Gender difference in coping strategies among

patients enrolled in an inpatient rehabilitation

program
Grégory Ninot, PhD,a Marina Fortes, PhD,a Magali Poulain, PhD,b Audrey Brun, Psychologist,b
Jacques Desplan, MD,b Christian Préfaut, MD, Professor,c and Alain Varray, PhD, Professor,d Montpellier
and Osseja, France

BACKGROUND: Previous research has not addressed gender differences in coping strategies among
patients with mild to moderate chronic obstructive pulmonary disease (COPD) who are enrolled in
inpatient and multidisciplinary rehabilitation programs.
METHODS: The coping strategies of 182 consecutive patients (61 women aged 61.1 years; 121 men
aged 62.7 years) with mild to moderate COPD were assessed on admission and then at discharge
after 29 days of pulmonary rehabilitation, using the Coping Inventory for Stressful Situations. A
one-way analysis of variance for repeated measures was used to test the differences in coping scores.
RESULTS: During the rehabilitation program, problem-focused strategies increased (⫹2.54 [95%
confidence interval: 1.41–3.67] with F ⫽ 23.77, P ⬍ .0001), emotion-focused strategies decreased (⫺2.75
[95% confidence interval: ⫺4.06, ⫺1.45], F ⫽ 15.37, P ⬍ .001), and avoidance strategies were
differently (t ⫽ 2.97, P ⬍ .05) influenced in women (⫹2.43 [95% confidence interval: .66 – 4.19])
compared with men (⫺1.30 [95% confidence interval: ⫺2.82–.22]). The prevalence of COPD in women
is increasing, and rehabilitation professionals need a greater awareness of how women cope differently
than men with this disease. (Heart Lung® 2006;35:130 –136.)

T he increasing prevalence of chronic obstruc-

tive pulmonary disease (COPD) worldwide,
particularly in women, places an increasing
burden on public health services,1 as well as on the
patients’ families2 One means of managing this
problem has been to create individualized exercise-
training programs to improve pulmonary function,
exercise tolerance, and dyspnea.2 Today’s multidis-
ciplinary rehabilitation programs also try to improve
quality of life2,3 and decrease reliance on health
services.2,4 Pulmonary rehabilitation is an accepted
From the aLaboratory Symbolic Process for Health and Sport,
University of Montpellier I, Montpellier, France; b“Clinique du
Souffle” La Solane, Osséja, France; cLaboratory Physiology of
Interactions, Faculty of Medicine, University of Montpellier I,
Montpellier, France; dLaboratory Motor Efficiency and Deficiency,
University of Montpellier I, Montpellier, France.
Reprint requests: Grégory Ninot, JE 2416, Laboratory Symbolic
Process for Health and Sport, University of Montpellier I, 700
avenue du Pic St-Loup 34080 Montpellier, France.
0147-9563/$ – see front matter
Copyright © 2006 by Mosby, Inc.
doi:10.1016/j.hrtlng.2005.09.004
therapeutic intervention that has been shown to
result in important benefits in health self-manage-
ment. A particular aim of the rehabilitation program
is to educate patients about self-management of
COPD.2,4 The way patients cope with COPD greatly
influences physical health, psychologic well-being,
and life expectancy.5
Coping is a constantly changing cognitive and
behavioral effort to manage specific external and/or
internal demands6 to enhance well-being7 Three
coping strategies are generally distinguished.8 The
problem-focused strategies, which are characterized
as being active and expressive and by positive think-
ing, result in significantly higher levels of function-
ing, as well as more positive scores on clinical
measures of disease and higher levels of psycho-
logic well-being.6 Emotion-focused coping is a pas-
sive strategy; nothing is done to reduce the threat
itself.8,9 Examples of passive strategies are respond-
ing to situations with anxiety, anger, wishful think-
ing, or helplessness. Avoidance-focused coping is a

