and adaptive coping for women (β = −.280, p = .037, R2 = .078), but not for men (β = −.035, p = .719, R2 = .001). Approximately 8% of the variability in adaptive coping was explained by perceived stress for women only.
Coping and HRQOL by Gender
Adaptive coping was found to be related to general well-being in women. More use of maladaptive coping strategies was associated with poorer quality of life on the mental component of the SF-36 as well as the subscales including role limitations due to emotional problems, general health, and pain in women only (See Table 4). There were no significant associations between adaptive or maladaptive coping and HRQOL for men.
Table 4.
Associations between Coping and Quality of Life by Gender
| Coping | Adaptive | Maladaptive | |
|---|---|---|---|
| β | β | R-Squared | |
| Men | |||
| Coping-PCS | −.036 | .022 | .151 |
| Coping-MCS | .015 | .057 | .322 |
| Coping – Physical Function | .057 | −.003 | .042 |
| Coping – Role Limit: Physical | −.115 | .033 | .106 |
| Coping – Role Limit: Emotion | .020 | .134 | .116 |
| Coping – Energy/Fatigue | .145 | .038 | .106 |
| Coping – Emotional Well-Being | .080 | .096 | .352 |
| Coping – Social Well-Being | −.103 | .078 | .281 |
| Coping – Pain | −.125 | .057 | .077 |
| Coping – General Health | .163 | −.137 | .279 |
| Women | |||
| Coping-PCS | −.009 | −.213 | .100 |
| Coping-MCS | .167 | −.403* | .350 |
| Coping – Physical Function | .008 | .035 | .001 |
| Coping – Role Limit: Physical | −.010 | −.133 | .090 |
| Coping – Role Limit: Emotion | .110 | −.425* | .185 |
| Coping – Energy/Fatigue | .133 | −.125 | .281 |
| Coping – Emotional Well-being | .541* | .027 | .440 |
| Coping – Social Well-Being | .159 | −.296 | .125 |
| Coping – Pain | −.037 | −.257* | .090 |
| Coping – General Health | .036 | −.283* | .150 |
p<.05
Perceived Stress and HRQOL by Gender
For men, perceived stress was associated with more role limitations due to physical or emotional problems, less energy, poorer emotional wellbeing, poorer social functioning, and worse general health (See Table 5). For women, greater levels of perceived stress were associated with less energy and poorer emotional wellbeing.
Table 5.
Associations between Perceived Stress and Quality of Life
| β | p | ||
|---|---|---|---|
| Men | |||
| Perceived Stress-Physical Functioning | −.194 | .101 | |
| Role Limitations: Physical | −.292 | .017 | |
| Role Limitations: Emotion | −.433 | <.001 | |
| Energy/fatigue | −.362 | .001 | |
| Emotional Wellbeing | −.533 | <.001 | |
| Social Functioning | −.507 | <.001 | |
| Pain | −.175 | .116 | |
| General Health | −.484 | <.001 | |
| Women | |||
| Perceived Stress-Physical Functioning | −.004 | .978 | |
| Role Limitations: Physical | −.226 | .063 | |
| Role Limitations: Emotion | −.039 | .750 | |
| Energy/fatigue | −.431 | .001 | |
| Emotional Wellbeing | −.541 | <.001 | |
| Social Functioning | −.092 | .466 | |
| Pain | −.075 | .558 | |
| General Health | −.181 | .157 | |
In men, the set of predictors (perceived stress, maladaptive coping, and adaptive coping) accounted for 4.2% of the variability in physical functioning, 9.1% of the variability in role limitations due to physical problems, 17.5% of the variance in role limitations due to emotional problems, 13.2% of the variance in energy, 35.5% of the variance in emotional wellbeing, 24.2% of the variance in social functioning, 10.9% of the variance in pain, and 24.5% of the variance in general health. This indicates that, in men, the set of predictors were moderate predictors of physical functioning and role limitations due to physical problems; and strong predictors of role limitations due to emotional problems, energy, emotional wellbeing, social functioning, pain and general health.
