(2024) 24:591
Ahmadian et al. BMC Pediatrics
https://doi.org/10.1186/s12887-024-05057-7

BMC Pediatrics

RESEARCH

Open Access

The effect of applying emotional
intelligence components on coping strategies
in adolescents with beta‑thalassemia major:
a randomized clinical trial
Bahareh Ahmadian1, Monir Ramezani2,3*, Zahra Badiei4 and Saeed Vaghee5

Abstract
Background Thalassemia is one of the most common genetic disorders. Patients with beta-thalassemia major confront serious clinical and psychosocial challenges in their all lives, which require coping strategies. It appears that psychological interventions are necessary to improve their coping skills. The aim of this study was to determine the effectof applying emotional intelligence components on coping strategies in adolescents with beta- thalassemia major.
Methods This randomized clinical trial study involved 60 teenagers with beta- thalassemia major who were divided
equally into intervention and control groups. The experimental group participated in 9 sessions of an emotional
intelligence program consisting of 90 min, held both virtually and in person, two sessions per week. We investigatedproblem-focused and emotion-focused (including positive emotion-focused and negative emotion-focused) coping
strategies of both groups of adolescents using the Billings and Moos questionnaire before the intervention, immediately after the intervention, and one month after the intervention. Data were analyzed using SPSS 21. Then, according
to the research objectives, independent t-tests, Chi-square, Mann–Whitney, repeated measures Analysis of Variance(ANOVA) and Bonferroni test were used.
Results In experimental group, the mean score of problem-focused (problem-solving, cognitive evaluation)and positive emotion-focused (social support) coping increased from (14.2 ± 2.6) and (5.0 ± 0.5) before the intervention to (29.6 ± 3.1) and (10.9 ± 1.3) one month after the intervention, respectively (P < 0.001). However, the mean scoreof emotional inhibition and somatic inhibition (negative emotion-focused) decreased from (13.8 ± 1.7) and (6.7 ± 1.5)
before the intervention to (8.6 ± 2.0) and (3.8 ± 1.8) one month after the intervention, respectively (P < 0.001). While
the mean score of problem-focused and emotion-focused coping strategies before and one month after the intervention remained stable in the control group.
Conclusions Adolescents with beta-thalassemia suffer from psychosocial disorders and they also cope maladaptive
with their illness. Applying emotional intelligence has improved their coping strategies. Caregivers should be encouraged to assess coping skills in teenagers with beta-thalassemia major and use methods such as emotional intelligence to improve them. Therefore, it can help these adolescents to deal effectively with stress and complicationsof the disease.

*Correspondence:Monir Ramezaniramezanimn@mums.ac.ir
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as longas you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article orparts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicatedotherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To
view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Ahmadian et al. BMC Pediatrics(2024) 24:591

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Trial registration number IRCT20210521051356N1 (17/06/2021).
Keywords Adolescent, Beta-thalassemia, Coping strategies, Emotional intelligence, Clinical trial

Background
Thalassemia is a heritable disorder characterized by adefect in the production or non-production of the globin chain of hemoglobin [1, 2]. This synthetic defectleads to severe anemia, requiring regular blood transfusions and iron chelation therapy [3]. Thalassemia is themost prevalent inherited hemoglobin disease reported in
more than 60 countries [1]. This chronic disease has great
incidence in the Middle East, Mediterranean, Indian subcontinent, and Southeast Asia [4]. Iran is a country with
about 26,000 patients with thalassemia, and its frequency
is between 2.5% and 15% in different regions of the country [5].
Patients with Beta-thalassemia and their families beara significant psychosocial burden throughout their lives[6], which is especially important during childhood [4].
These children suffer from physical, social, emotional andschool problems [7]. Physical problems such as chronic
anemia, bone deformities, growth retardation, delayed
physical maturation, and short height cause poor body
image and lack of self-confidence [3, 8]. Also, they facesocial problems such as separation from family, physical and facial deformities, fear of death, and limitations
in social activities, schoolwork, and play which can leadto depression and anxiety in these children [9]. Children with thalassemia think they are different from theirfriends and have negative beliefs about their lives. Therefore, they feel guilty, highly nervous, and low self-respect[7]. On the other hand, adolescents with thalassemia not
only have to cope with the transition from childhood toadulthood and all the challenges that come with it, butalso have to adapt to thalassemia and its treatment [10].
Therefore, coping with their emotional problems requires
adaptive coping skills [11].
Coping is considered a response to reduce the emotional, physical and psychological distress related to challenging life situations and daily bothers [12]. Lazarus
and Folkman (1980) defined coping as the cognitive andbehavioral efforts to overcome, tolerate, or decrease
external and internal demands and conflicts between
them [13]. Coping strategies can be divided into two
types: problem-solving strategies involve actively reducing challenging conditions, whereas emotion-focused
coping strategies aim to manage the emotional impact ofstressful or potentially stressful situations [14]. Effective
coping styles alleviate emotional distress, while inappropriate coping strategies exacerbate the negative effectsof stress [15]. Results of different studies indicate thatchildren suffering from long-lasting illnesses are less able
to cope adaptive with the disease and its side effects [1,5, 12]. In the treatment of chronic diseases, the patient`sability to effectively manage the burden of long-lastingillness in daily life can play an impressive role in treatment outcomes [1, 16]. According to the importance of
coping skills and the use of maladaptive coping strategies
in dealing with stress in beta-thalassemia patients, more
attention should be paid to improving coping strategies.
Bar-On & Parker (2000) describe coping strategies
and adaptability as important components of emotional
intelligence [17]. Salovey and Mayer (1990) introduced
emotional intelligence as the ability to observe feelingsand emotions of individuals and others, to differentiate
between them, and to use this data to guide one`s beliefs
and activities [18]. According to the Bar-On model, emotional intelligence includes emotionally and sociallyrelated skills and abilities that specify how to understandand represent oneself, realize other people and communicate with them, and cope with everyday demands [19].
Bar-On identified 5 components of emotional intelligencethat comprise 15 subscale, including: Intrapersonal (comprising self-regard, emotional self-awareness, assertiveness, independence, and self-actualization); Interpersonal(comprising empathy, social responsibility, and interpersonal relationship); Stress management (comprising stress
tolerance and impulse control); Adaptability (comprising
reality-testing, flexibility, and problem-solving); and General mood (comprising optimism and happiness) [19]. The
results of some studies found that there was a significant
correlation between emotional intelligence and coping
strategies [14, 20, 21]. However, other studies indicate that
there was not a meaningful relation between emotional
intelligence and coping skills [17, 22]. According to theimportance of coping with complications of beta-thalassemia major, specific conditions of these patients and also
the limitations of studies in this field in Iran, the purposeof the study was to examine the effect of applying emotional intelligence components on coping strategies inadolescents with beta-thalassemia major.