130 www.heartandlung.org MARCH/APRIL 2006 HEART & LUNG

Ninot et al
defensive reappraisal or behavior.8 Examples of de-
fensive strategies are responding with avoidance or
distraction.
The pulmonary and physiologic impairments of
COPD are accompanied by psychologic distur-
bances such as depression, anxiety, and coping
difficulties.2,9,10,11 Patients with COPD have been
found to rely most heavily on emotion-focused
coping,12,13 avoidance-focused coping,14 or
both.15 Anxieties caused by the unpredictability
of symptom exacerbation (especially dyspnea) ac-
tivate emotion-focused strategies.11 Avoidance-
coping characterizes those patients who attempt
to be less influenced by symptoms and tends to
preserve the activities of daily living.16 Avoidance
strategies also characterize patients with COPD
who try both to calculate and plan every move-
ment with minimal effort and to stay away from
stressful situations.11
One study using the Freiburg Coping Question-
naire showed that reliance on problem-focused cop-
ing strategies increased over a period of inpatient
rehabilitation.17 Moreover, patients with COPD who
participated in a systematic exercise program used
fewer emotion-focused coping strategies than did
nonexercisers.14 A study, however, showed no sig-
nificant difference in coping scores between admis-
sion and discharge after inpatient rehabilitation
with a nonvalidated version of the Asthma Coping
Questionnaire.18
The steep increase of COPD in women compared
with men could be changing the general way we
understand the psychosocial consequences of
COPD, and thus the work of physicians, behavioral
scientists, and other health care personnel. A qual-
itative study indicated that women with COPD used
emotion-focused strategies more often than men.13
According to Western stereotypes,6 women can
more easily express emotional and irrational reac-
tions (crying, expecting help, hoping for a miracle),
and men must remain stoic and in control (never
expressing emotion, showing rational, and con-
structive thinking).
No studies were found that used quantitative
measures of coping strategies in a large sample
distinguishing women and men with COPD. The
question of which patients show greater improve-
ment in coping strategies after pulmonary reha-
bilitation remains to a large extent unan-
swered.2,18 During a rehabilitation program, it is
important to make patients with COPD aware of
the risks associated with chronic stress exposure
and help them to develop adaptive responses. We
explored the influence of gender on the coping
HEART & LUNG VOL. 35, NO. 2
Gender difference in coping strategies
styles of patients with COPD over the rehabilita-
tion period.
METHODS
Participants
Patients with COPD entered the study on admis-
sion to the inpatient pulmonary rehabilitation cen-
ter. Criteria for inclusion were diagnosis of COPD
according to American Thoracic Society guidelines,2
age between 40 and 80 years, and ability to read in
French. A patient was defined as having stable dis-
ease if he or she had had no change in symptoms or
medication for 2 months before entry.2 A total of
182 patients with mild to moderate COPD, 61
women and 121 men, took part in this study. Nine-
teen males and 9 females presented with a comor-
bidity criterion of obesity. The participants repre-
sented all parts the country equally. They were for
the most part long-time smokers (75%), and most
were not working (60%) because of long-term dis-
ease or retirement. In regard to marital status, 67%
were married or living together and 29% were single,
separated, widowed, or divorced. Patients were ex-
cluded if they were oxygen-dependent or if they had
any pharmacologically treated psychiatric disorder
or major illness that would affect psychologic or
physiologic function. No difference between groups
(women vs men) was found for age, body mass
index, forced expiratory volume in 1 second (FEV1),
and FEV1/forced vital capacity (measured the day
after admission). Descriptive data on the partici-
pants are shown in Table I.
Study design
The descriptive study included consecutive pa-
tients admitted to an inpatient rehabilitation pro-
gram between August and December 2002. During
the first medical visit in the rehabilitation center,
participants completed the coping questionnaire.
After completion of testing, participants began a
facility-based 4-week program of rehabilitation
based on individualized exercise.19 Before dis-
charge, the participants completed the same coping
questionnaire. The protocol was approved by the
institutional review board, and all patients gave
