Changes in personal control as a predictor of quality of life after pulmonary rehabilitation

Abstract

Objective

Perceptions of mastery and self-efficacy may be related to better outcomes in pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD). This study examined (1) whether patients with COPD improved during a rehabilitation programme with respect to quality of life (QoL) and perceptions of self-efficacy and mastery, and (2) whether increased perceptions of mastery and self-efficacy contributed to a higher QoL after rehabilitation.

Methods

Thirty-nine consecutive COPD patients (aged 60.5 ± 9.0) were included from a rehabilitation centre and completed self-report questionnaires assessing symptoms, QoL, and perceptions of personal control.

Results

COPD patients improved during rehabilitation in overall QoL and self-efficacy, although no significant changes were found in QoL domains and mastery. Changes in self-efficacy during rehabilitation contributed to the explanation of the social and psychological functioning QoL domains.

Conclusion

Even in seriously impaired COPD patients in advanced stages of illness, positive changes in self-efficacy and overall well-being can be established during rehabilitation. Changes in self-efficacy were related to a better QoL, suggesting the importance of personal control in the adjustment to COPD.

Practice implications

Focussing more explicitly on the enhancement of perceptions of personal control in COPD patients may be an important aim of pulmonary rehabilitation.

Introduction

Chronic obstructive pulmonary disease (COPD) is one of the main causes of disability in persons over 40 [1]. COPD is characterised by airflow limitation and a loss of pulmonary function that is not fully reversible by pharmacological treatment [2], [3]. This airflow obstruction is usually progressive and is associated with an abnormal inflammatory response of the lungs to particles or gases [2], [4]. Most patients with COPD experience symptoms such as a chronic cough, dyspnoea and the production of sputum [5]. The diagnosis of COPD includes patients with chronic bronchitis, characterised by a fixed obstruction of the airways, and pulmonary emphysema, caused by a decreased elasticity of the lung tissue. COPD has a serious impact on the quality of life (QoL) of patients [6], for example, most patients with COPD experience physical limitations as well as psychological problems, such as feelings of anxiety or depression [7].

Since COPD is an incurable disease, the treatment of patients with COPD is mainly aimed at effective disease management focussed on the prevention of disease progression and on improvements with respect to symptoms and exercise tolerance [2]. In addition to pharmacological treatment, in the more severely affected patients pulmonary rehabilitation is recommended to support the management of COPD [1]. A comprehensive rehabilitation programme should consist of exercise training, nutrition counselling, and education [2]. Patients at all stages of COPD may benefit from exercise training (aerobic exercise and respiratory muscle strength training) during rehabilitation, leading to improvements in exercise tolerance and symptoms of dyspnoea and fatigue [8], [9], [10]. Pulmonary rehabilitation is particularly indicated in the more severely impaired patients with COPD, given the multidisciplinary approach of the programmes targeted at both pulmonary and non-pulmonary problems, and the improvement of QoL [2].

Part of the effects of the treatment of COPD patients depends on their efforts to engage in certain healthy behaviours, like stopping smoking or doing more physical exercise. Mostly, these are unhealthy behaviours the patients have engaged in for many years and therefore these behaviours are resistant to change. For example, smoking is the most important contributing factor in the development and progression of COPD [5], [11], which patients find hard to change. Therefore, it is very important for the patients to be motivated and committed to the rehabilitation programme to be able to accomplish changes in their behaviour. Many of these patients, however, face multiple and often complex problems, both physical and psycho-social [8]. Previous research has shown that COPD patients referred for rehabilitation had often lost their motivation to improve [12]. Moreover, repeated, failed efforts to change their behaviour may have resulted in decreases in their perceptions of personal control [13], [14], [15].

Personal control refers to individuals’ belief about their capacity to exert control over their own lives [16], [17] and can be divided into several forms of control. Mastery, which is the extent to which people feel in control of the forces that affect their lives [18], has been found to be negatively associated with functional decline [19]. Self-efficacy refers to the confidence people have in being able to execute actions that are required to deal with particular situations [20], [21] and appears to be related to the effectiveness of rehabilitation [22]. Furthermore, self-efficacy has been associated with stopping smoking [14], adherence to medication [23] and to physical exercise [13], all important factors in the management of COPD [1].

Previous studies have shown that perceptions of personal control are important factors related to the outcomes of pulmonary rehabilitation [14], [24], [25], [26], [27], since these perceptions influence patients’ motivation [20] to make the required efforts during rehabilitation. Due to the often multiple problems and the diminished sense of personal control of COPD patients, their treatment is rather difficult. Though a number of studies have reported the effects of rehabilitation on exercise tolerance and QoL [28], these effects often decrease in the long term [10], [24], [29], [30]. Positive effects of rehabilitation are difficult to achieve and many patients experience relapse, even if they initially improved during rehabilitation [31], [32]. As a result, patients with lower perceptions of personal control may fail to attain their goals during rehabilitation or may more easily relapse afterwards. Higher perceptions of personal control, however, may be related to better outcomes of pulmonary rehabilitation.

In this study, we first examined whether QoL and perceptions of mastery and self-efficacy improved in patients with COPD referred to a rehabilitation programme. Given the often multiple and complex problems patients with COPD have to face, and a decreased level of motivation to change their behaviour, these patients were in fairly poor psychological shape, rendering it unlikely that changes in their perceptions of personal control during rehabilitation could be expected. Moreover, the assessed patients with COPD were quite seriously ill with respect to their lung function parameters (stage III of the GOLD classification (global initiative for chronic obstructive lung disease) [2], indicating serious COPD). Consequently, on the basis of previous research [31], only modest changes in QoL during rehabilitation were expected. Second, we studied whether changes in mastery and self-efficacy were related to a higher QoL after rehabilitation.