ABSTRACT

BACKGROUND:

Asthma is a chronic airway disease that affects 339 million people worldwide. It is a heterogeneous disease with different risks, including in family environments, where intimate partner violence occurs.

OBJECTIVE:

This study aimed to investigate the possible association between psychosocial factors and asthma control in adults exposed to intimate partner violence.

DESIGN AND SETTING:

This cross-sectional study was conducted at a Brazilian public higher education institution in Salvador, Bahia, Brazil.

METHODS:

The study population consisted of adults clinically diagnosed with severe asthma and those with mild/moderate asthma identified at an asthma referral outpatient clinic. The sample comprised 492 participants who underwent clinical evaluation and completed questionnaires to assess asthma control, depression, stress, and resilience. The Conflict Tactics Scale, which measures tactics for managing marital conflicts, was used to estimate the level of intimate partner violence.

RESULTS:

Of the 492 participants, 76.2% were women and 91% self-referenced color black/brown, 37.8% reported low family income, 87.4% reported low education level, 71.7% reported high stress, 32.5% reported low resilience, 18.5% reported moderate or severe depression, 83.3% reported resolute negotiation, 49.4% reported major psychological aggression, 19.6% reported major physical aggression, 15.5% reported major injury, and 7.3% reported major sexual coercion. Regression analysis revealed that sex was an effect modifier.

CONCLUSION:

Women in situations of social vulnerability, with low income and poor education, with depression, severe asthma, and those who used aggression to resolve marital conflicts had a profile associated with a lack of asthma control.

KEY WORDS (MeSH terms):
Depression; Mental health; Domestic violence; Intimate partner violence; Asthma

AUTHORS’ KEY WORDS:
Asthma control; Conflict Tactics Scale; Physical aggression

INTRODUCTION

Asthma is a chronic disease, which is typically characterized by increased responsiveness of the airways, with consequent obstruction of the airflow.Asthma is usually reversible spontaneously or with treatment. Its main symptoms are shortness of breath, wheezing, and tightness in the chest.¹1. Pizzichini MMM, Carvalho-Pinto RM, Cançado JED, et al.2020 Brazilian Thoracic Association recommendations for the management of asthma. J Bras Pneumol. 2020;46(1):e20190307. PMID: 32130345; https://doi.org/10.1590/1806-3713/e20190307.
https://doi.org/10.1590/1806-3713/e20190...

According to the Global Initiative for Asthma (GINA), asthma is a heterogeneous and multifactorial disease with different pathological processes that affects 1–22% of the world’s population, regardless of age. Although the incidence of asthma among children has decreased in recent decades, it is estimated that 358 million individuals are affected worldwide. Furthermore, 495,000 deaths are caused by the disease annually.²2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention; 2020. Avaliable from:https://ginasthma.org/wp-content/uploads/2020/06/GINA-2020-report_20_06_04-1-wms.pdf. Accessed in 2021 (May 12).
https://ginasthma.org/wp-content/uploads... In Brazil, it is estimated that 12.4% of adults are diagnosed with asthma.³3. To T, Stanojevic S, Moores G, et al. Global asthma prevalence in adults: findings from the cross-sectional world health survey. BMC Public Health. 2012;12:204. PMID: 22429515; https://doi.org/10.1186/1471-2458-12-204. Erratum in: BMC Public Health. 2021;21(1):1809.
https://doi.org/10.1186/1471-2458-12-204...

Several factors contribute to the risk of developing asthma, including genetics, obesity, diet, female sex, occupational exposure, exposure to allergens, and high levels of family stress.²2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention; 2020. Avaliable from:https://ginasthma.org/wp-content/uploads/2020/06/GINA-2020-report_20_06_04-1-wms.pdf. Accessed in 2021 (May 12).
https://ginasthma.org/wp-content/uploads...