informed written consent to participate. No patients
refused to participate in the study.
Rehabilitation program
The patients participated in the 4-week rehabilita-
tion program in small groups of 8 to 10 (including men
and women) who met 5 days per week (20 sessions) in
www.heartandlung.org 131
 Gender difference in coping strategies
Table I
Baseline characteristics of participants with mild to moderate COPD
Women
(n ⴝ 61)
Age (y) 60.3 ⫾ 9.7
Weight (kg) 67.3 ⫾ 13.2
Height (cm) 161.0 ⫾ 5.5 170.8 ⫾ 6.1
Body mass index 25.9 ⫾ 5.0
FEV1 (% predicted) 54.7 ⫾ 15.5
FEV1/FVC (%) 58.1 ⫾ 11.4
Mild/moderate (n/n) 34/27
Single/marital status (n/n) 40/21
NS, Not significant; FEV1, forced expiratory volume in 1 second; FEV1/FVC, ratio of forced expiratory volume in 1 second to
forced vital capacity.
Values are mean ⫾ SD. P indicates whether the difference between the two groups were significant (independent ⫾ tests).
a rehabilitation center in France following a typical
pulmonary rehabilitation program reported in ran-
domized controlled trials.2 The program included the
following: (1) individualized exercise training (4 hours/
day), (2) respiratory therapy with aerosol and/or drain-
age if necessary (1 hour/day), (3) health education (2
hours/week) with information on pulmonary disease,
medications, and healthful daily living strategies, (4)
psychosocial support (discussion group 1 hour/week),
and (5) dietary monitoring (1 hour/week). The training
included cycling, mountain walking, general exercises
(strength training, breathing exercise, team sports, cir-
cuit training, swimming–moderate effort), and relax-
ation. The cycling component consisted of 45 minutes
on a cycle ergometer with three successive pedaling
periods of 10 minutes separated by 5 minutes of active
recovery. The intensity of work was individualized for
each patient with COPD and was determined by the
heart rate corresponding to the ventilatory threshold
assessed throughout an incremental test.20 After cy-
cling, patients stretched for 10 minutes and then had
30 minutes of relaxation. The second component was
2 hours of nature walking with 45 minutes at ventila-
tory threshold intensity and 75 minutes at lower walk-
ing speed. Cycling, general exercises, and relaxation
were done in the same half-day, and walking was done
in the other half-day. The goal was to ensure that all
patients could perform the exercise program compo-
nents without experiencing more than mild pain and
without significant dyspnea. Program compliance was
thus very high (of 182 patients, only 5 with bronchial
infection stopped for ⬍1 week). The group dynamic,
active pedagogical approach, and adapted environ-
ment all had a major impact on individual motivation.
132 www.heartandlung.org
Ninot et al
Men
(n ⴝ 121) t test P Chi-square
62.6 ⫾ 9.6 .13 .08
78.3 ⫾ 12.1 ⫺5.64 ⬍.001
⫺10.52 ⬍.001
26.9 ⫾ 4.0 ⫺1.32 .19
52.1 ⫾ 15.2 1.77 .13
54.5 ⫾ 12.7 1.07 .13
63/58 NS
82/39 NS
Coping strategies assessment
Originally, Endler and Parker21 developed the
Multidimensional Coping Inventory; then on the ba-
sis of a series of factor analyses, they further revised
this measure and renamed it the Coping Inventory
for Stressful Situations (CISS).8,22 The CISS is a
48-item measure composed of three scales assess-
ing problem-focused behaviors, emotion-focused
behaviors, and avoidance strategies, which are three
of the most-robust dimensions identified in the
general coping literature.23 Endler and Parker24 re-
ported that the CISS has a stable factor structure,
excellent internal consistency, and adequate test–
retest reliability, and they provided support for its
construct validity. The CISS, validated in French,25 is
a Likert-type scale that identifies behaviors as rang-
ing from 1 for “never” to 5 for “very often.” The
coping strategies are grouped into three 16-item
subscale measures. The problem-focused strategies
describe task-oriented efforts to resolve a problem,
restructure a task, or modify a situation. The emo-
tion-focused strategies describe ego-oriented ef-
forts to decrease stress with emotional reactions
(culpability, fear, anger, or tension), personal pre-
occupations, or daydreaming. The avoidance strat-
egies include activity and cognitive modifications to
avoid stressful situations (distractions, social diver-
sion). The total scores on each scale indicate indi-
vidual response rate. Moreover, the results are pre-
sented as relative scores with subscale scores
indicating the percentage (or proportion) of each
strategy used.
MARCH/APRIL 2006 HEART & LUNG
Ninot et al Gender difference in coping strategies