MethodStudy design and settingThis was a randomized clinical trial study conducted toinvestigate the effects of applying emotional intelligencecomponents on problem-focused and emotion-focused(including positive emotion-focused and negative

Ahmadian et al. BMC Pediatrics(2024) 24:591

emotion-focused) coping strategies in adolescents suffering from beta-thalassemia major referred to Thalassemia and Hemophilia Clinic Center (Sarvar) from July
6th to October 30th 2021 (with the trial registration
number IRCT20210521051356N1 in 17/06/2021). This
study examined the effects of applying emotional intelligence components on two types of coping skills comprising problem-focused strategies (problem-solving
and cognitive evaluation) and emotion-focused strategies, including positive emotion-focused (social support)
and negative emotion-focused (emotional inhibition andsomatic inhibition). This article is written based on the
TREND statement checklist.

Participants
The inclusion criteria were 1) Having the informed consent to participate in the study, 2) Willingness to participate in the study, 3) having a medical record diagnosed
with beta-thalassemia major, 4) Aged between 12 and18 years, 5) Having the ability to read and write, 6) do not
suffer from mental illness based on the medical records,
7) do not pass similar courses of emotional intelligence,8) Lack of complementary therapies (such as acupuncture, yoga).
The exclusion criteria were 1) absence in 2 sessions ormore of educational intervention 2) unwillingness to continue cooperation with the researcher during the study, 3)
Failure to participate in the post-test 4) occurring stressful
events for the patient or his/her family.
Data collect
The data were gathered through demographic information
form and Billings and Moos coping strategies questionnaire.
Demographic data included 13 questions of gender, age, educational status, parental economic status,
insurance, underlying disease, marital status, and duration of illness, hemoglobin level, ferritin level, historyof splenectomy, iron chelation drug and occupation.
Billings and Moos (1981), designed a questionnaire
consisting of 19 Yes/No questions to assess coping
strategies in difficult situations. Its modified version
was published by them in 1984 and contained 32 items
and evaluated two domains of problem-focused coping(comprising two subscales of problem-solving and cognitive evaluation) and emotion-focused coping (comprising three subscales of social support, emotional
inhibition and somatic inhibition) [21, 23]. All these
items were scored through a 4-point Likert scale from0(never used) to 3(always used). The minimum andmaximum scores are 0 to 96, respectively; the higherscores show a greater use of all the above-mentioned
coping strategies. The retest reliability coefficient
was reported 0.79 and for problem-solving, cognitive

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evaluation, social support, emotional inhibition andsomatic inhibition were 0.90, 0.68, 0.90, 0.65 and 0.90,
respectively. The internal consistency reliability of the
Persian version for the whole questionnaire was considered to be 0.41 to 0.66 [24]. In this study, Cronbach’s
alpha coefficients for problem-solving, cognitive evaluation, social support, emotional inhibition and somatic
inhibition subscales were 0.76, 0.74, 0.78, 0.72 and 0.84,
respectively. Moreover, the validity of this tool was
determined by the content validity method. This questionnaire was approved by 10 experts and specialists inthe field of the research topic. Back-translation method
was used to translate the questionnaire by two independent translators.

