||Effects of Executive Function and Coping Strategy on Posttraumatic Growth in Women with Rheumatoid Arthritis.
||Institute of Behavioral Medicine
目的：慢性疾病患者對於疾病的心理調適和適應結果有極大的個別差異，由於生理不適和功能受限，可能會對其心理健康造成損害；但是，個體經歷疾患之挑戰，也可能產生正向心理改變，即創傷後成長(Posttraumatic Growth)。研究指出患者的負向情緒或創傷後成長會受到因應策略的影響，也有研究指出患者本身的執行功能具備影響因應策略選擇的結果。然過去較少研究直接探討執行功能對創傷後成長之影響，故本研究欲以類風濕性關節炎(Rheumatoid arthritis, RA)婦女為例，探討執行功能和因應策略對創傷後成長的預測關係。
方法：於南臺灣某醫學中心過敏免疫風濕科兩位專科醫師之門診立意取樣。研究進行13個月，由門診總共轉介119位符合納入條款者，其中7位拒絕、8位未完成以及1位問卷無效。研究工具包含基本資料及病史問卷、執行功能問卷、因應策略量表及創傷後成長量表。以結構方程模式(Structural Equation Modeling, SEM)分析檢驗執行功能與因應策略對創傷後成長之預測模式。
結果：共103位受試者，平均年齡56.00(±13.38)歲，平均罹病時間11.26(±8.72)年，日常活動功能分數平均為13.22(±19.33)分。人口學變項含年齡、教育程度、有無宗教信仰，和疾病變項含罹病時間、罹病年齡、自評手腳變形程度、日常活動功能，皆與創傷後成長無顯著相關。執行功能、正向因應以及負向因應均對創傷後成長有顯著的預測效果，以SEM檢驗此三變項對創傷後成長的預測模式，結果顯示執行功能對創傷後成長有直接預測效果(β=.44, p<.001)，且會透過正向因應(β=.53, p<.001)預測創傷後成長 (β=.32, p<.001)。整體預測模式對創傷後成長的解釋量達39.3%。
SUMMARY：The objective of this study is to investigate the predictive effects of executive function and coping strategy on posttraumatic growth in women with rheumatoid arthritis(RA). 103 outpatients who satisfied the criteria for RA were recruited in this study. The demographic data and disease-related information were collected. Meanwhile, all participants were asked to complete the Health Assessment Questionnaire, the Coping Strategies Scale-RA, self-reported Executive Function scale and the Posttraumatic Growth Scale-RA. Correlation analysis and structural equation modeling (SEM) were conducted to assess the relationships among these data. The results of the study on a prediction model for predicting posttraumatic growth by self-reported executive function and positive coping strategy. Both executive function and positive coping strategy had positive effects on posttraumatic growth in women with rheumatoid arthritis, and self-reported executive function was the stronger influential factor than positive coping strategy. Hence, strengthening the rheumatoid arthritis patients’ self-reported executive function and positive coping strategy may be helpful for enhancing their adaptation to illness and positive psychological growth.
INTRODUCTION：Previous studies focused more on the negative results of stress and traumatic events on individuals. Recently, a growing number of studies have highlighted the positive influence and change generated by stress and traumatic events. Posttraumatic growth refers to positive psychological change experienced as a result of the struggle with a traumatic event. Several terms are used to describe the phenomenon, including stress-related growth, finding benefits, thriving and adversial growth. Previous studies represented that posttraumatic growth can be affected by coping strategies. Therefore, those who adopted adaptive coping strategies for managing stress experienced fewer depressive symptoms and more positive changes. Meanwhile, problem-focused coping as well as acceptance and positive reinterpretation coping style are related to adversial growth.
Rheumatoid arthritis (RA), a long-lasting and progressive autoimmune disease which will lead to the systemic inflammatory response, affects about 0.5~1% of the population worldwide. The prevalence of RA in Taiwan is approximately 0.65% and the incidence rate among women is three times higher than men. It does not only detriment to the physical health, such as causing prolonged pain, joint deformity and functional decline, but also have significant negative effects on mental health and well-being. However, recent studies showed that patients with chronic diseases can successfully adjust to their illness or even facilitate personal psychological growth from their illness experience.
Executive function is a set of higher-level cognitive functions, including cognitive flexibility, impulse control, planning, working memory, motivation/initiation and emotional regulation. Result from previous studies showed that executive function is positively correlated to the adoption of coping strategies; thus, people with better executive functions are more likely to have constructive coping strategies. For example, multiple sclerosis patients with better executive function were prone to adopt positive coping strategies and had more positive adjustment to their illness. Moreover, posttraumatic growth can be predicted by executive function among earthquake survivors. However, none studies were conducted to investigate the factors that influence of executive function on posttraumatic growth among patients with RA or other chronic illness. Therefore, the purpose of this study was to explore the relationships between posttraumatic growth and executive function as well as coping strategies among women with RA, and develop a prediction model for predicting posttraumatic growth among patients with RA.
