472709 9Journal of Transcultural NursingPark et al.

TCNXXX10.1177/104365961247270

Research Department

Dyspnea Coping Strategies in Korean Immigrants With Asthma or Chronic Obstructive Pulmonary Disease

Journal of  Transcultural Nursing 2014, Vol 25(1) 60­–69 © The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659612472709 http://tcn.sagepub.com

Soo Kyung Park, PhD, RN1, Nancy A. Stotts, EdD, RN, FAAN2, Marilyn K. Douglas, PhD, RN, FAAN2, DorAnne Donesky-Cuenco, PhD, RN2, and Virginia Carrieri-Kohlman, DNSc, RN, FAAN2

Abstract Purpose: Patients with lung disease develop coping strategies to relieve dyspnea.The coping strategies of Korean immigrants, however, are poorly understood. The purpose of this study was to describe the strategies that Korean immigrants with asthma or chronic obstructive pulmonary disease (COPD) use to cope with dyspnea and to compare similarities and differences in coping strategies between the two conditions. Design: Outpatients with asthma (n = 25) or COPD (n = 48) participated in a cross-sectional descriptive study. Method: Open-ended questions and a structured instrument were used to describe coping strategies for dyspnea. Descriptive and inferential statistics were used to analyze the data. Results: The most prevalent strategy was “I keep still or rest.” Korean immigrants also used traditional therapies to manage dyspnea. Conclusions: Although the coping strategies of Korean immigrants were similar to those of other ethnic groups, they incorporated elements of Asian medical practice and herbs. This finding enables health care providers to better understand Korean immigrants’ efforts to overcome dyspnea and to guide their patients’ approach to coping. Keywords asthma, chronic obstructive pulmonary disease, coping strategies, dyspnea, Korean immigrants

Approximately 0.3% to 0.4 % of the U.S. population is Korean (National Association of Korean Americans, 20032011). In 2007, Korean immigrants comprised 2.7% of all immigrants; currently, this group is the seventh largest immigrant group in the country (Migration Information Source, 2010). In Korea, the prevalence of chronic obstructive pulmonary disease (COPD) among people aged 45 years and older was 17.2% between 2001 and 2002 (Kim et al., 2005). The prevalence of asthma among Koreans residing in Korea also increased between 2005 and 2009 (Health Insurance Review & Assessment Service, 2009). In 2008, chronic lower respiratory disease was the sixth most frequent cause of death among Koreans (Korea National Statistical Office, 2008). In California, morbidity related to asthma among Asian adults was 9.7% (American Lung Association, 2007). In 1997, COPD was the fifth leading cause of death in the foreign-born U.S. population (Rubia, Marcos, & Muennig, 2002); it is also predicted to become the third most common cause of death worldwide by 2020 (Raherison & Girodet, 2009). Although no one definition of dyspnea has been universally accepted, several definitions have been suggested in the literature. Dyspnea is “difficult, laboured, uncomfortable

breathing” (Howell, 1966, p. 1). It has also been defined as “the sensation of feeling breathless or experiencing air hunger” (Wasserman & Casaburi, 1988, p. 503). Precise data on the prevalence of dyspnea symptoms in Koreans residing in Korea or in Korean immigrants have not been reported. However, one population-based study estimated that between 22.8% and 49.7% of 7,518 Koreans aged 40 to 69 years with normal pulmonary function experienced dyspnea (Shin et al., 2005). The prevalence of dyspnea in people with asthma or advanced COPD (N = 100) in the United States has been estimated to be 94% (Blinderman, Homel, Billings, Tennestedt, & Portenoy, 2009). Dyspnea is the most common, distressing symptom for people with asthma or COPD (Blinderman et al., 2009; Oh, 2008), which limits their physical and psychological

1

Korea University, Seoul, South Korea University of California, San Francisco, San Francisco, CA, USA

2

Corresponding Author: Soo Kyung Park, PhD, RN, School of Nursing, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul 136-713, South Korea. Email: [email protected]

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Park et al. functioning and subsequently affects their quality of life (Oh, 2008; Walke et al., 2007). Consequently, health care providers must devise a comprehensive approach to manage this symptom on a daily basis. Several approaches to ameliorate dyspnea have been recommended including breathing retraining, cognitive–behavioral therapy, exercise training, use of fans, medication, nutrition, oxygen therapy, positioning, surgical lung volume reduction, and vibration (American Thoracic Society, 1999). Even though these approaches have been successful in managing dyspnea in some people, not all approaches may be applicable or available to everyone. Individuals must decide which strategies can effectively manage chronic or acute dyspnea on a daily basis. For health care providers to guide patients in selecting coping strategies, they must understand how individuals deal with this symptom. As the prevalence of COPD increases among Koreans, and as the U.S. population of Korean immigrants grows, health care providers must understand how the latter manage their dyspnea. The purpose of this study was to describe the coping strategies that Korean immigrants with asthma or COPD use to manage their dyspnea and to compare coping strategies used for the two conditions.