Table II
Measures of coping strategies at admission to and discharge from in patient rehabilitation in the two
groups of participants with mild to moderate COPD
Domain Time Women Men P value

Problem- Admission 48.9 ⫾ 12.1 56.2 ⫾ 10.8

focused Discharge 53.0 ⫾ 9.9 57.9 ⫾ 11.4
Difference 4.13 (1.84, 6.42) 1.74 (.49, 2.98) .047 (t ⫽ 1.99)
P value .001 (t ⫽ ⫺3.60) .007 (t ⫽ ⫺2.75)
Emotion- Admission 49.0 ⫾ 14.0 42.5 ⫾ 13.1
focused Discharge 46.2 ⫾ 12.4 39.7 ⫾ 11.9
Difference ⫺2.75 (⫺5.41, ⫺.97) ⫺2.75 (⫺4.22, ⫺1.29) .997 (t ⫽ ⫺.001)
P value .042 (t ⫽ 2.07) .001 (t ⫽ 3.72)
Avoidance Admission 40.8 ⫾ 11.5 40.1 ⫾ 12.6
strategies Discharge 43.2 ⫾ 12.0 38.8 ⫾ 13.8
Difference 2.43 (.66, 4.19) ⫺1.30 (⫺2.82, .22) .034 (t ⫽ 2.97)
P value .008 (t ⫽ ⫺2.75) .094 (t ⫽ 1.69)

Values are mean ⫾ SD. The different values are absolute differences from admission to discharge and include 95% confidence
intervals. P indicates whether the difference from admission to discharge was significant (post-hoc Scheffe tests) in the Time
column. P value column indicates whether the differences between the two groups were significant (independent ⫾ test).
Increases in problem-focused coping are indicative of improved use of active strategies fo cope with stressful situations.
Decreases in emotion-focused coping are indicative of limited use of passive strategies. Increases in avoidance strategies are
indicative of intention and behavior to keep away from stressful situations. Decrease in avoidance strategies are indicative of
motivation and behavior to struggle with stressful situations.

Statistical analyses ance. The questionnaire measures independent and

Internal consistency reliability was assessed for
each scale using Cronbach’s alpha. To test the factor
structure, the data were also submitted to principal
components factor analysis with varimax rotation.
This factor analysis is important to determine that
scales are capable of measuring independent con-
structs.
The Shapiro-Wilk W test showed the normal dis-
tribution of the coping scores. A one-way analysis of
variance (ANOVA) for repeated measures was used
to test the differences in coping scores (group, time,
and/or interaction). When the test revealed a signif-
icant difference, the Scheffé test was used to display
the significant variations prominently. Significance
was set at the .05 level for all analyses.
RESULTS
Overall scale scores returned internal consis-
tency reliabilities using Cronbach’s alpha. The alpha
coefficients for the present study were .90, .83, and
.85, respectively. The principal components factor
analysis with varimax rotation showed excellent co-
efficients for each dimension (problem-focused:
.46 –.74; emotion-focused: .42–.75; avoidance strat-
egies: .41–.74), which explained 39.9% of the vari-
consistent dimensions.
For the problem-focused coping scores (Table II),
the one-way ANOVA for repeated measures showed
an increase between admission and discharge
(F[1,180] ⫽ 23.77, P ⬍ .0001). Women with COPD
showed an increase in the use of this strategy after
the rehabilitation period (P ⬍ .05). Compared with
men, women used this coping style less regularly
(F[1,180] ⫽ 14.22, P ⫽ .0003) at the two periods (P
⬍ .05). Nevertheless, the increase in the men’s use
of this strategy was significantly lower compared
with that of the women (P ⬍ .05).
For the emotion-focused coping scores (Table II),
the one-way ANOVA for repeated measures showed
significant differences for time indicating an overall
decrease of this coping style between admission
and discharge (F[1,180] ⫽ 15.37, P ⬍ .001) and for
gender (F[1,180] ⫽ 11.90, P ⬍ .001). The indepen-
dent t test showed significantly lower scores for men
compared with women (P ⬍ .05).
For the avoidance scores (Table II), the one-way
ANOVA for repeated measures showed significant
differences for interaction between gender and time
(F[1,180] ⫽ 8.84, P ⫽ .004). The analysis of interac-
tion showed that women with COPD showed an

