Review
Illness perceptions and coping in physical health conditions: A meta-analysis

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Highlights

  • The relationships between illness perceptions and psychological outcomes are consistent across a range of physical illnesses.

  • Coping variables tend to be stronger predictors of outcomes than the illness perception variables.

  • There is no clarity about the theoretical position of coping in relation to illness perceptions in this literature.

Abstract

Objective

There is a considerable body of research linking elements of Leventhal's Common Sense Model (CSM) to emotional well-being/distress outcomes among people with physical illness. The present study aims to consolidate this literature and examine the evidence for the role of coping strategies within this literature.

Methods

A systematic review was conducted where the outcomes of interest were: depression, anxiety and quality of life. A total of 1050 articles were identified and 31 articles were considered eligible to be included in the review.

Results

Across a range of illnesses, perceptions of consequences of the illness and emotional representations were consistently the illness perceptions with the strongest relationship with the outcomes. Coping variables tend to be stronger predictors of outcomes than the illness perception variables. The evidence for the mediating effect of coping was inconsistent.

Conclusions

Illness perceptions and coping have an important role to play in the explanation of distress outcomes across a range of physical health conditions. However, some clarity about the theoretical position of coping in relation to illness perceptions, and further longitudinal work is needed if we are to apply this information to the design of interventions for the improvement of psychological health among people with physical health conditions.

Introduction

The Common Sense Model (CSM) [1] posits that when an individual is confronted with an illness or health condition, they will attempt to assign meaning to this illness by accessing their cognitive and emotional representations of illness (illness perceptions). The CSM proposes that individuals will develop coping procedures (based on their illness perceptions), which will then be evaluated in terms of their success. The result of this evaluation may be a change in coping strategy and/or a change in perceptions about the illness. The CSM, therefore, illustrates the relationship between cognitive and emotional representations of an illness and coping strategies.

Originally, the CSM viewed coping strategies as behavioural outcomes and research based on the model has examined whether illness perceptions are important predictors of coping procedures in terms of behavioural outcomes such as medication adherence [2], [3], [4], attendance at cardiac rehabilitation [5] and self-care in diabetes [6]. Subsequently, the CSM has been used as a model to explain physical or psychological outcomes (e.g. glycaemic control [7]; quality of life [8]). This research has usually considered coping as a concept broader than behavioural outcomes and has also included cognitive and emotional strategies that a person might use to manage a potentially negative situation. For example, in this context, coping is taken to mean avoidant coping strategies, such as behavioural disengagement (giving up attempts to manage the situation); approach coping strategies, such as acceptance (learning to live with the situation); emotion-focused coping strategies, such as venting (expressing negative feelings); and problem-focused coping strategies, such as active coping (doing something to make the situation better). These categories are not mutually exclusive.

There is a considerable body of research linking elements of the CSM to psychological outcomes among people with physical illness. However, using the CSM to explain psychological outcomes is an extrapolation of the original model and this extrapolation has clearly left researchers unsure about the role of coping (now conceptualised in its broader sense). Although the CSM includes emotional representations of the illness and emotional coping strategies as considerations, the CSM does not explicitly address psychological outcomes. Not surprisingly, therefore, the application of the CSM to explain psychological outcomes has been open to individual researchers' interpretations, which has resulted in inconsistencies around which elements of the CSM are considered to be important in explaining psychological outcomes (i.e the relevance of emotional representations) and confusion about how the elements of the CSM are considered to relate to each other (i.e. whether or not coping procedures are hypothesised to mediate the relationship between illness perceptions and outcomes).

For example, Price et al. [9] and Dempster et al. [10] both hypothesised that illness perceptions and coping variables are important when explaining variation in distress outcomes among people with cancer. Yet, Dempster et al. tested a model that assumed the relationship between illness perceptions and distress would be mediated by coping, whereas Price et al. did not make any assumptions about mediation. Furthermore, Benyamini et al. [11] do not include a measure of coping in their examination of the relationship between illness perceptions and quality of life among people with dermatitis, even though the CSM is presented as the theoretical model justifying their research. Indeed, Wenninger et al. [12] merge the concepts of illness perceptions and coping. They assessed illness perceptions among adults who have survived childhood cancer, and referred to the illness perception measures as coping strategies. Consequently there is a need to bring some clarity to this area.

The questionnaires most commonly used in the literature to assess illness perceptions are the Illness Perception Questionnaire-Revised (IPQ-R) [13] and the Illness Perception Questionnaire (IPQ) [14]. The IPQ assesses 5 illness perceptions: identity (perceptions of symptoms associated with the illness), controllability/curability of the illness, timeline for the illness, consequences of the illness and cause of the illness. The IPQ-R added items designed to assess illness coherence (the person's perceptions of the extent to which they understand the illness) and emotional representations (the extent to which the person's illness makes them experience symptoms of anxiety or depression). The authors of the IPQ-R also divided the timeline dimension into 2 factors (timeline cyclical and timeline acute/chronic) and divided the cure/control dimension into 2 factors (personal control and treatment control). Timeline cyclical refers to the perception of the cyclical nature of the illness across time; timeline acute/chronic is the person's perception about the illness passing quickly or not. Personal control refers to perceptions of the person's ability to control the illness, whereas treatment control refers to perceptions about the effectiveness of any treatment or the effectiveness of medical personnel to control the illness.

The Brief IPQ [15] has been developed more recently. It uses a single item each to measure the illness perceptions of consequences, timeline, personal control, treatment control, identity, concern, understanding and emotional response. However, using a single item to address each construct makes the Brief IPQ more prone to random measurement error than the multi-item scales of the IPQ and IPQ-R.

Given the lack of consistency in the application of the CSM when focusing on psychological outcomes among people with physical illness, a review of the empirical evidence about the relationships between illness perceptions, coping and psychological health outcomes will be useful in contributing to deliberations that will provide theoretical clarity. A previous review of the CSM exists [16] but most of the research in this area has been published since this review was conducted.

The aim of the present review, therefore, is to determine the following:

  • 1.

    The extent to which illness perceptions (as assessed by the IPQ-R or IPQ) and coping strategies explain emotional outcomes (depression, anxiety, or quality of life) among people with physical illness.

  • 2.

    The evidence for the mediating role of coping strategies in this relationship.

Section snippets

Method

In comparison to the IPQ and IPQ-R, the use of any other measure to assess illness perceptions is relatively rare. The exception to this is the Brief IPQ, but it is not comparable to the IPQ or IPQ-R given the measurement problems outlined in the introduction section of this paper. On the other hand, there is less consensus in the literature regarding which coping measures are appropriate within this body of research. Therefore, this review focused on studies that employed the IPQ or IPQ-R, but

Results

Of the remaining 31 articles reviewed, it was apparent that there was some overlap in the data presented in different articles. In some cases, baseline data from a longitudinal study were presented and then the longitudinal analysis was presented in a separate article. In other cases, a subset of participants or scores were re-analysed in a separate article. These articles were grouped and counted as a single record. Therefore, the Oesophageal Cancer Study refers to the 3 articles by Dempster

Discussion

The review found that, across a range of illnesses, illness perceptions explained between 25% and 30% of the variance in the emotional health outcomes in cross-sectional studies, before any coping variables were considered. This is a notably homogenous finding given the range of illnesses covered in the research. In addition, perceptions of consequences of the illness and emotional representations were consistently the illness perceptions with the strongest relationship with these outcomes.

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