Theoretical Framework The theoretical framework for this study involved two theories: the model of illness labeling (Angel & Thoits, 1987) and the cognitive-motivational-relational theory of stress and coping (Lazarus & Folkman, 1987). The former helps explain the effect of culture on different processes in symptom perception and responses, whereas the latter helps one interpret the coping process and understand different coping styles. The model of illness labeling holds that the labeling of health and illness, which is inherited from cultures, can constrain the interpretation of physical and psychological states and limit help-seeking options. The model is concerned with how individuals notice and interpret physical or emotional changes, how they choose to take action on such changes, and how they reevaluate those changes, all of which are influenced by culture (Angel & Thoits, 1987). Lazarus and Folkman (1987) developed the cognitivemotivational-relational theory, which subscribes to a continual interplay between the subjective appraisal of stressful events, coping strategies, and short-term outcomes (Lazarus, 1991, 1999; Lazarus & Folkman, 1984). Individuals appraise stress and coping as being either primary or secondary (Lazarus & Folkman, 1984). In the primary appraisal, an individual evaluates a situation and assigns meaning or significance to an event. During secondary appraisal, coping options or resources for coping are considered. By using coping strategies, an individual can change or modify his or her response to a situation, thus altering its effect on the individual. In this process, two types of coping strategies are suggested: problem focused and emotion focused. In problem-focused coping (e.g., breathing techniques), the relationship between a stressor,

the situation causing the stress, and the individual is altered. Emotion-focused coping (e.g., relaxation techniques) regulates stressful emotions (Folkman & Lazarus, 1980). The two models may be useful in understanding how culture influences Korean immigrants’ choice and use of dyspnea coping strategies.

Review of the Literature Korean Model of Health and Cultural Heritage In Korea, as in many other Asian countries, Eastern medicine has been the principal health care system for many centuries (Miller, 1990). The introduction of Western medicine in the late 19th century led to the gradual establishment of a new system of health care in Korea. Over the past two centuries, both systems, Eastern and Western, have coexisted as complementary but quite different approaches to health care (Miller, 1990). Traditional Korean medicine, Han-Bang, although derived from Chinese medicine (Cha et al., 2007; Leem & Park, 2007), has developed its own characteristics. Integral to Korean medical practices are acupuncture, Buhwang, Han-Yak, and Moxa (Pang, 1989; Parish & Parish, 1971). Furthermore, philosophical beliefs drawn from Buddhism, Confucianism, and Taoism have become the foundation of Korean beliefs about health and illness and the theoretical basis of traditional Korean medicine (Parish & Parish, 1971). Buddhists believe that the body comprises four elements: wet, hot, dry, and cold; disease occurs when these elements are not in harmony (Parish & Parish, 1971). Additionally, Buddhists emphasize the truth of cause and effect (karma) and that everything moves in a cyclical motion based on cause and effect (Lee, 2003). Confucianism emphasizes the concept of balance, but it is concerned more with how people live in a social context (Lee, 2003; Parish & Parish, 1971). The Korean concept of Um and Yang originated from Taoism, which emphasizes that one must act in a moderate way to avoid the consequences of extremes and that nature is benign when Um and Yang are in balance (Eerdmans, 1994; Spector, 2004). Together with these philosophical influences, Um and Yang form the theoretical basis of traditional Korean medicine. Signs of illness and the symptoms of disease are interpreted according to the tenets of metaphysical and cosmological philosophy, Um and Yang, and the five elements: fire, earth, metal, water, and wood (Maciocia, 2005; Maloney, 1956; Nestler, 2002). Yin (same as Um) and Yang represent opposite but complementary energy, such as day and night, and darkness and light; the five elements are used to categorize the body’s organs (Maciocia, 2005). All human nature acts through these two opposing and unifying forces, Um and Yang (Pang, 1989), which are balanced by the vital energy, Qi or Ki, in a healthy person (Pang, 1989). Qi or Ki is

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considered the motor of all human activity (Nestler, 2002). A deficiency or excess of this vital energy causes an imbalance of the two forces and results in disease and pathological symptoms (Pang, 1989). Thus, all treatments are designed to restore balance and harmony, based on the principle of Um and Yang (Nestler, 2002; Pang, 1989). Buddhism and Confucianism affect Koreans’ way of life in a most significant way (Lee, 2003). These philosophies discourage self-expression, confrontation, and individualism and emphasize modesty, self-control, patience, moderation in behavior, and an indirect approach to problems (Spector, 2004). Koreans also believe in collectivistic family values (Giger & Davidhizar, 2004), which reinforce the importance of family over individual needs, filial piety, obedience to parental authority, respect for elders, and conformity to a hierarchical, patriarchal family structure (Spector, 2004). Together, the philosophies described and collectivistic family values strongly affect self-representation (Nilchaikovit, Hill, & Holland, 1993). They influence one’s relationship with others, communication style, and expression of emotion (Nilchaikovit et al., 1993). Consequently, Korean patients may avoid expressing feelings, questioning authority, expressing new ideas, or directly communicating emotions (Nah, 1993). And, because being assertive is discouraged, they may not ask for assistance when needed (Park & Peterson, 1991). Thus, Koreans may have great difficulty expressing the severity of their dyspnea symptoms or the emotional distress caused by dyspnea.