HEART & LUNG VOL. 35, NO. 2 www.heartandlung.org 133

Gender difference in coping strategies
increased use of avoidance between admission and
discharge (P ⬍ .05). In contrast, no significant dif-
ferences were shown for the men, although a trend
toward decrease was noted. The change in the use
of this strategy was significantly different between
the men and women (P ⬍ .05).
DISCUSSION
The aim of the study was to explore coping strat-
egies among males and females with mild to mod-
erate COPD in an inpatient rehabilitation program.
The results showed a difference between men and
women with mild to moderate COPD regarding cop-
ing strategies. Compared with the men, the women
used fewer problem-focused strategies and more
emotion-focused strategies.
This gender difference regarding coping strate-
gies could be explained by findings that women
generally show higher anxiety than men,26,27 espe-
cially regarding dyspnea, and less knowledge of dis-
ease-management techniques15 and/or by conform-
ism to Western stereotypes about masculine and
feminine behaviors.6 The women with COPD coped
with their disease in ways that were more deleteri-
ous, because an emotional coping style can amplify
the consequences of COPD. Coping in a very emo-
tional way is not favorable for a feeling of well-
being.16 Classic emotion-focused coping includes
anger toward self or others. This strategy can be
related to depression and emotional dysfunction.28
Moreover, avoidance strategies increased over the
rehabilitation session in these women. The de-
crease in emotion-focused coping may thus have
been compensated by increased reliance on avoid-
ance strategies, indicating a motivation to be less
influenced by disease symptoms in daily life. The
men, on the other hand, wanted to more actively
control the outcome of the disease. They refused to
accept limitations on their capacities for physical
and sexual performance or losses in social and fam-
ily position.29
This investigation thus provides practical infor-
mation for physicians, behavioral scientists, and
other health care personnel on how men and
women with COPD differ in the ways they cope with
their disease. This information will help rehabilita-
tion professionals and patients work toward com-
mon goals based on the patients’ coping style
rather than make decisions solely on the basis of
pulmonary function and exercise tolerance. During
the health education sessions, the men requested
information on disease functioning, the specific
skills needed to control symptoms like dyspnea, and
134 www.heartandlung.org
Ninot et al
the steps to take to prevent exacerbations like in-
fection. Conversely, the women needed to express
their emotions and exchange feelings about the
disease and its consequences in their lives. For
women, psychosocial group sessions emphasizing
dialogue, the expression of feelings, and the ex-
change of behavioral solutions would be more ap-
propriate.
In a large number of patients, the results showed
an increased reliance on problem-focused coping
strategies and a decrease in emotion-focused cop-
ing strategies between admission and discharge.
Men and women made equal improvements in
terms of emotion-focused coping. These results,
which respectively support two qualitative stud-
ies17,14 can indicate that the inpatient rehabilitation
program based on individualized and methodical
exercise over a 4-week period fostered positive ad-
justment in the coping style of patients with COPD.
However, randomized controlled trials are needed
to determine whether such coping styles are the
result of the program or of other factors in patients’
lives.
Problem-focused coping is an active attempt to
reduce threat either by eliminating the problem or
by changing its meaning. Desensitization to dys-
pnea with reduction in fear and anxiety as a result of
repeated exercise has been suggested as a possible
mechanism for this change.2,3,30 Reduction in anxi-
ety or distress associated with dyspnea could result
in global decrease of the frame of reference from
which the patient perceives the symptom. This
would be analogous to desensitization training for
phobias in which repeated exposure to a graded
stimulus over time in a safe environment gradually
lessens fear and anxiety associated with the stimu-
lus.31 Although the COPD itself is uncontrollable,
patients rediscover their own abilities to tolerate
exercise and thus decrease emotion-focused coping
strategies linked to the fear of dyspnea.12,14,16 More-
over, the health education sessions included in the