Environmental and social stressors can affect different health conditions.⁴4. Selye H. Stress and the general adaptation syndrome. Br Med J. 1950;1(4667):1383-92. PMID: 15426759; https://doi.org/10.1136/bmj.1.4667.1383.
https://doi.org/10.1136/bmj.1.4667.1383... ,⁵5. Faro AS, Pereira ME. Estresse: Revisão narrativa da evolução conceitual, perspetivas teóricas e metodológicas. Psicol Saude Doenças. 2013;14(1):78-100. Available from: https://ri.ufs.br/handle/riufs/1920. Accessed in 2022 (May 16).
https://ri.ufs.br/handle/riufs/1920... Psychosocial stress alters the susceptibility to infectious and systemic diseases, which can increase airway inflammation in asthma, causing exacerbations.⁶6. Haczku A, Panettieri RA Jr. Social stress and asthma: The role of corticosteroid insensitivity. J Allergy Clin Immunol. 2010;125(3):550-8. PMID: 20153032; https://doi.org/10.1016/j.jaci.2009.11.005.
https://doi.org/10.1016/j.jaci.2009.11.0...

Intimate partner violence can be considered as a stressor related to asthma. There is evidence that stressful environments, wherein violent events are experienced, can significantly affect asthma control.⁶6. Haczku A, Panettieri RA Jr. Social stress and asthma: The role of corticosteroid insensitivity. J Allergy Clin Immunol. 2010;125(3):550-8. PMID: 20153032; https://doi.org/10.1016/j.jaci.2009.11.005.
https://doi.org/10.1016/j.jaci.2009.11.0... ,⁷7. Subramanian SV, Ackerson LK, Subramanyam MA, Wright RJ. Domestic violence is associated with adult and childhood asthma prevalence in India. Int J Epidemiol. 2007;36(3):569-79. PMID: 17329314; https://doi.org/10.1093/ije/dym007.
https://doi.org/10.1093/ije/dym007...

There is evidence obtained through experimental and observational studies of the causal relationship between stress and poor asthma control; however, there is little evidence of causality between exposure to family, work, or community violence and asthma.⁸8. Landeo-Gutierrez J, Forno E, Miller GE, Celedón JC. Exposure to violence, psychosocial stress, and asthma. Am J Respir Crit Care Med. 2020;201(8):917-22. PMID: 31801032; https://doi.org/10.1164/rccm.201905-1073PP.
https://doi.org/10.1164/rccm.201905-1073...

The current World Health Organization definition of violence covers interpersonal violence, suicidal behavior, and armed conflict. It also encompasses a wide range of “acts,” going beyond physical assaults, including coercion and intimidation. The latter studies mainly investigated the relationship between aggressors and victims within the scope, while marital conflict was also investigated.⁹9. World Health Organization. World report on violence and health: summary. Geneva: World Health Organization; 2002. Avaliable from: https://apps.who.int/iris/bitstream/handle/10665/42512/9241545623_eng.pdf?sequence=1&isAllowed=y. Accessed in 2021 (May 12).
https://apps.who.int/iris/bitstream/hand...

The Conflict Tactics Scales (CTS2) assess the different ways couples lead conflict, considering how both manage it.Aggressive behavior as a conflict management tactic was assessed using one of the CTS2 subscales.

Marital violence has been studied in different contexts and centered on gender relations; however, it has been poorly studied along with chronic diseases, such as asthma. Therefore, it is necessary to investigate the dimensions of conjugal violence and spousal conflict management associated with asthma control. The CTS2 was used in this study. Therefore, disease control is essential to prevent crises and hospitalization.

OBJECTIVE

Considering the relationships described in the literature between asthma and psychosocial factors, the aims of the present study were I) to describe CTS2 through the latent class analysis using the subscales of CTS2 in patients with asthma, II) assess the relationship between CTS2 and asthma control, and III) identify differences between sexes.

METHODS

Type of study

This is a cross-sectional study of data collected in the case-control study titled “Risk Factors, Biomarkers and Endophenotypes of Severe Asthma,” from Program for the Control of Asthma in Bahia (Programa de Controle da Asma, ProAR) – Universidade Federal da Bahia (UFBA). The participants were evaluated between 2013 and 2015 using ProAR. ProAR is the main reference center for specialized care in the treatment of severe asthma in Salvador.