Coping Strategies for Dyspnea Few studies have been conducted to describe coping strategies for dyspnea by people with chronic lung disease and lung cancer. Carrieri-Kohlman and Janson-Bjerklie (1986) used a structured interview to identify and compare coping strategies across different respiratory diseases. They found that patients were more likely to use problem-focused strategies than emotion-focused strategies to manage dyspnea. Nield (2000) found some commonality in dyspnea coping strategies between those with COPD and sarcoidosis, but African Americans with chronic lung diseases used “spiritual resources” to manage dyspnea, which reflects their historic reliance on religious faith. Overall, coping strategies used by people with chronic lung disease and lung cancer were relatively similar (Brown, Carrieri, JansonBjerklie, & Dodd, 1986; Henoch, Bergman, & Danielson, 2008; Janson-Bjerklie, Ferketich, Benner, & Becker, 1992). However, a qualitative study of Chinese patients (N = 11) with lung cancer (Lai, Chan, & Lopez, 2007) reported use of traditional therapies to manage dyspnea. Past studies have been mainly descriptive or qualitative, using openended questions to describe types or prevalence of coping strategies. Only one study (Christenbery, 2005), using a structured instrument, examined the perceived effectiveness of 11 dyspnea coping strategies in people with COPD, which

found that patients perceived limited effectiveness of various strategies and used individualized therapy to relieve dyspnea. Little is known about the effectiveness of coping strategies for patients with chronic lung diseases, particularly Korean immigrants. Thus, the specific aims of this study were to describe the types of strategies that Korean immigrants with asthma or COPD used to manage dyspnea and the frequency and effectiveness of their use. To appropriately target their patient teaching and interventions, health care professionals who care for Korean immigrants with asthma or COPD would benefit from knowing which strategies their patients use most frequently and find most effective.

Method Design This was a cross-sectional descriptive study.

Sample and Settings A convenience sample of 73 participants were recruited between June and October 2008 through advertisements or by referral from physicians or nurses in primary care settings located in a Korean neighborhood in a large urban area in the western United States. Sixty participants were recruited from an internal medicine outpatient clinic that specializes in pulmonary medicine, and the rest were from three other internal medicine outpatient clinics. Individuals were included in the study if they were born and raised in Korea; could speak, write, and read Korean; had emigrated to the United States as an adult (aged ≥19 years old); had been diagnosed by a physician as having asthma or COPD; and had a history of shortness of breath with daily activities or on exertion during the past 12 months. Those with a diagnosis of cognitive impairment were excluded. Cognitive impairment was confirmed through a review of medical records and consultation with health care providers at the recruitment sites.

Instruments Demographic and clinical characteristics. Interviews were conducted to collect information on a participant’s age, gender, educational level, marital status, annual income, length of stay in the United States, comorbidities, medication use, oxygen use, smoking history, and work status. Dyspnea intensity, distress, severity, and sensations. A Visual Analog Scale (VAS) was used to measure the participants’ usual and worst dyspnea intensity and distress scores on a vertical 100-mm line anchored at either end with the words no breathlessness and worst imaginable breathlessness for dyspnea intensity and no distress and worst imaginable distress for dyspnea distress. Test–retest reliability (no significant

