In Chapters 3 and 4 we focused on predictors of subjective wellbeing, as measured by QOL. We did this by using an adolescent-specific and asthma-specific instrument, the Adolescent Asthma Quality of Life Questionnaire (AAQOL) (Rutishauser, Sawyer, Bond, Coffey, & Bowes, 2001), the only asthma-specific QOL designed specifically for this age group, covering domains that are relevant for adolescents with asthma, and with the specific problems they might encounter. These domains are Symptoms, Medication, Physical Activities, Emotion,
Social interaction, and Positive effects. The first five domains compose an Overall QOL
score, the last domain (Positive effects that asthma could have on the daily life of adolescents) could not be meaningfully added to the overall score (Rutishauser et al., 2001).
Of the five domains of Overall QOL, adolescents with asthma scored relatively low on the
Physical Activities domain. Although research demonstrated that people with asthma can
exercise safely (see review by Lucas & Platts-Mills, 2005), the findings in Chapters 3 and 4 showed that adolescents with asthma had relatively low QOL scores for physical activities. Several studies revealed that physical activity had a positive influence on psychological wellbeing of adolescents in general (e.g., Kirkcaldy, Shephard, & Siefen, 2002; Steptoe & Butler, 1996). In adolescents with asthma, research indicated that physical activity programmes can not only improve aerobic fitness, but can also improve QOL, in both physical and psychological domains. It can reduce hospital admissions, wheeze frequency, medication use, and school absenteeism (Welsh, Kemp, & Roberts, 2005). During asthma consultations with health workers, more attention should be given to a better control of asthma, to stimulate adolescents with asthma to participate in physical activities just like their healthy peers. Specific problems with taking part in physical activities, as well as ways to prepare for physical activities by medication should be discussed. Besides improving QOL, it may also affect the smoking behaviour of adolescents with asthma: it is suggested that adolescents with asthma might smoke because they feel different, and smoking is a way to gain peer acceptance. Playing sports may take over the role of smoking to achieve peer approval in adolescents with asthma and to distinguish oneself in a more positive manner (Tyc & Throckmorton-Belzer, 2006).
Most previous research in adolescents with asthma focused on the influence of disease characteristics on QOL, such as asthma severity. The results of the study described in Chapter 3 demonstrated that QOL was negatively associated with severity of symptoms of asthma, replicating the results of earlier studies on adults and adolescents with asthma (Horak et al., 2005; Warschburger et al., 2004). However, a recent study suggested that psychological factors were more important than asthma severity in QOL of children and adolescents with asthma (Goldbeck, Koffmane, Lecheler, Thiessen, & Fegert, 2007). Chapter 4 shows that several personality factors from the Five Factor Model of personality (Goldberg, 1990) were related to QOL in adolescents with asthma. Overall QOL was higher in adolescents higher on extraversion and lower on neuroticism (thus more emotionally stable). Agreeableness was the only personality factor related to positive QOL, with higher positive QOL for adolescents higher on agreeableness. This is the first study to reveal these associations in adolescents with
asthma and the results are in line with studies in (mostly adult) patient groups with other somatic and mental illnesses (e.g., De Clercq, De Fruyt, Koot, & Benoit, 2004; Masthoff, Trompenaars, Van Heck, Hodiamont, & De Vries, 2007; Van Straten, Cuijpers, Van Zuuren, Smits, & Donker, 2007; Vollrath & Landolt, 2005; Yamaoka et al., 1998).
In addition to looking at the relation between personality and QOL, this thesis also aimed at testing explanatory mechanism for this relationship. We therefore tested the mediating roles of coping strategies and the reporting of symptoms. Six different strategies for coping with asthma were distinguished (Aalto, Harkapaa, Aro, & Rissanen, 2002): restricted lifestyle,
hiding asthma, positive reappraisal, information seeking, ignoring asthma, and worrying about asthma. In the literature about personality and QOL it was suggested that personality
affects QOL because it influences the way people approach situations and interpret and react to stressful situations (Wrosch & Scheier, 2003).
People high on extraversion are believed to have a tendency to focus on positive emotions (Masthoff et al., 2007; Van Straten et al., 2007). Although this indicates that adolescents high on extraversion would engage more in the coping strategy ‘positive reappraisal’, the results of our study in Chapter 4 demonstrate that adolescents high on extraversion have a lower tendency to lead a restricted lifestyle, and thus do not avoid situations for their asthma. This is in line with the hypothesis that extraverted people are more focused on social contacts, and may focus less on their own problems (Van Straten et al., 2007). Adolescents with asthma who are high on extraversion seem to think that the (social) advantages of taking part in certain activities outweigh the risk of an asthma attack.