In this case-control study, 1,448 participants were included. The severe asthma, no asthma, and mild/moderate asthma groups included 544, 454, and 450 participants, respectively. In this cross-sectional study, only participants with asthma who responded to the CTS2 and performed an assessment for asthma control were analyzed.

Study population

The population considered included all participants in the case-control study. Participants with severe asthma were included from a ProAR cohort. Participants with mild/moderate asthma were recruited from the community. Posters were distributed in places of great circulation, including buses and places of primary care, where interviews were conducted in the waiting room or as indicated by the patients of the ProAR cohort.

The classification of patients with mild/moderate asthma was based on the concept of severity when the patient was evaluated in ProAR, including individuals with intermittent symptoms and without treatment or using low doses of controlling drugs upon evaluation by a specialist, following the criteria of the 2006 GINA,¹⁰10. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention; 2006. Avaliable from:https://ginasthma.org/wp-content/uploads/2019/01/2006-GINA.pdf. Accessed in 2022 (May 12).
https://ginasthma.org/wp-content/uploads... maintaining criteria similar to those of participants with severe asthma classified according to the 2002 GINA criteria.¹¹11. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention; 2002. Avaliable from:https://ginasthma.org/wp-content/uploads/2019/01/2002-GINA.pdf. Accessed in 2022 (May 12).
https://ginasthma.org/wp-content/uploads...

The diagnostic criteria were based on the presence of typical symptoms, improvement of symptoms with the use of bronchodilators or inhaled corticosteroids, and an increase in forced expiratory volume in 1 second by 12% and 200 ml after bronchodilator use.

Sample, participants, and patients

A total of 492 volunteers with asthma were evaluated in multiple dimensions of their disease for possible risk factors and biomarkers, as described previously. In this study, a sample of 500 participants per group was estimated, and for a sample of 400 participants, we had at least 80% power.¹²12. Cruz AA, Riley JH, Bansal AT, et al. Asthma similarities across ProAR (Brazil) and U-BIOPRED (Europe) adult cohorts of contrasting locations, ethnicity and socioeconomic status. Respir Med. 2020;161:105817. PMID: 31790928; https://doi.org/10.1016/j.rmed.2019.105817.
https://doi.org/10.1016/j.rmed.2019.1058...

For the present study, the following inclusion and exclusion criteria were applied.

Inclusion Criteria: Patients aged above 18 years, residing in Salvador or in the metropolitan region, diagnosed with mild/moderate or severe asthma, who were in an intimate relationship in the last year, responded to the CTS2, and agreed to sign an informed consent form.

Exclusion Criteria: Pregnant women and patients with a history of serious illnesses, such as chronic obstructive pulmonary disease, or advanced neoplasia, that made it difficult to assess asthma control. Individuals who suffered a stroke (stroke), cardiac insufficiency, any other diseases that cause dyspnea; patients who suffered clinical complications that may interfere with the autonomy to answer questionnaires and that required a caregiver; and those who did not accept the signed informed consent form were also excluded.

The participants were aged ≥ 18 years, the diagnosis of asthma was confirmed by a specialist, and the individuals’ clinical history and current pulmonary function were considered. Therefore, as part of our protocol, spirometry tests were used to evaluate variable airflow obstruction, and chest radiography was performed to exclude other lung diseases.

Individuals who had previous smoking records ≥ 10 packs/year and those with other serious conditions that could confuse or interfere in the asthma diagnosis and asthma control were not included.

Main measures, variables, and outcomes

Participants’ data were collected using an extensive standard form filled out by nurses and doctors. All relevant and general information, including sociodemographic variables, such as age, weight, height, income, education, and self-reported color, was registered.¹³13. Chaves C, Ibiapina Cda C, de Andrade CR, et al. Correlation between peak nasal inspiratory flow and peak expiratory flow in children and adolescents. Rhinology. 2012;50(4):381-5. PMID: 23181252;https://doi.org/10.4193/Rhino12.073.
https://doi.org/10.4193/Rhino12.073...