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Park et al. mean differences between two repeated VAS scores) and concurrent validity of the VAS with the Borg Scale (Pearson correlation coefficient, r = .71) have been documented in patients with different pulmonary diseases (Brown et al., 1986; Gift, 1989; Wilson & Jones, 1989). The Modified Medical Research Council (MMRC) Dyspnea Scale was used to quantify how dyspnea affects daily activities. Participants were asked to select one of five choices, from Grade 0 to 4. The higher the grade, the more dyspnea affects daily activities. Interrater reliability (κ = .92) and concurrent validity of the MMRC scale with the Baseline Dyspnea Index (Pearson correlation coefficient, r = −.70) have been documented in patients with cardiac or pulmonary disease (Mahler & Wells, 1988). One open-ended question—“Can you describe in your own words how it felt when you were short of breath?”—was used to describe participants’ dyspnea sensations. Coping strategies for dyspnea. A modified Self-Efficacy and Dyspnea Self-Management Strategies Scale (SEADS) was used to document which strategies a participant used to manage dyspnea. In addition, participants were asked two open-ended questions: “What helps your shortness of breath go away?” and “Have you had any classes or learned about your shortness of breath or attended a pulmonary rehabilitation program?” The SEADS scale, developed by Kwiatkowski (1994), consists of 35 coping strategies and includes confidence subscales. The SEADS scale was reported to be internally consistent (Cronbach’s α = .81) and concurrent validity with the Stanford Self-Efficacy for Managing Dyspnea question (Pearson correlation coefficient, r = .46; Tseng et al., 2001). The principal investigator modified the SEADS scale by adding a frequency subscale and including coping strategies that were reported in the literature. The scale ultimately included 38 questions about coping strategies and 1 question about the participant’s own strategy to manage dyspnea. Participants were first asked to answer “yes” or “no” about their use of each strategy. If they answered yes, they were then asked to report the frequency of use on a scale of 1 (rarely) to 4 (almost constantly) and the effectiveness of the coping strategies on a scale of 0 (not at all) to 10 (very much). This 38-item modified SEADS scale was reviewed by the coinvestigators who were experienced pulmonary researchers and also tested in two subjects before starting this investigation. The two subjects agreed that the 38 items were prevalent strategies to manage dyspnea. The Kuder–Richardson score for this modified SEADS scale was .826. Role of family. To describe the role of a family member caring for someone with dyspnea, participants were asked, “What things does your family do to help you when you are short of breath or help you to prevent your shortness of breath?” Acculturation. Acculturation was assessed with a brief version of the Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA; Suinn, Ahuna, & Khoo, 1992). The

brief version used in this study was the Item-Total Correlation (ITC) short form of the SL-ASIA developed by Leong and Chou (1998). This instrument includes five questions about the language participants use, speak, and read; the ethnic origin of the participants’ childhood friends; and how they evaluate their ethnicity. The mean scores range from 1 to 5. A higher score indicates a greater degree of Western identification. Internal consistency and concurrent validity of the ITC short form and the full scale of the SL-ASIA have been reported (Leong & Chou, 1998; Suinn et al., 1992). In this study, the internal consistency of the scale was Cronbach’s α = .75.

Procedures This study was reviewed and approved by the university’s institutional review board. Following the guidelines of the Translation and Cultural Adaptation Group (Wild et al., 2005), all instruments were translated into Korean by two native Koreans and back-translated into English by two different people who were fluent in written Korean and English. The translators examined the wording of the English and Korean questionnaires to evaluate semantic content, cultural relevance, and conceptual equivalence of the translated items. No major differences were detected between the original instruments and the back-translated versions. The principal investigator and one of the translators translated the responses from open-ended questions into English. When health care providers referred potential participants, the principal investigator (PI) contacted them, described the study, invited their participation, and if affirmative, obtained their written informed consent. Demographic and clinical information were obtained by survey, interviews were conducted, and study questionnaires were administered. All interviews and data collection were performed by the PI at participants’ homes, in clinic offices, or in a private area in the participant’s apartment.

Data Analysis Data were analyzed using SPSS version 15.0. All continuous data were expressed as means and standard deviations. Categorical variables were presented with percentages, frequencies, or medians. Similar terms were grouped together and percentages and frequencies were used to analyze dyspnea sensations from the open-ended question and a question about the role of family. Guided by Lazarus’s theory of coping (Folkman & Lazarus, 1980) and classification established by Carrieri-Kohlman and Janson-Bjerklie (1986), similar terms from openended interview questions about coping strategies were grouped as problem focused, emotion focused, or mixed problem and emotion focused. Percentages and frequencies were then used to describe the results. Univariate

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Journal of T  ranscultural Nursing 25(1)

Table 1. Demographic and Clinical Characteristics of Total Sample (N = 73).

Age Gender (males/females) Education   High school and lower   Bachelor and higher Income   $20,000 Living situation  Alone   Married or living with someone Working Years of stay in the United States Acculturation Current smoker Past smoker Pack years of smoking Duration of diseases (years) Comorbidities (yes) Usual dyspnea intensity Usual dyspnea distress Worst dyspnea intensity Worst dyspnea distress MMRC

Total (N = 73), Mean ± SD or n (%)

COPD (n = 48), Mean ± SD or n

Asthma (n = 25), Mean ± SD or n

73.7 ± 7.3 (range; 55-89) 55/18

74.19 ± 6.89 45/3

72.76 ± 8.00 10/15*                      

32 (43.8%) 41 (56.2%) 16 (46.6%) 34 (31.5%) 18 (24.7%) 55 (75.3%) 11 (15.1%) 25.95 ± 9.6 (range = 2-50 years; median = 28 years) 1.53 ± 0.47 18 (24.7%) 34 (46.6%)