Intervention and process
The study samples were recruited through conveniencesampling based on the inclusion criteria in Thalassemia
and Hemophilia Clinic Center (Sarvar). After explaining the main aim and methodology of the research to theteenagers and their parents, the written consents wereobtained from adolescents and their fathers by researcher
in Sarvar Clinic, as well as a form to collect demographic
information. If the father was absent for any reason andthe mother was with adolescent, the written consent was
obtained from the mother. Then, potential participants
were divided into two groups of intervention and control based on the days of referral (Even and odd days).
Lottery was used to determine which day (odd or even)belonged to which group (intervention or control). Then,the intervention group divided into groups of 3–5 people based on lottery. This lottery was conducted by the
researcher in the clinic. A number was assigned to eachsample of the intervention group. She wrote the numbers
in small papers and folded the paper. Then she poured it
into a container and blended it. Then, in the presence ofother authors, 3 to 5 papers were selected and placed ina group.
The intervention group members took part in training
sessions about emotional intelligence components basedon Bar-on model. The educational concepts of the classes
were designed based on 5 components in Bar-on model
as shown in Table 1 [19, 25]. Emotional intelligence training was provided in 9 sessions consisting of 90 min, twosessions per week; the intervention was to be delivered
over one month period. Classes were held virtually andin person in groups of 3–5 individuals using lectures, discussion, questions and answers by researcher and clinicalpsychologist. Virtual meetings were held in WhatsApp byvoice and video call. The face-to-face sessions were delivered in the room of Sarvar Clinic. The training content
of the classes was the same for all experimental groups(Table 1). The participants of the intervention group wereAhmadian et al. BMC Pediatrics(2024) 24:591

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Table 1 Content of emotional intelligence program training
Session no Subject

Training content

1

Emotional intelligence

Identifying participants and introduction the basic concepts of emotional intelligence and typesof emotions

2

Emotional intelligence components Applying emotional intelligence in daily life and talking about 5 components and 15 subscalesof emotional intelligence

3

Intrapersonal component

Defining the concept of emotional self-awareness, increasing the ability to recognize one’s own,
awareness of strength and weakness and discussing about assertiveness, self-regard and self
confidence

4

Intrapersonal component

Talking about independence, how to set goals and plan to achieve them and self-actualization

5

Interpersonal component

Discussing about empathy, promoting the ability of creating emotional solidarity and friendship with others, talking about social responsibility and interpersonal relationship (such as verbal
and non-verbal communication and body language)

6

Stress management

Discussing stress tolerance and impulse control; Teaching stress process and its consequences,
stressors, ability to tolerate stress and its strategies

7

Adaptability

The ability to recognize and accept the problem as a modifiable natural phenomenon, attempting to solve a problem, decision making skills, Factors influencing decision making and explaining
about reality-testing and flexibility

8

General mood

Talking about optimism and its relation with hope and happiness

9

Overall summary

Summarizing all sessions and encouraging people to express their opinions

provided with an educational booklet about the emotional intelligence and asked to practice at home daily
and discuss their opinions at the beginning of the next
session. For ethical reasons the control group members
were provided with an educational booklet at the completion of the study. Moreover, the standard of care (including the Periodic medical visit, blood transfusion, ironchelation therapy, giving educational pamphlets, self-caretraining) was carried out. The intervention groups wereasked not to talk with control group members about
implementation due to avoid exchanging data between
them, all participants including experimental and control groups were asked to complete the Billings and Moos
questionnaire before the intervention, immediately after
the intervention, and one month after the intervention.
The participants were asked to think about the stressful events that happened to them in the last month andanswer the questionnaire based on how they responded
to the stressful events. A face-to-face self-report interview was used to collect information.

Statistical analysis
To calculate the sample size, we using G-POWER software and t test with the power of 80% and the error probability ratio of 5%, 33 individuals were assigned into eachgroup [26]. Then by considering attrition rate, 2 moreindividuals were added into each group and finally eachgroup comprised 35 people. We performed a statisticalpower analysis using independent t test. The power was
0.20 with considering 35 individuals in each group.
The collected data analysis was performed using
The SPSS software (version 21). For examining andsummarizing demographic data of subjects, descriptive
statistics, such as frequency, percentage, mean and standard deviation (SD) were used. We tested the normalityof quantitative variables by using Kolmogorov–Smirnov
and Shapiro Wilk tests. To examine the homogeneity ofthe two groups in terms of intervening and backgroundvariables, chi-square (qualitative variables), independentt (quantitative variables with normal distribution) and
Mann–Whitney (quantitative variables without normal
distribution or rank) was used. To achieve the objectivesof the research, repeated measures Analysis of Variance(ANOVA) and Bonferroni were used. Statistical significance was considered at p < 0.05 and reliability 95%. The
statistical analyst was blinded to minimize the bias.