The following questionnaires validated in Brazil were applied to all individuals at baseline:1) Beck Scale for Depression;¹⁴14. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361-70. PMID: 6880820; https://doi.org/10.1111/j.1600-0447.1983.tb09716.x.
https://doi.org/10.1111/j.1600-0447.1983... 2) Waldnig and Young’s scale of resilience;¹⁵15. Pesce RP, Assis SG, Avanci JQ, et al. Adaptação transcultural, confiabilidade e validade da escala de resiliência [Cross-cultural adaptation, reliability, and validity of the resilience scale]. Cad Saude Publica. 2005;21(2):436-48. PMID: 15905906; https://doi.org/10.1590/s0102-311x2005000200010.
https://doi.org/10.1590/s0102-311x200500... 3) Questionnaire to assess the level of psychological stress;¹⁶16. Reis RS, Hino AA, Añez CR. Perceived stress scale: reliability and validity study in Brazil. J Health Psychol. 2010;15(1):107-14. PMID: 20064889; https://doi.org/10.1177/1359105309346343.
https://doi.org/10.1177/1359105309346343... 4) CTS2 was proposed and developed by Straus to identify different aspects of domestic violence with at least 1 year in a stable marital situation¹⁷17. Straus MA, Hamby SL, Boney-McCoy S, Sugarman DB. The revised conflict tactics scales (CTS2): Development and Preliminary Psychometric Data. J Fam Issues. 1996;17(3):283-316. https://doi.org/10.1177/019251396017003001.
https://doi.org/10.1177/0192513960170030... and validated for Portuguese.¹⁸18. Moraes CL, Reichenheim ME. Cross-cultural measurement equivalence of the Revised Conflict Tactics Scales (CTS2) Portuguese version used to identify violence within couples. Cad Saude Publica. 2002;18(3):783-96. PMID: 12048604.

The CTS2 evaluated the variety of tactics used in response to the conflict with the partner but did not identify the causes of damage and health problems or the meaning of violent acts.¹⁷17. Straus MA, Hamby SL, Boney-McCoy S, Sugarman DB. The revised conflict tactics scales (CTS2): Development and Preliminary Psychometric Data. J Fam Issues. 1996;17(3):283-316. https://doi.org/10.1177/019251396017003001.
https://doi.org/10.1177/0192513960170030... ,¹⁹19. Straus MA. Measuring Intrafamily Conflict and Violence: The Conflict Tactics (CT) Scales. J Mar Fam. 1979;41(1):75-88. https://doi.org/10.2307/351733.
https://doi.org/10.2307/351733...

It consisted of 78 items related to behaviors or experiences that configure different tactics to resolve marital conflict. Half of the items must be answered according to the tactics used by the interviewee; for the other half, the respondent must answer references in the tactics used by his partner/partner for conflict resolution.

The instrument consisted of five dimensions that characterize different conflict resolution tactics: negotiation (with two subscales: cognitive and emotional), psychological aggression (minor and major), physical aggression (minor and major), injury, herein referred to as damage and health problems (minor and major), and sexual coercion (minor and major). The cognitive subscale is the way in which partners use emotion for negotiation through conversation, whereas the emotional subscale is when emotion is used in an attempt to negotiate. The smallest subscale can be considered absent or mild, and the largest as severe.¹⁷17. Straus MA, Hamby SL, Boney-McCoy S, Sugarman DB. The revised conflict tactics scales (CTS2): Development and Preliminary Psychometric Data. J Fam Issues. 1996;17(3):283-316. https://doi.org/10.1177/019251396017003001.
https://doi.org/10.1177/0192513960170030... ,²⁰20. Moraes CL, Hasselmann MH, Reichenheim ME. Adaptação transcultural para o português do instrumento “Revised Conflict Tactics Scales (CTS2)” utilizado para identificar violência entre casais [Portuguese-language cross-cultural adaptation of the Revised Conflict Tactics Scales (CTS2), an instrument used to identify violence in couples]. Cad Saude Publica. 2002;18(1):163-76. PMID: 11910435; https://doi.org/10.1590/s0102-311x2002000100017.
https://doi.org/10.1590/s0102-311x200200... ,²¹21. Gelles RJ, Straus MA. Determinants of violence in the family: Towards a theoretical integration. In: Burr WR, Hill R, Nye FI, Reiss IL, editors. Contemporary Theories about the family. New York: Free Press; 1979. p. 550-81. Notably, some of the conflict tactics characterized by the instrument corroborate the forms of violence from the perspective of current Brazilian law.²²22. Presidência da República. Secretaria-Geral Subchefia para Assuntos Jurídicos. Lei Maria da Penha. 2006. Avaliable from: http://www.planalto.gov.br/ccivil_03/_Ato2004-2006/2006/Lei/L11340.htm. Accessed in 2022 (May 12).
http://www.planalto.gov.br/ccivil_03/_At...