57 (78%) 1.73 ± 1.81 1.62 ± 1.93 6.86 ± 2.06 5.60 ± 3.23 1.95 ± 1.15

40.29 ± 31.14 5.54 ± 9.67 36 1.69 ± 1.77 1.54 ± 1.76 6.40 ± 1.94 5.10 ± 3.07 1.90 ± 1.13

      11.44 ± 24.78* 14.96 ± 14.95* 21 1.79 ± 1.90 1.78 ± 2.25 7.73 ± 2.03* 6.65 ± 3.33* 2.04 ± 1.21

Note: COPD = chronic obstructive pulmonary disease, MMRC = Modified Medical Research Council Scale. *p < .05; comparison between asthma and COPD.

analysis of variance was used to compare the VAS scores of those with asthma and those with COPD. The Mann– Whitney U test was used to compare the ordinal data from the MRC scale and the number of coping strategies for these same two groups and between genders. The percentages of participants with asthma and COPD who reported that they used a given strategy were compared using chisquare tests. Each strategy’s frequency and effectiveness ratings on the modified SEADS scale were compared using independent t tests. The relationship between worst dyspnea intensity and the number of strategies a patient used and the relationship between frequency and strategy effectiveness were analyzed using a Pearson correlation coefficient. Mean values of acculturation level between participants who used acupuncture or herbs, tai chi or yoga, and home remedies and those who did not were compared using independent t tests. A p < .05 was considered statistically significant.

Results Seventy-three participants completed this study (see Table 1). The mean age of participants was 73.7 ± 7.3 years (range =

55-89). More than 78% of the participants had comorbidities, consisting primarily of benign prostatic hyperplasia, diabetes, and hypertension.

Dyspnea Intensity, Distress, Severity, and Sensations Dyspnea intensity, distress, and severity are also presented in Table 1. The asthma group reported statistically higher mean worst scores for dyspnea intensity than the COPD group. Thirty-six percent of the participants (n = 26) found it difficult to describe shortness of breath. The first response to the question about their dyspnea sensation was usually “I don’t know,” “How can I describe it,” “I cannot find a word for it,” or “I cannot think about anything else. I was just short of breath.” Others used phrases such as “felt tight” (n = 19, 26%), “smothering” (n = 9, 12%), and “felt like my breathing stops” (n = 8, 11%). One participant described it as “felt like dying from it.” Participants with COPD described their dyspnea sensation as “felt tight, ” “smothering,” “hard to breathe,” and “felt like breathing stops,” whereas participants with asthma in particular described their dyspnea sensation as “felt tight,” “felt like breathing

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Park et al. Table 2. Dyspnea Coping Strategies Used by Participants With Asthma or COPD, as Reported During Interview (N = 73). Coping Strategies Problem focused   Position and motion   Move slower   Lie down   Keep still   Breathing strategies   Self-selected treatments   Use oxygen   Use bronchodilators   Home remedies   Fresh air   Physical distancing from aggravating factors   Activity modification   Health directed behavior Emotion focused   Tension reduction Mixed   Seeking social support   Distraction diversion

Total Sample (N = 73), %

COPD (n = 48), %

Asthma (n = 25), %

49 1 49 3

56 2 56 2

36 0 36 4

1 34 18 5 18

2 29 6 2 4

0 44 40 12 44

27 16

27 19

28 12

14

15

12

3 1

2 0

4 4

Note: COPD = chronic obstructive pulmonary disease. The value reported is percentage of each group or total sample.

stops,” “constricted chest,” “felt like someone put a stone on my chest,” “blocked chi,” “narrowed bronchi,” and “compressed neck (choking feeling).”

Dyspnea Coping Strategies From Open-Ended Question Participants were asked to answer the open-ended question, “What helps your shortness of breath go away?” Most of them used problem-focused strategies. The most frequently used strategies were “keep still” (49%), “move slower” (49%), and “use bronchodilator” (34%; Table 2). Twentyseven percent of participants also used activity modification such as “decreasing aggressive activity,” “avoiding lifting heavy things,” and “driving instead of walking.” Only two participants (3%) used breathing techniques, such as pursed-lip breathing. Participants with COPD mainly used position- and motion-related strategies, whereas participants with asthma used bronchodilators and avoided aggravating factors such as hot weather, wind, smoke, dust, and acidic foods.

Dyspnea Coping Strategies From Modified SEADS Scale The 17 coping strategies that were reported by more than 30% of each group are presented in Table 3. The mean number of coping strategies used by the total sample was 13.97.