In women, predictors (perceived stress, maladaptive coping, and adaptive coping) accounted for .1% of the variability in physical functioning, 9.0% of the variability in role limitations due to physical problems, 18.5% of the variance in role limitations due to emotional problems, 28.1% of the variance in energy, 44.0% of the variance in emotional wellbeing, 12.5% of the variance in social functioning, 9.0% of the variance in pain, and 15.0% of the variance in general health. This indicates that, in women, this set of predictors were moderate predictors of physical functioning, role limitations due to physical problems, and social functioning; and strong predictors of role limitations due to emotional problems, energy, emotional wellbeing, pain and general health.
Discussion
The purpose of this study was to examine racial and gender differences in HRQOL and variables from the Transactional Theory of Stress and Coping (perceived stress and maladaptive/adaptive coping) using well-validated and accepted measures. With regards to gender differences in stress and coping, under higher levels of perceived stress, women tended to use of maladaptive and adaptive coping strategies, whereas men tended to use maladaptive coping strategies more frequently. These findings are consistent with results from a previous study of gender differences in coping in adolescents that found that women use a wider range of coping strategies than men (Wilson et al., 2005).
In women, greater use of maladaptive coping strategies was associated with poorer quality of life on the mental components domain of the SF-36 as well as subscales including role limitations due to emotional problems, pain, and poorer general health. Little is known about the relationship between coping strategies and HRQOL in patients with CKD, or patients with health problems in general. These findings suggest that there is an association between the use of maladaptive coping in women and poorer HRQOL; however this association is not present for men with CKD.
There were a greater number of associations between perceived stress and domains of HRQOL for men than for women. Greater levels of perceived stress were associated with poorer ratings of HRQOL in six domains for men and only two domains for women. This suggests that stress may more directly impact HRQOL in men, and the impact of stress may have more of an effect on other aspects of women’s lives outside of their HRQOL. Alternatively, the wider range of coping strategies women utilize may buffer the link between stress and quality of life.
There are many strengths to the study including the large sample size, large percentage of minority patients included in the study (34%) and the measurement of stress, coping, and quality of life in a single study. However, limitations included the study being conducted at a single center limiting the generalizability. Furthermore, additional information regarding the patients' stressors could have been captured with an instrument or structured interview that measures life events. Furthermore, the cross-sectional nature of the data makes it impossible to make statements about the causality of significant associations found. For example, we cannot say whether coping strategies used by women impact HRQOL such that the use of more maladaptive coping strategies is related to poorer HRQOL or if poorer rating in some domains of HRQOL in women leads to the use of more maladaptive coping strategies. This cross-sectional data does allow us to better understand what important patient factors are related to HRQOL for future study. We were also unable to determine whether or not coping styles reported were persistent or flexible and prospective studies are needed.
In this sample of CKD patients, women used both maladaptive and adaptive coping strategies, and the use of maladaptive coping strategies was associated with poorer HRQOL. This finding indicates that women may benefit more from coping skills training that would facilitate the utilization of adaptive coping strategies in times of stress. Alternately, men tended to use more maladaptive coping strategies that did not appear to buffer the link between stress and quality of life. As a result, men may benefit from coping skills training to learn new adaptive ways to cope with stress. Men may further benefit from other components of stress management interventions including life style changes (e.g., sleep, exercise), relaxation techniques, cognitive distortions and alternative thoughts, and exploring values and beliefs that may be at the core of the distorted thought patterns.
Future research should focus on examining the relationships among perceived stress, coping and HRQOL over time in patients with CKD. It could be the case that some coping strategies that are adaptive in the short term may be maladaptive in the long-term. Looking at these relationships over time will allow for the examination of flexibility in copings styles (i.e., using a variety of coping strategies according to a given stressful situation) and how such flexibility may affect perceived stress and HRQOL. Given the gender differences in the relationships among perceived stress, coping, and HRQOL, future studies may want to examine these variables separately for men and women or control for gender in analyses.
Footnotes
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