Results
Recruitment

The per protocol analysis used for this clinical trial. During the study, 31 of the 35 teenagers in the intervention
group completed the training courses. 1 of the 31 who
were in the experimental group and 5 of the 35 adolescents in the control group were not able to complete thesecond and third evaluation. Finally, the study was performed on 60 individuals (30 in the intervention groupand 30 in the control group) and the results were calculated without missing samples (Fig. 1; Diagram of theparticipants in the study).
The mean age of the participants was 15.6 ± 1.8 and15.5 ± 2.3 years in the intervention and control groups,
respectively. 33.3% (n = 10) were female and 66.7%(n = 20) were male in the intervention group and 33.3%(n = 10) were female and 66.7% (n = 20) were male in theAhmadian et al. BMC Pediatrics(2024) 24:591

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Fig. 1 Diagram of the participants in the study

control group. Considering the duration of disease in theexperimental group was 15.0 ± 2.0 years and in the control group was 15.1 ± 2.2 years (Table 3).

Findings
First, the normality of quantitative variables was tested
by using Kolmogorov–Smirnov and Shapiro Wilk tests(Table 2). Independent t-test (for normal quantitative variables), Mann–Whitney test (for non-normal quantitativeand rank variables) were used to compare two groups.
Nominal variables were also compared in two groups using
the chi-square test. This statistical analysis showed there
were no meaningful differences between the demographic
variables of intervention and control groups (Table 3). Statistical significance was considered at p < 0.05.
A repeated-measures ANOVA was performed to evaluate the effect of applying emotional intelligence components on coping strategies. The means and standard
deviations for coping strategies are presented in Table 6.
Mauchly’s test indicated that the assumption of sphericity
had been violated, [Mauchly’s W = 0.676] and [P < 0.001],
and therefore degrees of freedom were corrected using
Huynh–Feldt as presented in Table 4.
The effect of time on total score of coping strategies
was significant at the [0.05] level, F-ratio = [777.906],
p = [< 0.001], partial Eta Squared = [0.86] and degreeof freedom = [1.557]. The effect of group on total
score of coping strategies was significant at the [0.05]
level, F-ratio = [9022.576], p = [< 0.001], partial Eta

Squared = [0.98] and degree of freedom = [1]. The resultsof weighted repeated measures analysis of variance(ANOVA) of coping strategies based on the effect of timeand group are presented in Table 5.
Post-hoc pairwise comparisons with a [Bonferroni]
adjustment indicated that there was no significant difference between the total scores of coping strategies in thecontrol [34.73 ± 5.420] and experiment [34.90 ± 6.359]
groups before the intervention (p = [0.169]). However,there was a significant difference between the total scoresof coping strategies before the intervention [the initialassessment] and immediately after the intervention [thefollow-up assessment] in the control [34.80 ± 5.359] andintervention [39.07 ± 6.297] groups, (P < 0.001). Similarly,
there was a significant difference between the total scoresof coping strategies immediately after the intervention[the first] and one month after the intervention [second
follow up assessments] in the control [34.83 ± 5.331] andintervention groups [41.20 ± 6.440], (P < 0.001). Moreover, the total scores of coping strategies were significantly
higher at the second follow-up assessment [one monthafter the intervention] than the first assessment [immediately after the intervention], (P < 0.001). The results of
Bonferroni test are shown in the Table 6.

Problem‑focused coping strategy
The effect of time on problem-focused strategies was significant at the [0.05] level, F-ratio = [7951.162], p = [< 0.001],
partial Eta Squared = [0.98] and degree of freedom = [1.455].

Ahmadian et al. BMC Pediatrics(2024) 24:591

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Table 2 The normality of quantitative variables in control and intervention groups
Variables

Intervention group

Control group

Kolmogorov– Shapiro Wilk Result
Smirnov

Kolmogorov– Shapiro Wilk Result
Smirnov

Age

0.012

0.035

Non-normal distribution

0.034

0.001

Non-normal distribution

Duration of illness

0.164

0.110

Normal distribution

0.040

0.005

Non-normal distribution

Hemoglobin level

0.020

0.080

Normal distribution

0.200

0.564

Normal distribution

Ferritin level

0.089

0.003

Normal distribution< 0.001< 0.001

Non-normal distribution

The total score of coping strategies
before the intervention< 0.001

0.005

Non-normal distribution< 0.001

0.001

Non-normal distribution

The total score of coping strategies
immediately after the intervention

0.020

0.012

Non-normal distribution< 0.001

0.001

Non-normal distribution

The total score of coping strategies
one month after the intervention

0.053

0.019

Normal distribution< 0.001

0.001

Non-normal distribution

The total score of coping strategies
immediately after the intervention
compared to before the intervention

0.007

0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of coping strategies
one month after the intervention
compared to before the intervention

0.013

0.029

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of coping strategies
one month after the intervention
compared to immediately after theintervention< 0.001< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Problem-focusedstrategies before the intervention