No significant difference between women and men and between disease groups was found (Men:Women = 13.18 ± 5.8: 16.39 ± 6.7, p = .053; asthma:COPD = 13.29:15.28, p = .19). A significant relationship was observed between worst dyspnea intensity and total number of strategies a patient used (Pearson correlation coefficient, r = .48, p = .001). Twenty-six percent of participants (n = 19) used acupuncture or herbs, 15% (n = 11) used home remedies, and 7% (n = 5) used tai chi or yoga. Home remedies used include drinking water; irrigating nasal passages with warm salt water; drinking honey tea mixed with ground pear, apricot, or Chinese balloon flower; and taking special oriental medications. No differences were observed in the level of acculturation between participants who used acupuncture or herbs, tai chi or yoga, and home remedies and those who did not. Significant differences in prevalence were found in 3 of the 39 strategies: (a) “I avoid wind, fog, or extreme temperature”; (b) “I avoid infection”; and (c) “I use home remedies.” Participants with asthma chose the following two strategies more often than those with COPD: “I avoid infection” (56% vs. 27.1%, p = .022) and “I use home remedies” (28% vs. 8.3%, p = .039). If a participant said yes to a specific strategy, he or she was then asked to detail its frequency on a scale of 1 (rarely) to 4 (almost constantly). In general, participants with asthma used dyspnea coping strategies more frequently than participants with COPD. When the mean frequency of strategy used by participants with asthma and COPD was compared, only 4 of the 39 strategies showed significant differences: “I move slower,” “I avoid strenuous activities,” “I decrease activity,” and “I pray and meditate” (see Table 3). The effectiveness of the most prevalent strategies is shown in Table 3. Few participants (n = 3) used oxygen, but if a participant did, it was rated to be highly effective (mean score = 9.67 ± 0.58). When the mean effectiveness of each strategy was compared for both groups, 6 of the 39 strategies showed significant differences (see Table 3). Mean effectiveness was 5.16 ± 2.97 for acupuncture or herbs, 5.10 ± 2.59 for home remedies, and 4.80 ± 2.49 for tai chi or yoga. The frequency of using strategies was significantly related to their effectiveness in 20 of the 39 strategies (Pearson correlation coefficient, r = .316-.868) for both groups of participants. The frequency of “I use cool, such as fans or open windows” (n = 24, Pearson correlation coefficient, r = .868) had the strongest relationship with the effectiveness of this strategy (Table 4).

Education for Dyspnea Management and Role of Family Only one participant received formal education about dyspnea management in the hospital, including specific techniques to manage dyspnea. Twenty participants were advised by a physician that they needed to stop smoking, comply with their prescribed medication regimen, and

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Table 3. Prevalence, Frequency, and Effectiveness of Most Frequently Reported Dyspnea Coping Strategies from Modified SEADSa by Participants With Asthma or COPD (N = 73). Patients With COPD Using Strategy (n = 48) c

Coping Strategy I keep still or rest. I move slower. I get some fresh air. I avoid strenuous activities. I decrease activity. I take bronchodilators. I exercise, such as walking or any other exercise. I calm myself down. I avoid irritants such as smoke. I try not to think about it and don’t worry. I pray or meditate. I change position, such as lean on something. I get support from friends and family. I avoid wind, fog, or extreme temperature. I use cool, such as use fans or open windows. I plan activities in advance. I avoid exercise

Patients With Asthma Using Strategy (n = 25) c

n (%) Usingb Strategy

Frequency of Strategy (Mean ± SD)

Effectiveness of Strategy (Mean ± SD)

n (%) Using Strategy

Frequency of Strategy (Mean ± SD)

Effectiveness of Strategy (mean ± SD)

41 (85%) 38 (79%) 35 (73%) 35 (73%) 30 (63%) 30 (63%) 28 (58%) 28 (58%) 27 (56%) 27 (56%) 26 (54%) 24 (50%) 17 (35%) 16 (33%) 16 (33%) 16 (33%) 15 (31%)

2.88 ± 0.87 3.00 ± 0.87 3.06 ± 0.84 3.26 ± 0.92 2.80 ± 0.93 3.00 ± 0.79 2.79 ± 0.83 2.79 ± 0.96 3.56 ± 0.80 2.78 ± 0.97 2.77 ± 0.65 2.54 ± 0.83 2.82 ± 0.88 2.63 ± 0.89 2.81 ± 0.98 2.44 ± 0.89 2.73 ± 1.10

7.00 ± 2.16 7.13 ± 2.17 6.77 ± 2.10 7.06 ± 1.91 6.73 ± 2.36 6.73 ± 2.33 6.86 ± 2.69 6.07 ± 1.96 7.41 ± 2.14 5.67 ± 2.39 6.31 ± 1.69 6.67 ± 2.57 5.88 ± 2.34 6.13 ± 2.94 6.38 ± 2.90 6.13 ± 2.45 6.27 ± 3.67