Statistical analysis

Descriptive statistics were calculated for all the variables. Bivariate analyses were performed using Chi-square and Fisher’s exact tests to identify associated and clinically relevant variables in relation to asthma control within the clinical context and violence between partners. The Mann–Whitney U test was used to verify the differences in body mass index (BMI) between the controlled and uncontrolled asthma groups. Latent class analysis (LCA) was used to describe the CTS2 of individuals on each CTS2 subscale to prevent participant overlap. Thus, the same participant was avoided from being allocated simultaneously to the subscales of the same dimension.

Questions 47, 48, 75, and 76, corresponding to the sexual coercion dimension of CTS2, were excluded from the LCA because there wasn’t at least one positive answer. The number of latent classes was determined using the Akaike information criterion, Bayesian information criterion, and entropy statistics for models with two, three, and four classes, respectively. However, the better results were those closer to 1.²³23. Collins LM, Lanza ST. Latent Class and Latent Transition Analysis: With Applications in the Social, Behavioral, and Health Sciences. New Jersey: John Wiley & Sons; 2009. https://doi.org/10.1002/9780470567333.
https://doi.org/10.1002/9780470567333... The best model was selected based on a combination of statistical criteria, parsimony, and interpretability of the latent classes. The assumption of local independence was assessed using a residual model (values < two were expected).

LCA has established itself as a useful statistical technique for grouping individuals into subtypes within a population when there is no prior knowledge about which individual belongs to which subpopulation.²³23. Collins LM, Lanza ST. Latent Class and Latent Transition Analysis: With Applications in the Social, Behavioral, and Health Sciences. New Jersey: John Wiley & Sons; 2009. https://doi.org/10.1002/9780470567333.
https://doi.org/10.1002/9780470567333... ,²⁴24. Rhead R, Elliot M, Upham P. Using latent class analysis to produce a typology of environmental concern in the UK. Soc Sci Res. 2018;74:210-22. PMID: 29961487;https://doi.org/10.1016/j.ssresearch.2018.06.001. Erratum in: Soc Sci Res. 2018;76:202.
https://doi.org/10.1016/j.ssresearch.201... ,²⁵25. Santos LM, Amorim LD, Santos DN, Barreto ML. Measuring the level of social support using latent class analysis. Soc Sci Res. 2015;50:139-46. PMID: 25592926;https://doi.org/10.1016/j.ssresearch.2014.11.009.
https://doi.org/10.1016/j.ssresearch.201... ,²⁶26. Berlin KS, Williams NA, Parra GR. An introduction to latent variable mixture modeling (part 1): Overview and cross-sectional latent class and latent profile analyses. J Pediatr Psychol. 2014;39(2):174-87. PMID: 24277769; https://doi.org/10.1093/jpepsy/jst084.
https://doi.org/10.1093/jpepsy/jst084... LCA is a method that uses the maximum likelihood estimation to form subgroups (latent classes), internally homogeneous and externally heterogeneous.²⁴24. Rhead R, Elliot M, Upham P. Using latent class analysis to produce a typology of environmental concern in the UK. Soc Sci Res. 2018;74:210-22. PMID: 29961487;https://doi.org/10.1016/j.ssresearch.2018.06.001. Erratum in: Soc Sci Res. 2018;76:202.
https://doi.org/10.1016/j.ssresearch.201... The subgroups generated from LCA can be used to investigate the relationships with other characteristics, such as risk or protective factors.