0.036

0.067

Normal distribution

0.146

0.175

Normal distribution

The total score of Problem-focusedstrategies immediately after theintervention

0.001

0.004

Non-normal distribution

0.070

0.224

Normal distribution

The total score of Problem-focusedstrategies one month after theintervention

0.015

0.007

Non-normal distribution

0.161

0.114

Normal distribution

The total score of Problem-focusedstrategies immediately after theintervention compared to before
the intervention

0.032

0.029

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Problem-focusedstrategies one month after theintervention compared to before
the intervention

0.044

0.012

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Problem-focused < 0.001
strategies one month after the intervention compared to immediately
after the intervention< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Emotion-focusedstrategies before the intervention

0.081

0.072

Normal distribution

0.200

0.289

Normal distribution

The total score of Emotion-focusedstrategies immediately after theintervention

0.200

0.060

Normal distribution

0.035

0.060

Normal distribution

The total score of Emotion-focusedstrategies one month after theintervention

0.067

0.062

Normal distribution

0.200

0.090

Normal distribution

The total score of Emotion-focusedstrategies immediately after theintervention compared to before
the intervention< 0.001

0.001

Non-normal distribution< 0.001

0.001

Non-normal distribution

Ahmadian et al. BMC Pediatrics(2024) 24:591

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Table 2 (continued)
Variables

Intervention group

Control group

Kolmogorov– Shapiro Wilk Result
Smirnov

Kolmogorov– Shapiro Wilk Result
Smirnov

0.010

0.117

Normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Emotion-focused < 0.001
strategies one month after the intervention compared to immediately
after the intervention< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Problem-solving
strategies before the intervention< 0.001< 0.001

Non-normal distribution

0.004

0.004

Non-normal distribution

The total score of Problem-solving
strategies immediately after theintervention< 0.001< 0.001

Non-normal distribution

0.004

0.004

Non-normal distribution

The total score of Problem-solving
strategies one month after theintervention< 0.001< 0.001

Non-normal distribution

0.002

0.005

Non-normal distribution

The total score of Problem-solving
strategies immediately after theintervention compared to before
the intervention< 0.001< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Problem-solving
strategies one month after theintervention compared to before
the intervention< 0.001< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Problem-solving< 0.001
strategies one month after the intervention compared to immediately
after the intervention< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Cognitive
evaluation strategies before theintervention

0.009

Non-normal distribution

0.042

0.013

Non-normal distribution

The total score of Cognitive evalua- < 0.001
tion strategies immediately after theintervention

0.005

Non-normal distribution

0.039

0.042

Non-normal distribution

The total score of Cognitive evaluation strategies one month after theintervention

0.019

Non-normal distribution

0.014

0.007

Non-normal distribution

The total score of Cognitive evalua- < 0.001
tion strategies immediately after theintervention compared to before
the intervention< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Cognitive evaluation strategies one month after theintervention compared to before
the intervention< 0.001< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Cognitive evaluation strategies one month after theintervention compared to immediately after the intervention< 0.001< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Emotional
inhibition strategies before theintervention

0.012

0.023

Non-normal distribution

0.007

0.002

Non-normal distribution

The total score of Emotional inhibi- 0.003
tion strategies immediately after theintervention

0.040

Non-normal distribution

0.028

0.014

Non-normal distribution

The total score of Emotional inhibition strategies one month after theintervention

0.091

Normal distribution

0.072

0.015

Normal distribution

The total score of Emotion-focusedstrategies one month after theintervention compared to before
the intervention

0.005

0.004

0.087

Ahmadian et al. BMC Pediatrics(2024) 24:591

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Table 2 (continued)
Variables

Intervention group

Control group

Kolmogorov– Shapiro Wilk Result
Smirnov

Kolmogorov– Shapiro Wilk Result
Smirnov

The total score of Emotional inhibi- < 0.001
tion strategies immediately after theintervention compared to before
the intervention< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Emotional inhibition strategies one month after theintervention compared to before
the intervention< 0.001< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Emotional inhibition strategies one month after theintervention compared to immediately after the intervention< 0.001< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of social support
strategies before the intervention< 0.001

0.005

Non-normal distribution

0.028

0.009

Non-normal distribution

The total score of social support
strategies immediately after theintervention

0.034

0.259

Normal distribution

0.002

0.019

Non-normal distribution

The total score of social support
strategies one month after theintervention

0.008

0.073

Normal distribution

0.031

0.151

Normal distribution

The total score of social support
strategies immediately after theintervention compared to before
the intervention< 0.001

0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of social support
strategies one month after theintervention compared to before
the intervention< 0.001

0.006

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of social support< 0.001
strategies one month after the intervention compared to immediately
after the intervention< 0.001

Non-normal distribution< 0.001< 0.001

Non-normal distribution

The total score of Somatic inhibition 0.020
strategies before the intervention

0.009

Non-normal distribution 0.003

0.005

Non-normal distribution

The total score of Somatic inhibi0.077
tion strategies immediately after theintervention