rehabilitation program helped patients to under-
stand their disease better and cope with stressors
more effectively. The social support of other partic-
ipants with COPD in small groups32 and the encour-
agement of rehabilitation professionals further en-
couraged attempts to reduce emotional reactions
and choose adaptive behaviors. Therefore, this may
facilitate postrehabilitation exercise and ultimately
reduce avoidance of feared (unsafe) situations. Both
may be important in maintaining physical fitness
and general well-being in patients with COPD. Tak-
ing into account that the coping scale is a signifi-
cant predictor of hospitalization for COPD,33 the
MARCH/APRIL 2006 HEART & LUNG
 Ninot et al
improvement of patients’ capabilities to cope with
their COPD could potentially prevent major anxiety
events.
Nevertheless, the results showed that men and
women made opposite changes regarding avoid-
ance strategies: The men decreased and the women
increased their reliance on this coping style. Avoid-
ance strategies, which restrain anxiety and other
extreme emotions, can reduce the incidences of
dyspnea and increase functional performance. Re-
habilitation professionals need to pay particular at-
tention to this coping style during the program and
should be ready to offer specific advice before dis-
charge regarding both its usefulness and its dan-
gers. Men may have the desire to provoke dyspnea
in an ultimately self-defeating attempt to struggle
against stimuli and surpass their limits. This means
of coping reflects the persistence of both denial
(which is very frequent during the first period of the
disease) and self-destructive behaviors, and it con-
tradicts the goals of rehabilitation, which are to
promote self-management and improve the quality
of life and autonomy of individuals with chronic
disease (COPD). In the long term, the adherence to
health care recommendations can be arbitrary, spo-
radic, and finally unfavorable. In contrast, the
women developed a better ability during the pro-
gram to recognize symptom-provoking situations in
advance and then choosing to stay away from them.
This classic coping style (avoidance and cata-
strophic withdrawal) is used more by patients with
COPD than by patients with any other chronic ill-
ness.10,34 Although it is useful in the short term,
professionals need to determine whether this style
of functioning will increase over time (especially
after several rehabilitation sessions). If women de-
velop an overreliance on avoidance, they risk be-
coming more vulnerable to unpredictable events
and more dependent on external conditions (drugs,
health professionals, the “safety” of staying at
home).
Overall, rehabilitation professionals have to de-
tect coping failure based on maladaptive physical
responses (common physical signs and symptoms
of stress) and/or observable indictors of inadequate
stress coping skills (irritability, fear, anger, anxiety,
and depression). For a comprehensive assessment,
a battery of questionnaires, a structured interview,
and an interview with the spouse or family will be
useful to obtain more detailed information about
the coping ability of the individual in stress.
Without a randomized controlled clinical trial de-
sign, the benefits of the rehabilitation program in
coping strategies cannot be concluded in this study.
HEART & LUNG VOL. 35, NO. 2
Gender difference in coping strategies
Other factors may have contributed to improvement
in coping styles. Further randomized controlled clin-
ical trials are needed to confirm this hypothesis.
CONCLUSION
Our study described relationships between a pro-
gram of intensive inpatient rehabilitation session
and coping styles in patients with mild to moderate
COPD. The results suggest that a program improves
the use of problem-focused strategies, decreases
reliance on emotion-focused strategies, and influ-
ences the use of avoidance strategies differently in
men and women. Randomized controlled trials are
needed to confirm these changes, which were prob-
ably the result of rehabilitation programs. The re-
sults suggest that inpatient pulmonary rehabilita-
tion programs can promote the use of more
appropriate coping strategies that the patient with
COPD can then incorporate into his or her lifestyle.
More studies are needed to determine whether
these coping strategies lead to healthier behaviors.
Longitudinal investigations will be useful to deter-
mine the stability of new healthy behaviors and
their cost-effectiveness.35
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