Regression models were performed with dichotomized categorical predictor variables: physical aggression (minor and major), asthma severity (severe asthma and mild/moderate asthma), income (up to one salary or more than one salary), education (up to completing high school and at least not completing higher education), resilience (high and low), and depression (minimal/mild and severe/moderate). BMI was the only numerical predictor. Associations with other CTS2 dimensions were evaluated, but only the physical aggression dimension was relevant in the adjusted models.

SPSS (International Business Machines Corporation. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, New York, United States) was used to perform the descriptive analyses and hypothesis tests, and M-plus (Version 5. Computer Software. Los Angeles, California, United States: Muthén and Muthén) was used to obtain latent classes.

Ethical aspects and financial source

We received funding from the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico, CNPq) support 471057/2014-2, the State of Bahia Foundation for Research Support (Fundação de Amparo à Pesquisa do Estado da Bahia, FAPESB), and GlaxoSmilthKline (an investigator-initiated grant). Additional support was provided by the Coordination for the Improvement of Higher Education Personnel, Brazil (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior CAPES; Financing Code 001). It contemplated the preservation of the ethical and bioethical rights of the research subjects in accordance with the rules recommended in Resolution 466/2012 of the Council National Health Agency for Research in Human Beings. This project was approved by the Ethics Committee of the Maternidade Climério de Oliveira under OPINION/RESOLUTION No. 099/2009 on November 11, 2009, with additive opinion No. 032/2014.

RESULTS

The participants’ main characteristics are listed in Table 1. Individuals with uncontrolled asthma were more likely to have severe asthma, a family income of up to one minimum wage, an education level of up to high school, a low level of resilience, severe or moderate depression, and a higher average BMI compared to those with controlled asthma.

Regarding the LCA, two models were chosen because models with more than two classes hindered the interpretation and concept of each subscale and the characterization of the patients’ profiles according to the subscales of the CTS2 (https://documentcloud.adobe.com/link/review?uri=urnhttp://www.:aaid:scds:US:282ef302-057a-4291-992a-258baa9fcee0). The subscales for the dimensions of psychological aggression, physical aggression, injury, and sexual coercion were determined as described by Moraes, Paiva, and Figueiredo,¹⁶16. Reis RS, Hino AA, Añez CR. Perceived stress scale: reliability and validity study in Brazil. J Health Psychol. 2010;15(1):107-14. PMID: 20064889; https://doi.org/10.1177/1359105309346343.
https://doi.org/10.1177/1359105309346343... ,²³23. Collins LM, Lanza ST. Latent Class and Latent Transition Analysis: With Applications in the Social, Behavioral, and Health Sciences. New Jersey: John Wiley & Sons; 2009. https://doi.org/10.1002/9780470567333.
https://doi.org/10.1002/9780470567333... except for the negotiation dimension, where the cognitive negotiation subscale was replaced by resolutive negotiation as both the participants and their partners had a high probability of a positive answer to the cognitive negotiation and emotional negotiation questions.

Analysis of the CTS2 subscales revealed the conflicting tactics adopted for intimate partner conflict management. As shown in Table 2, 82.4% of participants reported resolutive negotiations, 46.4% reported major psychological aggression, 15.2% reported minor physical aggression, 10.9% reported major injury, and 11.9% reported sexual coercion. According to them, 65.1% of their partners used resolutive negotiations, 39.6% used psychological aggression, 15.9% used physical aggression, 6.2% used injury, and 7.3% used sexual coercion (https://documentcloud.adobe.com/link/review?uri=urn:aaid:scds:US:282ef302-057a-4291-992a-258baa9fcee0).

Although there was no association between the domain of negotiation and asthma control, high percentages of its use were observed regardless of sex; that is, the use of other conflict tactics jointly involves resolutive negotiation, in which the couple tries to resolve their conflicts through conversation.

According to the stratified analysis by sex, a vulnerability profile was identified for women in relation to the lack of asthma control (Table 3).