0.015

Normal distribution

0.039

0.023

Non-normal distribution

0.033

0.006

Non-normal distribution 0.010

0.012

Non-normal distribution

0.001

Non-normal distribution < 0.001< 0.001

Non-normal distribution

0.016

Non-normal distribution < 0.001< 0.001

Non-normal distribution< 0.001

Non-normal distribution < 0.001< 0.001

Non-normal distribution

The total score of Somatic inhibition strategies one month after theintervention

The total score of Somatic inhibi< 0.001
tion strategies immediately after theintervention compared to before
the intervention
The total score of Somatic inhibition strategies one month after theintervention compared to before
the intervention

0.005

The total score of Somatic inhibition < 0.001
strategies one month after the intervention compared to immediately
after the intervention

The effect of group on problem-focused strategies was significant at the [0.05] level, F-ratio = [1407.417], p = [< 0.001],
partial Eta Squared = [0.90] and degree of freedom = [1](Table 5).

Post-hoc pairwise comparisons with a [Bonferroni]
adjustment indicated that there was no significant difference between the scores of problem-focused strategies (problem-solving and cognitive evaluation) in theAhmadian et al. BMC Pediatrics(2024) 24:591

Page 9 of 14

Table 3 Comparing demographic characteristics of both control and intervention groups
Variables

Control group

Experience group

Quantitative variables

Mean ± SD

Mean ± SD

Age (year)

15.47 ± 2.285

15.57 ± 1.832

ResultMann–Whitney test
Z = 0.0
P value = 0.976*

Duration of illness (year)

15.13 ± 2.161

15.02 ± 1.976

Mann–Whitney test
Z = -0.3
P value = 0.789*

Hemoglobin level (mg/dL)

9.52 ± 0.806

9.780 ± 0.645

Independent t-test
P value = 0.168*
T = -1.397 Df = 58

Ferritin level (ng/ml)

3583.20 ± 2445.715

3272.23 ± 1797.070

Mann–Whitney test
Z = -0.3
P value = 0.734*

Qualitative variables
GenderEthnicity

Number(percent)Number(percent)Female10 (33.3%)

10 (33.3%)

Chi square Tests

Male

20 (66.7%)

20 (66.7%)

P value -a

Iranian (Khorasan province)

30 (100%)

30 (100%)

Chi square Tests
P value -b

Education status

High school

30 (100%)

30 (100%)

Chi square Tests
P value -b

Marital status

Married1 (3.3%)1 (3.3%)Chi square Tests

Single29 (96.7%)

29 (96.7%)

P value -a

Employed

8 (26.7%)

8 (26.7%)

Chi square Tests

Unemployed22 (73.3%)

22 (73.3%)

P value -aParental economic status

Sufficient

20 (66.7%)

20 (66.7%)

Chi square Tests

Low than sufficient

10 (33.3%)

10 (33.3%)

P value -aParental education

Elementary school

10 (33.3%)

10 (33.3%)

Chi square Tests

High school

20 (66.7%)

20 (66.7%)

P value -a

InsuranceYes

27 (90.0%)27 (90.0%)

Chi square Tests

No

3 (10.0%)

3 (10.0%)

P value -aYes

2 (6.7%)

3 (10.0%)

Chi square Tests

No

28 (93.3%)

27 (90.0%)

Chi square = 0.218
Df = 1
P value = 0.640*

Yes

3 (10.0%)

4 (13.3%)

Chi square Tests

No

27 (90.0%)26 (86.7%)

Chi square = 0.162
Df = 1
P value = 0.688*

Occupation

Splenectomy

Underlying disease*(P > 0.05) is not considered statistically significant

acannot be calculated because the frequency of the variable in both control and intervention groups is completely equalbcannot be calculated because the variable has only one category

control [14.200 ± 2.551] and experiment [14.233 ± 2.661]
groups before the intervention (p = [0.913]). However,there was a significant difference between the scoresof problem-focused strategies before the intervention [the initial assessment] and immediately after theintervention [the follow-up assessment] in the control [14.266 ± 2.476] and intervention [24.333 ± 2.941]
groups, (P < 0.001). Similarly, there was a significant
difference between the scores of problem-focusedstrategies immediately after the intervention [the first]
and one month after the intervention [second follow up
assessments] in the control [14.400 ± 2.443] and intervention groups [29.633 ± 3.189], (P < 0.001). Moreover,the scores of problem-focused strategies were significantly higher at the second follow-up assessment [onemonth after the intervention] than the first assessment[immediately after the intervention], (P < 0.001) in theintervention group (Table 6).

Ahmadian et al. BMC Pediatrics(2024) 24:591

Page 10 of 14

Table 4 Mauchly’s test sphericity of coping strategies
Variables

Mauchly’s Test of Sphericity
Mauchly’s W

Sig.