Therefore, the objective of this study is to investigate the predictive effects of executive function and coping strategy on posttraumatic growth in women with RA.
MATERIALS AND METHODS：103 participants were recruited from the Division of Allergy, Immunology and Rheumatology (AIR) at an academic medical center in southern Taiwan. Outpatients who met the American College of Rheumatology classification criteria for RA were invited to participate in the study. Demographic data, including age, education level, marital status, occupational status, religion and menopausal stage, were collected by a standardized questionnaire. The physical variables contain disease-related information, including age of onset, disease duration, the degree of hand and foot deformity and physical disability. The Health Assessment Questionnaire (HAQ), a widely used, reliable, and valid assessment of physical disability in RA, was adopted to evaluate the physical disability of the participants.
Executive function was measured with the self-reported Executive Function (sr-EF) scale, consists of 21 items to assess the participant’s daily executive behaviors (including motivation & planning, emotion regulation, self-awareness and inefficacy). The participants rated the degree of similarity between these items and their behaviors. The possible total scores range from 21 to 126 and higher scores indicate better self-reported executive function performances.
Coping Strategy was measured with the Coping Strategy Scale-RA. The result of factor analysis revealed that two factors, positive coping and negative coping. The positive coping subscale consists of 18 items and the possible total score range from 0 to 54. The higher score indicate that the participant used positive strategies more frequently. The negative coping subscale consists of 16 items and the possible total score range from 0 to 48. The higher scores indicate that the participant use negative strategies more frequently.
Posttraumatic growth was measured with the Posttraumatic Growth Scale-RA. The visual analog scale (VAS) consists of 20 items with a range of scores from 0-100 to assess the PTG-related beliefs and behaviors after RA, including exploring & action, self-regulation, plasticity and commitment. The participants rated the degree of similarity or dissimilarity between these items and their beliefs or behaviors. The total possible score range from 0 to 2000 and a higher score indicates more similarity.
Descriptive statistics were conducted to analyze the demographic, physical and psychological variables. Pearson’s correlation analysis was carried out to measure the strength of the linear relationships between the posttraumatic growth score and all demographic, physical and psychological variables. Structural equation modeling (SEM) was performed to examine the hypothetical model of the interrelation among coping strategy, executive function and posttraumatic growth. All statistical analyses were performed using SPSS-18 or Amos-21 software program.
RESULTS AND DISCUSSION：A total of 103 participants completed the study. The mean age of the participants was 56.00 years old (SD=13.38), 70.9% of the participants accepted at least 9 years of education, 74.8% were married, 39.8% were employed, 68.0% have religious beliefs and 68.9% had experiences of the menopause. The average duration of disease was 11.26 years (SD=8.72), the average age of disease onset was 44.76 years old (SD=13.61), the average degree of self-reported deformity was 3.14 (SD=0.94), the mean HAQ score was 13.22 (SD=19.33). The mean executive function score was 92.08 (SD=12.26), the mean positive coping scale score was 32.75 (SD=6.79), the mean negative coping score was 14.10 (SD=6.82) and the mean posttraumatic growth score was 1472.17 (SD=262.05).
Correlation analysis showed all demographic variables and physical variables as well as negative coping were not correlated with posttraumatic growth. Executive function and positive coping were significantly related to posttraumatic growth. In addition, analysis with SEM revealed that both executive function and positive coping had direct effects on posttraumatic growth(β=.44, p<.001; β=.32, p<.001), and executive function will also influence posttraumatic growth via the indirect pathway of positive coping(β=.53, p<.001). The final model fit the data well and accounted for 39.3% of total variance of posttraumatic growth.
Different from previous studies that were focus on the influences of coping strategies on posttraumatic growth, the present stress on the influences of executive function on posttraumatic growth. The result revealed that executive function is the main predictive factors of posttraumatic growth and it can influence posttraumatic growth directly as well as through positive coping strategies. Moreover, the study developed a prediction model for effectively predicting posttraumatic growth among patients with RA. Further studies should be conducted to investigate the generalization of these result to patients with other chronic illness.
CONCLUSION：The result showed that both executive function and positive coping had positive effects on posttraumatic growth in women with RA, and executive function is the stronger influential factor than positive coping. Hence, strengthening the RA patients’ executive function and positive coping strategies may be helpful for enhancing their adaptation to illness and positive psychological growth.
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