Coping Strategies of Mothers of Children with Cardiac Problems

Background: Assessment of coping strategies is important in planning of health education programs to enhance coping. Objective: The aim of the present work was to assess the knowledge and attitude of mothers concerning cardiac problems, to assess the coping strategies of mothers of children with cardiac problems, and to identify some predictors of the coping strategies. Methods: A cross sectional study of 187 mothers of children with cardiac problems who attended the cardiology school health insurance clinic of Sporting Student’s Hospital in Alexandria with their children within a period of one month was conducted. Every mother was subjected to the modified Jalowiec coping scale to assess the coping strategies. Knowledge and attitude of the mothers were assessed through a pre-designed interviewing questionnaire. Results: The results showed marked variability in correct responses to various statements about cardiac problems. However, most of mothers showed poor knowledge (87.17%) and about half of them (46.0%) showed negative attitude. These figures were significantly higher among mothers of children with congenital heart defects (CHD) than among those whose children suffer from rheumatic heart disease (RHD). The most commonly used coping method was "Pray; trust in god" (92.5%), followed by "Accept the situation as it is" (88.0%), and "Hope that things will be better" (73.5%). More than half of the mothers (55.5%) reported that they always "Resign themselves to the situation because it is their fate" while 28.0% reported that they always "Worry." The percent mean score of use of problem-oriented coping methods was nearly equal to that for affective-oriented coping methods. Duration of illness (p<0.01), previous hospitalization (p=0.01), and attitude of mothers to illness (p=0.05) were all significantly associated with coping strategies. However, after adjustment for other variables, high percent mean total coping scores were more likely among mothers of children with longer disease duration and those whose mother showed negative attitude towards cardiac problems (p<0.05). Conclusion: Health education programs are needed to enhance coping strategies, knowledge, and attitude of mothers of children with cardiac problems. However, high coping strategy scores are significantly associated with the longer duration of illness and the negative attitude of mothers, possibly due to prolonged exposure to stress and the feeling that their children are different. Support group for parents is a highly recommended strategy to help a family benefit from communication with others who share common concerns, interests, and goals.


INTRODUCTION
Rheumatic and congenital heart diseases are still significant causes of morbidity and mortality in Egyptian children. 1 In Egypt, rheumatic heart disease (RHD) is a significant health problem, with an estimated prevalence rate of 5.1/1000 school children. 2 On the other hand, there is little information on the prevalence of congenital heart disease (CHD) in school-age children in Egypt.It is estimated that 8 of every 1,000 babies are born with a congenital heart defect. 3th improvements in longevity and quality of life, these children and adolescents, and their families have become the focus of scientific investigation. 4As a result of these advances, caregivers of these children are subject to many potential stressors including the scheduling of frequent clinic visits, Bull High Inst Public Health Vol.37 No. 1 [2007]   monitoring and limiting their child's activities, and administering medication.The findings of a previous study upon school children with cardiac problems in Alexandria showed nonparticipation in physical education lessons of 72.2% and 80% of RHD and CHD children respectively, mainly due to private doctor's certificate for non-participation and parental overprotection. 5Thus, they must adapt to novel responsibilities in the care of their children as well as endure continued psychological and financial stressors associated with having a child with a potentially life-threatening chronic illness. 3 the family's stress increases, the likelihood of treatment compliance for the ill child decreases.For some illnesses, psychological stress directly affects the physiological processes that regulate symptom expression.Thus, the potential for a vicious circle is created as coping with a child's illness heightens family stress, which in turn reduces treatment compliance and increases the occurrence of symptoms, which may then further heighten family stress, and so on. 6rental coping is a major aspect of children coping with chronic diseases.The manner in which parents cope can affect family functioning, the child's functioning and most importantly, how successful the child's needs are being met. 7Coping strategies refer to the specific efforts, both behavioral and psychological, that people employ to master, tolerate, reduce, or minimize stressful events.
Two general coping strategies have been distinguished: problem-solving strategies are efforts to do something active to alleviate stressful circumstances, whereas emotionfocused coping strategies involve efforts to regulate the emotional consequences of stressful or potentially stressful events. 8search indicates that people use both types of strategies to combat most stressful events.The predominance of one type of strategy over another is determined, in part, by personal style (e.g., some people cope more actively than others) and also by the type of stressful event; for example, people typically employ problem-focused coping to deal with potential controllable problems such as work-related problems and family-related problems, whereas stressors perceived as less controllable, such as certain kinds of physical health problems, prompt more emotionfocused coping. 9sessment of coping strategies is important in planning of health education programs to enhance coping.Unfortunately, such work on mothers of children with cardiac problems has lagged far behind.The aim of the present work was: 1) to assess the knowledge and attitude of mothers concerning cardiac problems, 2) to assess the coping strategies of mothers of children with cardiac problems, and 3) to identify some predictors of the coping strategies.