Strategies (Total score)

0.676

P < 0.001

Problem-focused strategies

0.727

P < 0.001

Emotion-focused strategies

0.503

P < 0.001

Cognitive evaluation

0.671

P < 0.001

Problem-solving

0.766

P < 0.001

Emotional inhibition

0.501

P < 0.001

Social support

0.786

P < 0.001

Somatic inhibition

0.655

P < 0.001

Emotion‑focused coping strategy
The effect of time on total emotion-focused strategies
was significant at the [0.05] level, F-ratio = [846.535],
p = [< 0.001], partial Eta Squared = [0.94] and degree of
freedom = [1.380]. The effect of group on total emotion-focused strategies was significant at the [0.05] level,
F-ratio = [901.775], p = [< 0.001], partial Eta Squared = [0.94]
and degree of freedom = [1] (Table 5).
Post-hoc pairwise comparisons with a [Bonferroni]
adjustment indicated that there was no significant difference between the scores of emotion-focused strategies in
the control [20.533 ± 4.023] and experiment [20.666 ± 5.261]
groups before the intervention (p = [0.913]). However, there
was a significant difference between the scores of emotion-focused strategies before the intervention [the initialassessment] and immediately after the intervention [thefollow-up assessment] in the control [20.533 ± 4.049] andintervention [14.733 ± 5.258] groups, (P < 0.001). Similarly,
there was a significant difference between the scores of
emotion-focused strategies immediately after the intervention [the first] and one month after the intervention [second follow up assessments] in the control [20.433 ± 4.091]
and intervention groups [11.5667 ± 5.230], (P < 0.001).
Moreover, the scores of emotion-focused strategies (emotional inhibition and somatic inhibition) were significantly
lower at the second follow-up assessment [one monthafter the intervention] than the first assessment [immediately after the intervention] in the intervention group,(P < 0.001). However, the score of social support was significantly higher at the second follow-up assessment [onemonth after the intervention] than the first assessment[immediately after the intervention] in the intervention
group, (P < 0.001) (Table 6).
Discussion
Studies have indicated that patients with beta-thalassemia major suffer from psychosocial disorders. For
instance, the study of Messina et al. (2008) revealed

that thalassemic patients are likely suffer from psychiatric problems and impaired psychosocial functioning
such as somatization, depression and obsessive–compulsive traits and also the most used coping skills was
escape-avoidance [27]. Moreover, Adib-Hajbaghery
et al. [3] reported that a majority of beta-thalassemia
patients suffer from mild to severe depression, anxiety,and stress [3]. According to the psychosocial problems,
it could be helpful to identify the strategies that can
improve the coping skills of the patients. Therefore, inthe present study, the effect of applying emotional intelligence components on coping strategies in adolescentswith beta-thalassemia major was investigated.
Based on the findings of this study, Bonferroni test
indicated no statistically differences in the mean scores ofproblem-focused and emotion-focused coping strategies
in both intervention and control groups in the pre-intervention phase. Hence, it can be assumed the used coping
strategies in the terms of types and amounts were samein the two groups before the intervention.

Problem‑focused coping strategies
The present study showed that there are positive effects
of applying components of emotional intelligence on
problem-focused coping strategies and the mean scoresof problem-solving and cognitive evaluations are significantly increased in adolescents with beta-thalassemia
major. Simply put, patients in the experimental groupused more problem-focused coping strategies after theintervention, in comparison to the control group.
In line with the present study, Kovaþeviü et al.,(2018) conducted a study on patients with Schizophrenia, showed that there is a significant positive relation
between emotional intelligence and problem-focused
coping strategies [17]. Nogaj(2020), also found thatemotional intelligence correlates positively significant
with coping strategies among music school students inthe context of visual art and general education students[28]. Additionally, the study of Moradi et al., [21] demonstrated that emotional intelligence had positive relationship with problem-solving and cognitive evaluationin university students [21]. Moreover, Noorbakhsh et al.,(2010) revealed that emotional intelligence was positively associated with problem-focused coping strategies [14]. Furthermore, the study of Boyer et al., (2017)
on depressed patients and their caregivers indicated theircaregivers, who get higher score of emotional intelligence than patients, used more problem-focused coping
strategies [29]. Besides, Delhom et al., [30] in the study
on investigation the associations among emotional intelligence, coping and depressed mood, concluded thatelderly people with high emotional intelligence are more

0.94
0.90

Emotion-focused strate- Repeated Measures
gies

Weighted RepeatedMeasuresWeighted RepeatedMeasuresWeighted RepeatedMeasuresWeighted RepeatedMeasuresWeighted RepeatedMeasures

Cognitive evaluation

Problem-solving

Emotional inhibition

Social support

Somatic inhibition(P < 0.05) is considered statistically significant

0.98

Problem-focused strate- Weighted Repeatedgies
Measures*0.86

Weighted RepeatedMeasures

Strategies (Total score)

0.71

0.85

0.85

0.90

PartialEta
SquaredTime Effect

The name of the test

Variables

1.557

Degreesoffreedom

1.380

434.291.22

1342.414 1.619

2212.092 1.481

1436.989 1.740

1817.845 1.167

846.535

7951.162 1.455

777.906

F-ratioP < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

0.32

0.69

0.32

0.85

0.85

0.94

0.90

0.98

Degreesoffreedom

1

92.25

517.334

191.817880.997

1

1

1

1

1143.069 1

901.775

1407.417 1

9022.576 1

F-ratioGroup Effect
Test result Partial
Eta
SquaredTable 5 Weighted repeated measures analysis of variance (ANOVA) of coping strategies