21 (84%) 20 (80%) 19 (76%) 19 (76%) 17 (68%) 19 (76%) 19 (76%) 16 (64%) 19 (76%) 16 (64%) 15 (60%) 14 (56%) 10 (40%) 19 (76%)* 8 (32%) 8 (32%) 8 (32%)

3.29 ± 0.85 3.50 ± 0.69* 3.26 ± 0.81 3.74 ± 0.56* 3.59 ± 0.62* 3.16 ± 0.50 2.95 ± 0.78 3.13 ± 0.62 3.74 ± 0.56 3.06 ± 0.68 3.27 ± 0.70* 2.79 ± 0.89 3.20 ± 0.92 3.16 ± 1.07 3.25 ± 0.71 2.88 ± 0.84 3.00 ± 0.93

7.81 ± 1.81 7.95 ± 1.82 8.11 ± 1.66* 8.00 ± 2.03 8.24 ± 1.56* 8.11 ± 1.67* 7.32 ± 1.97 7.44 ± 1.71* 8.84 ± 1.34* 7.50 ± 1.93* 7.13 ± 2.20 7.29 ± 2.02 7.10 ± 1.97 7.21 ± 2.15 7.88 ± 1.81 7.25 ± 1.58 7.38 ± 2.45

Note: COPD = chronic obstructive pulmonary disease. a. SEADS = Modified Self-Efficacy and Dyspnea Self-Management Strategies Scale; 17 most frequently reported strategies from 38 items on the scale. b. Chi-square test used to compare data between groups. c. Independent t test was used to compare data between groups. *p < .05, comparison between COPD and asthma groups.

exercise regularly. Eleven participants mentioned that nurses instructed them about dyspnea management. Fortyfour participants (60%) reported that they relied on selfcare most of the time. However, when they experienced severe symptoms or an asthma attack, they relied on family members for tasks such as driving, preparing meals, and lifting heavy objects. Thirty-three participants (45%) received some help from family members or other caregivers on a daily or weekly basis.

Discussion Thirty-six Korean immigrants could not describe their breathing sensation. This may be attributable, in part, to cultural differences because the willingness to report or express symptoms in public differs among cultures (Angel & Thoits, 1987). In the Korean culture, value is placed on controlling expressive behavior and nonverbal communications (Kagawa-Singer & Blackhall, 2001; Nilchaikovit et al., 1993). Thus, symptoms may not be verbally reported or publicly expressed but may be communicated nonverbally within one’s own ethnic group. It is possible that the question may have been ambiguous, and participants may have responded differently if the question about sensation had been more specific. The description of dyspnea sensation in this study’s participants was similar to Western descriptors (Simon et al., 1990), except for “blocked qui.” Further

investigation is needed to determine whether blocked qui is the cause of dyspnea or was associated with coping strategies, such as acupuncture. Although the participants in this study did not receive formal instruction from a health care provider on how to manage their dyspnea, they developed and used their own selfmanagement strategies. The findings on types of coping strategies, in general, are consistent with studies of Whites and African Americans with chronic lung disease or lung cancer, indicating that coping strategies were relatively similar regardless of ethnicity, except the use of traditional medicine. The participants used traditional treatments (at least 26%), which may indicate their cultural preferences in managing dyspnea, although these strategies did not seem to be as effective as any other strategies in this study. This finding was consistent with Lai et al.’s (2007) study of Chinese patients with advanced lung cancer. Traditional Korean medicine has been influenced by traditional Chinese medicine but has developed some unique characteristics (Cha et al., 2007). Traditional Korean medicine has remained important in the health care of Koreans (Cha et al., 2007) with as many as 36% to 53% of Korean people using it (Hong, 2001). These unique treatment options need further investigation to examine their effectiveness and applicability to other culture groups. No studies have been conducted to compare the prevalence of coping strategies between people with asthma and

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Park et al. Table 4. Relationship Between Frequency and Effectiveness of Dyspnea Coping Strategies From Modified SEADS by Participants With Asthma or COPD (N = 73). Pearson Correlation Coefficient (r)

Strategiesa I change position, such as lean on something. I avoid wind, fog, or extreme temperature. I keep still or rest. I change dressing habits. I move slower. I decrease activity. I exercise, such as walking or any other exercise. I plan activities in advance. I use abdominal/ diaphragmatic breathing. I use cool, such as use fans or open windows. I get some fresh air. I avoid irritants such as smoke. I take bronchodilators. I calm myself down. I try not to think about it and don’t worry. I use distraction, such as TV, read, or music. I pray or meditate. I talk to others with same disease and dyspnea. I socialize and participate in leisure activities with others. I decrease social participation and try to be alone.

.382 .649 .653 .580 .670 .433 .316 .466 .751 .868 .486 .620 .690 .458 .524 .524 .487 .590 .432 .521

Note: COPD = chronic obstructive pulmonary disease. a. We presented coping strategies that showed significant relationship (p < .05) between frequency and effectiveness, among 38 strategies.