The negative relation between neuroticism and QOL found in Chapter 4 is in line with most other studies on this relation (e.g., De Clercq et al., 2004; Masthoff et al., 2007; Vollrath & Landolt, 2005) and may also be explained by whether or not adolescents concentrate on their own problems. In contrast with people high on extraversion, people high on neuroticism are more focused on their own problems, and they recall and report more symptoms (Larsen, 1992). In addition, it is suggested that neuroticism is related to less effective coping with stress (Vollrath, 2001). The results described in Chapter 4 demonstrate that the relation between neuroticism and QOL in adolescents with asthma is indeed explained by more symptom reporting. Another explanation has to do with the coping strategy worrying about asthma: adolescents with asthma worry more about their asthma, which in turn decreases QOL. These two mechanisms together may explain why adolescents with asthma high on neuroticism have lower QOL.
The positive relation between agreeableness and QOL had been documented before in adult and paediatric patient groups (De Clercq et al., 2004; Penedo et al., 2003; Vollrath & Landolt, 2005). Agreeableness was only associated with the positive effects QOL subscale, indicating that adolescents high on agreeableness felt that they got more help and understanding from people in their direct social network. This is in line with a study in children demonstrating that agreeableness was related to perceiving more social support from the family (Branje, van Lieshout, & van Aken, 2004). It is suggested that children and young adolescents high on agreeableness are believed to have more friends, are more relaxed, and pay less attention to physical symptoms, resulting in higher QOL (Van Straten
et al., 2007). In addition, coping skills are assumed to be better in children and adolescents high on benevolence (the term used for agreeableness in research on paediatric groups) (Vollraht 2005). Chapter 4 revealed that the relation between agreeableness and QOL can be explained by less hiding of asthma. In addition, the positive relation between agreeableness and positive effects QOL was explained by making more use of the coping strategy positive reappraisal (a cognitive strategy used to attach positive meanings to having asthma and to see the benefits of the illness). Taking these two explanations together, the results suggest that since agreeable adolescents try to see the positive aspects of having asthma, and do not try to hide it, it may be easier for people in their immediate social environment (e.g., their family and friends) to support these adolescents, and to accept the limitations associated with having asthma, thereby increasing the positive effects QOL of adolescents with asthma.
Personality may be difficult to change, but the coping strategies associated with these personality traits are more open to change through interventions (e.g., Colland, 1993). Adolescent personality may act as an early indicator for reduced QOL in adolescents with asthma, and tailored coping interventions could be given to adolescents with personality traits that put them at risk for lower QOL. Short personality questionnaires such as the one used in this thesis (The Quick Big Five, 30 items, Vermulst, 2005) may be used as a screening instrument to assess which adolescents are at risk for low QOL. These adolescents could be offered an intervention aimed at improving the coping strategy connected to that personality trait. Possible coping interventions are given below in the section “Practical implications and prevention”.
The study described in Chapter 3 further demonstrates the roles of coping strategies in QOL. The strategies restricted lifestyle and worrying about asthma were associated with poorer overall QOL, the use of the coping strategies restricted lifestyle, positive reappraisal, and information seeking was related to higher scores on the positive QOL domain, whereas
hiding asthma was related to lower scores on the positive QOL domain. In addition, we
found indirect effects of severity on QOL via several coping strategies, indicating a way to intervene in the relation between severity and QOL. Even when asthma is more severe, using certain coping strategies may prevent a decline in QOL of adolescents with asthma. As mentioned before, possible interventions to improve the use of these coping strategies will be considered below when we discuss some implications of the research described in this thesis.
Taken together, our studies about QOL show that both disease characteristics (severity of symptoms) and psychological factors (personality and coping) are related to QOL in adolescents with asthma. Besides changing severity of symptoms by helping adolescents to manage their asthma and to increase their knowledge, the results in the first part of this thesis provide us with ways to improve QOL of adolescents with asthma. Results of personality questionnaires may function as warning signs for adolescents with asthma who are at risk for reduced QOL, and the results may help to adapt coping interventions for adolescents with specific personality traits. Since coping strategies were found to intervene in the relations between severity and personality on the one hand and QOL on the other, there are opportunities for adolescents with asthma to improve their QOL by using effective
coping strategies. Coping skills training should be made easily accessible for them, and the training should be targeted at the specific problems these youngsters encounter, such as missing out on social activities or being embarrassed to take medication in a social situation. These training programmes might give adolescents a feeling of control over their illness; teach them what they can do to improve QOL. Besides positive effects for QOL, the training might also influence other health behaviours such as medication adherence or smoking, since adolescents with asthma sometimes want to rebel against their asthma, and might engage in health-compromising behaviours (such as smoking and non-adherence) to gain some control over their illness, even if it is control that has a negative impact on their asthma (Creer & Bender, 1995; Tercyak, 2003).