Study setting and sampling:
The study was conducted at the Cardiology

Methods:
For the execution of the present study, the following tools were used: 1) Modified Jalowiec coping scale (JCS) 10 was used to assess the coping strategies of the mothers.Table 2: shows the percentage distribution of mothers of children with cardiac problems according to their use of different coping methods.The results revealed that "Pray; trust in god" coping method was always used by most of mothers of children with cardiac problems (92.5%),followed by "Accept the situation as it is" (88.0%), and "Hope that things will be better" (73.5%).More than half of the mothers (55.5%) reported that they always "Resign themselves to the situation because it is their fate" while 28.0% reported that they always "Worry".
On the other hand, the least used coping methods by the mothers were "Take drugs (hypnotics, sedatives), where only 1% reported using this coping method, followed by "Eat; chew gum" where only 6% reported using this method, "Blame someone else for your problem", where only 8.5% reported using this method, "Let someone else solve the problem" and "Take tea, coffee, and/or cigarette" where 12.5 % reported using these coping methods

DISCUSSION
The presence of a chronic illness in a child commits the family to long-term difficulties and problems comprising a variety of different stressors.Effective coping alleviates the problem and reduces emotional distress.If coping is ineffective, distress remains unchanged or becomes aggravated. 12w parents cognitively appraise concerns related to the care of their child will determine their coping strategies. 13e aim of the present work was to assess coping strategies of mothers of children with cardiac problems which are important for planning intervention programs to enhance their coping.In consistent with the study done by Yousef et al., (2004) 14 on the mothers of mentally handicapped children, the present study revealed that "Pray; trust in god" coping method was always used by most of mothers of children with cardiac problems, followed by "Accept the situation as it is".These two coping methods are adopted by mothers in an attempt to maintain some control over the situation that facilitate effective adaptation and diminish a feeling of helplessness and hopelessness. 15It is well known that people in our community always pray and trust god when they face their problems to help them overcome the stress evoked by that problem.
Also, religion gives them strength that helps them accept the situation.The third adopted coping method was "Hope that things will be better".Hopeful perspective is of importance for adaptation because it allows a person to become aware of alternative options for coping with stress. 10More than half of the mothers reported that they always "Resign themselves to the situation because it is their fate".This is because most people in our community believe that everything they face is their fate.However, about a quarter of the sample reported that they always "Worry." Meanwhile, the least used coping methods by the mothers were "Take drugs (hypnotics, or sedatives), followed by "Eat; chew gum", "Blame someone else for your problem", "Let someone else solves the problem" and "Take tea, coffee, and/or cigarette".Taking drugs, chew gum, and take Bull High Inst Public Health Vol.37 No. 1 [2007]   tea and coffee, and cigarette are not coping methods commonly used by females in our culture to help them face their problems, especially females of low socioeconomic class that constitute the study sample.Also, females belonging to this stratum depend usually upon themselves in solving their problems and never blame someone else.
Most people use multiple coping behaviors in any given stressful situation.The choice of behaviors is directed by the changing environment and the altering situation. 16The present study revealed that the percent mean score of use of problemoriented coping method (37.00±16.34%)was nearly equal to that for affective-oriented coping method (37.42±11.40%).Many studies indicated the need for balance between problem-oriented and affective-oriented coping methods. 10,17Others consider problem solving a pre requisite for accommodation and successful dealing with the problems. 15,18 individual's perception of the event is a critical factor in determining whether the event will be stressful or not.Parents who defined having a child with a disability in a positive way had more successful adaptations and family strengths. 15The present work revealed that about half of the mothers showed negative attitude towards the cardiac problems, a figure which was significantly higher among mothers of congenital cases.
Parents of children with CHD have identified psychological stress as their most significant problem 19 .Diagnostic procedures, medical and surgical interventions, perception of the child as "different," social problems, sports restrictions, uncertainty, and disease prognosis have also been identified as sources of stress [20][21][22] .Among parents of adolescents and young adults, a 1997 study reported that issues related to the perception of their offspring as different persisted.
Additional concerns were related to decisions about disclosure of the diagnosis and transitioning offspring to self-management of the chronic illness. 4e present study revealed that the % mean problem-oriented and total coping scores of mothers were significantly higher Caregiving issues identified in the literature include difficulties with nutrition and feedings and intensive medication regimens 21 .
However, mothers of children with CHD -in the present study -were not significantly different from those of children with RF/RHD in terms of coping strategy inspite of the significally longer duration of the former group.

Mothers of children who reported previous
hospitalization in the present study, recorded higher percent mean affective-, problemoriented, and total coping strategy scores in the bivariate analysis.Hospitalized patients are the severe cases that may need surgery and more care from the mother.This may increase the stress and coping strategies of the mother.Despite the difficulties including hospitalization, however, many families adapt successfully 22 .After adjusting for all other variables in the present study, previous hospitalization was not a significant predictor of coping strategies.

RECOMMENDATIONS:
In order to cope, families may benefit from communication with others who share common concerns, interests, and goals.Some with cardiac problem have important knowledge gaps and show negative attitude towards their diseased children.Poor knowledge of and negative attitudes towards cardiac problems were significantly more prevalent among mothers of children with CHD than among those of children with RHD.2.Coping strategies of mothers of children with cardiac problem are inadequate.However, high coping strategy scores are significantly associated with the longer duration of illness and the negative attitude of mothers, possibly due to prolonged exposure to stress and anxiety, and the feeling that their children are different.The type of cardiac defect is not a significant predictor of coping skills.
factors that impact a family's ability to cope are: ability to understand/comprehend medical concepts, what the child's physical condition is and parent' perception that they "did something wrong" and caused the heart defect.Support group for parents is a highly recommended strategy to help a family cope in different ways; provide emotional support for short-term and long-term coping, decrease feelings of isolation for those whose family and friends are at a loss on how to provide support, reduce anxiety and stress of family members, gather and share information about the same or similar defect, and focus on positive aspects of the situation.