The use of physical assault tactics, severe asthma, low education, low income, low resilience, and moderate or severe depression determined asthma control. However, this was not observed in men, where only the severity of asthma increased the risk of having uncontrolled asthma. Several regression models were used to investigate the conflict tactic management used by partners, but no associations were found.

DISCUSSION

According to the results, 20% of the participants reported the use of physical aggression, injury, and sexual coercion to deal with conflicts within marital relationships. Although these tactics have been reported by a minority of individuals, mainly women, they still require special attention in health services because the real dimensions of women’s psychological suffering and how a violent profile impacts chronic diseases, such as asthma, are unknown.

Although the results of the present study showed that women used aggression to resolve conflicts with their intimate partners, it is known that the greatest burden of violence falls on them. Women have been the main victims of men over time²⁷27. Hou L, Zhu L, Zhang M, et al. Participation of Antidiuretic Hormone (ADH) in Asthma Exacerbations Induced by Psychological Stress via PKA/PKC Signal Pathway in Airway-Related Vagal Preganglionic Neurons (AVPNs). Cell Physiol Biochem. 2017;41(6):2230-41. PMID: 28448991; https://doi.org/10.1159/000475638.
https://doi.org/10.1159/000475638... and also those who have suffered great damage to their health.⁴4. Selye H. Stress and the general adaptation syndrome. Br Med J. 1950;1(4667):1383-92. PMID: 15426759; https://doi.org/10.1136/bmj.1.4667.1383.
https://doi.org/10.1136/bmj.1.4667.1383...

Despite the literature showing associations between risk factors for asthma and its control,⁴4. Selye H. Stress and the general adaptation syndrome. Br Med J. 1950;1(4667):1383-92. PMID: 15426759; https://doi.org/10.1136/bmj.1.4667.1383.
https://doi.org/10.1136/bmj.1.4667.1383... –⁶6. Haczku A, Panettieri RA Jr. Social stress and asthma: The role of corticosteroid insensitivity. J Allergy Clin Immunol. 2010;125(3):550-8. PMID: 20153032; https://doi.org/10.1016/j.jaci.2009.11.005.
https://doi.org/10.1016/j.jaci.2009.11.0... there is little evidence on the relationship between spousal violence and asthma. However, it was identified that women who suffered violence, whether in the past or recently, were at a high risk of developing asthma. In line with the present study, a stratified analysis by sex and age showed that women in the age groups below 44 years needed to use physical aggression as a conflict resolution tactic and that they were also at a high risk of uncontrolled asthma.⁷7. Subramanian SV, Ackerson LK, Subramanyam MA, Wright RJ. Domestic violence is associated with adult and childhood asthma prevalence in India. Int J Epidemiol. 2007;36(3):569-79. PMID: 17329314; https://doi.org/10.1093/ije/dym007.
https://doi.org/10.1093/ije/dym007...

Our results reinforce the psychosocial vulnerability of this population and demonstrate its impact on marital relationships. It is noteworthy that the ability to be resilient is related to sociodemographic characteristics, such as high schooling and high income,²⁸28. Melo CF, Vasconcelos FJE, Teófilo MB, et al. Resiliência: uma análise a partir das características sociodemográficas da população brasileira [Resilience: an analysis based on the sociodemographic chacarteristics of the Brazilian population]. Psico-USF. 2020;25(1):139-54. https://doi.org/10.1590/1413-82712020250112.
https://doi.org/10.1590/1413-82712020250... and study participants had the opposite characteristics. In addition, we believe that depression reveals psychological suffering in this population. These findings are also addressed by other authors who demonstrated the relationship between intimate partner violence and psychological stress with a lack of asthma control and psychosocial aspects.²⁷27. Hou L, Zhu L, Zhang M, et al. Participation of Antidiuretic Hormone (ADH) in Asthma Exacerbations Induced by Psychological Stress via PKA/PKC Signal Pathway in Airway-Related Vagal Preganglionic Neurons (AVPNs). Cell Physiol Biochem. 2017;41(6):2230-41. PMID: 28448991; https://doi.org/10.1159/000475638.
https://doi.org/10.1159/000475638... ,²⁹29. Bair-Merritt M, Johnson SB, Okelo S, Page G. Intimate partner violence exposure, salivary cortisol, and childhood asthma. Child Abuse Negl. 2012;36(7-8):596-601. PMID: 22858093; https://doi.org/10.1016/j.chiabu.2011.12.002.
https://doi.org/10.1016/j.chiabu.2011.12...