COPD. Most studies have only reported the prevalence of strategies used, among different disease groups, without performing statistical analyses. Using the SEADS instrument, the study found use of problem-focused strategies more than emotion-focused strategies to control dyspnea in both groups. It should be noted that the SEADS instrument includes more problem-focused strategies than emotionfocused strategies. However, during the open-ended interview, respondents indicated using problem-focused strategies to relieve dyspnea. Significant group differences were noted in the prevalence of strategies. People with asthma constantly tried to avoid potential asthmatic triggers, which gave them some protection, such as “I avoid wind, fog, or extreme temperature” and “I avoid infection.” Our study did not find any differences in prevalence of using emotion-focused strategies between asthma and COPD, which is inconsistent with the findings of Carrieri-Kohlman and Janson-Bjerklie (1986). These studies found that patients with asthma tended

to use more emotion-focused strategies (i.e., relaxation techniques) than patients with COPD; however, no statistical analyses were performed to compare the two groups. This study is among the first to examine the comprehensive effectiveness of coping strategies used by people with asthma or COPD. The findings indicate that generally some strategies were useful in relieving dyspnea and some were not. Most participants from both groups rated emotion-focused strategies to be less effective than problem-focused strategies. Participants with asthma rated the air-focused strategies (i.e., avoiding irritants and getting fresh air) and emotionfocused strategies (i.e., I calm myself down) to be more effective than participants with COPD. Because emotion plays such an important role in dyspnea perception and management, emotion-focused strategies must be emphasized in teaching patients, especially those with asthma. Most (98.9%) participants had never participated in a formal pulmonary rehabilitation program, and only one (2.1%) participant received formal instruction about disease management while in the hospital. In addition, most participants were not taught about dyspnea management. As Christenbery (2005) mentioned, previous patient participation in pulmonary rehabilitation may have affected findings as these patients may have already learned strategies, such as pursed lip breathing. In our study, the low frequency of using breathing techniques may reflect a lack of knowledge that is available in pulmonary rehabilitation programs. We found that most Korean immigrants depended on and received support from family members, especially during an asthma attack or an exacerbation of their illness. Because the Asian culture has a strong collective sense of self, a patient’s illness is seen as a family rather than just an individual problem (Nilchaikovit et al., 1993). For this reason, American health care professionals often perceive the families of Asian patients to be overinvolved and, at times, even inappropriately assertive in assuming responsibilities and making decisions for the patient. Conversely, Asian families tend to do everything for a sick family member. Thus, the collectivistic family value may affect how Asian patients self-manage their symptoms. This study has several limitations. Few participants used oxygen, indicating mild or moderate disease, compared with participants from another study (Christenbery, 2005). Because there was gender imbalance in each group, some of our findings were not powered to attain significant findings. All strategies in the modified SEADS scale were based on strategies used by White individuals. Strategies identified from an open-ended question in the interviews were similar to those listed on the SEADS scale, indicating that the SEADS instrument may be useful in evaluating Korean immigrant populations. The original SEADS scale was tested in a doctoral dissertation, but this modified SEADS scale was not tested for reliability, except for content validity. Thus, careful consideration is needed to interpret the findings from multiple statistical analyses. Both diseases

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Journal of T  ranscultural Nursing 25(1)

were physician-diagnosed but FEV1 values were not available; thus, we were unable to show the clinical severity of these diseases. In conclusion, most of the Korean participants managed their dyspnea with a variety of strategies learned by trial and error. Their coping strategies were similar to those used by other ethnic groups, but they incorporated elements of Asian medical practice and herbs. Because the Korean family plays an important role in caring for its sick family members, families must be included in education programs.

Implications for Nursing Practice and Research This finding offers health care providers a more comprehensive understanding of how Korean patients cope to overcome dyspnea. Being aware of the coping methods that Korean participants use, carefully assessing their preferences and values about the use of traditional medicines and home remedies, and understanding the role of family in Asian culture could significantly help nurses in caring for and teaching this population how to cope with their symptoms on a daily basis and over time. More data are needed to determine whether pulmonary rehabilitation was offered to the participants. Further study is needed to identify which herbs are used; determine how, when, and why they are used; and understand how these herbs interact with prescribed medications. Such knowledge is important to assessing patients’ adherence to prescribed therapies, their effectiveness, or adverse effects. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is funded by Century Club Award and Graduate Student Research Award from University of California, San Francisco, and Small Grant from Sigma Theta Tau Honor Society of Nursing, Alpha Eta Chapter at University of California, San Francisco, and T32 postdoctoral fellowship (Health Promotion/Risk Reduction Interventions with Vulnerable Populations Training Grant) at University of Michigan, Ann Arbor.

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