Another important outcome relates to negotiations as a conflict resolution tactic. Although there was no statistical relevance, the high percentages in both the controlled and uncontrolled groups indicated that both partners used this tactic to resolve marital conflict. The most frequent form was resolutive negotiation, but it was probably ineffective in dealing with conflicts if we consider the high percentages of aggression reported by women.

The use of aggression as a form of conflict may be associated with other unstudied factors, such as irritability, which may be related to depression and lack of control over asthma. The association among uncontrolled asthma, parental depression, and family chaos, including commotion, disorganization, and routine at home, should be considered.³⁰30. Weinstein SM, Pugach O, Rosales G, et al. Family chaos and asthma control. Pediatrics. 2019;144(2):e20182758. PMID: 31289192; https://doi.org/10.1542/peds.2018-2758.
https://doi.org/10.1542/peds.2018-2758...

Our findings point to the need for studies, whether quantitative or qualitative, to better understand how each of these psychosocial characteristics is related to asthma control, as well as the etiopathogenesis of the disease. Psychosocial factors play an important role in asthma, either as precipitating elements of exacerbation or disease progression, showing that a poor perception of physical control is associated with a poor quality of life in asthmatics.³¹31. Bratek A, Zawada K, Barczyk A, et al. Analysis of psychoemotional state and intellectual abilities in patients with asthma and chronic obstructive pulmonary disease--preliminary results. Psychiatr Danub. 2013;25 Suppl 2:S207-11. PMID: 23995178.

In contrast, asthma itself has an impact on psychosomatic responses, as it involves biological and psychological factors directly linked to interpersonal relationships and social bonds in many ways. Asthma impacts the quality of life. The disease is related to difficult experiences permeated by suffering for the patient.³¹31. Bratek A, Zawada K, Barczyk A, et al. Analysis of psychoemotional state and intellectual abilities in patients with asthma and chronic obstructive pulmonary disease--preliminary results. Psychiatr Danub. 2013;25 Suppl 2:S207-11. PMID: 23995178. This is supported by our results, which revealed that depression (severe or moderate), low resilience, and physical aggression were associated with a lack of asthma control.

This study has some limitations. The first relates to reverse causality. It is impossible to state the temporality of the association between depression and the lack of asthma control. However, depression may also be related to recurrent breathing difficulties. We also considered a vicious cycle in which there was bidirectional causality between asthma and depression. Second, the sample of volunteers interfered with the external validity. Therefore, the findings can only be extrapolated to parsimony.

Despite these limitations, it is important to highlight the use of LCA, which is a poorly used technique in Brazil. However, it is important to define variables that are not directly observable. The use of latent classes within the health context was also important in identifying those that would be correlated with other variables in the adjustment of the regression models.

In addition, although CTS2 is a validated questionnaire with extensive bibliographic support, the results might be influenced by interview bias, as people with depression already have a negative view of the facts, which may overestimate the use of physical aggressive tactics and underestimate such occurrences by not reporting aggression.

CONCLUSIONS

In the present study, women in situations of social vulnerability, with low income and poor education, with depression, severe asthma, and those who used aggression as a means of resolving marital conflicts had a profile associated with a lack of asthma control. Although CTS2 does not clarify the origin of violence, it is understood that its use of physical aggression tactics is in response to a conflict that occurred previously. Further studies are needed to better assess the relationship between domestic violence, mental health, and asthma and to explore its causality. Multiprofessional health teams, especially referral centers for severe asthma, should consider the importance of marital relationships and depression in asthma control and seek interventions that contribute to the development of effective and nonviolent conflict resolutions.

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