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

0.62

0.83

0.85

0.90

0.90

0.94

0.98

0.85

Test result Partial
Eta
Squared1.557

Degreesoffreedom

1.380

327.891.22

1150.580 1.619

2165.933 1.481

1426.376 1.740

1761.945 1.167

814.7107649.624 1.455

719.019

F-ratioTime * Group Effect

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

P < 0.001*

Test result

Ahmadian et al. BMC Pediatrics(2024) 24:591
Page 11 of 14

Ahmadian et al. BMC Pediatrics(2024) 24:591

Page 12 of 14

Table 6 Comparison of mean scores of coping strategies in two groups before and after intervention
Variables

Coping Strategies (Total score)
Problem-focused strategies
Emotion-focused strategies
Cognitive evaluation
Problem-solving
Emotional inhibition
Social support
Somatic inhibition
*

Group

Before the intervention

Immediately after theintervention

One month after theintervention

Mean ± SD

Test result

Mean ± SD

Test result

Mean ± SD

Test result

Control

34.73 ± 5.420

39.07 ± 6.297

P < 0.001*
Bonferroni test

34.83 ± 5.331

34.90 ± 6.359

P = 0.169
Bonferroni test

34.80 ± 5.359

Experiment41.20 ± 6.440

P < 0.001*
Bonferroni test

P = 0.903
Bonferroni test

24.333 ± 2.941

P < 0.001*
Bonferroni test

29.633 ± 3.189

P = 0.913
Bonferroni test

14.733 ± 5.258

P < 0.001*
Bonferroni test

11.5667 ± 5.230

P = 0.008*
Bonferroni test

9.10 ± 1.269

P < 0.001*
Bonferroni test

11.00 ± 1.287

P = 0.003*
Bonferroni test

7.01 ± 0.521

P < 0.001*
Bonferroni test

8.40 ± 0.574

P < 0.001*
Bonferroni test

10.26 ± 2.093

P < 0.001*
Bonferroni test

8.61 ± 2.082

P = 0.011*
Bonferroni test

8.71 ± 0.958

P < 0.001*
Bonferroni test

10.93 ± 1.314

P = 0.002*
Bonferroni test

5.00 ± 1.774

P < 0.001*
Bonferroni test

3.82 ± 1.899

Control

14.200 ± 2.551

Experiment14.233 ± 2.661

Control

20.533 ± 4.023

Experiment20.666 ± 5.261

Control

5.27 ± 1.202

Experiment5.57 ± 1.040

Control

3.67 ± 0.735

Experiment3.97 ± 0.453

Control

13.00 ± 0.754

Experiment13.83 ± 1.759

Control

5.25 ± 0.936

Experiment5.00 ± 0.517

Control

7.39 ± 1.307

Experiment6.73 ± 1.578

14.266 ± 2.476
20.533 ± 4.049
5.37 ± 1.245
3.71 ± 0.817
12.80 ± 0.889
5.29 ± 0.980
7.32 ± 1.363

14.400 ± 2.443
20.433 ± 4.091
5.33 ± 1.184
3.67 ± 0.781
13.02 ± 1.032
5.49 ± 1.077
7.18 ± 1.458

P < 0.001*
Bonferroni test
P < 0.001*
Bonferroni test
P < 0.001*
Bonferroni test
P < 0.001*
Bonferroni test
P < 0.001*
Bonferroni test
P < 0.001*
Bonferroni test
P < 0.001*
Bonferroni test

(P < 0.05) is considered statistically significant

likely to use problem-centered strategies and achieve
better psychological adjustment [30]. These findings are
consistent with the results of the present study, whichindicates applying emotional intelligence can improve
problem-focused coping strategies.

Emotion‑focused coping strategies
This study indicated applying components of emotional
intelligence reduced the mean score of emotional andsomatic inhibition and promote the mean score of social
support. In other words, patients in the intervention
group used more social support coping strategy and lessemotional and somatic inhibition coping strategies after
the intervention, in comparison the control group.
The result of Noorbakhsh et al., `study (2010) that
aimed to determine the relationship between emotional
intelligence and coping styles with stress, revealed thatemotional intelligence was positively related with positive emotion-focused coping, and negatively associated with negative emotion-focused coping, which isin agreement with the present study [14]. Moradi et al.,[21] also confirmed that emotional intelligence has positive correlation with social support and negative relationship with physical control coping strategies [21].
Moreover, in the study of Enns et al., (2018) participants with higher emotional intelligence showed lower
perceived stress, used more of adaptive coping skills(included problem-solving and social support) and usedless of maladaptive coping strategies [31]. Furthermore,

the study of Hajisabbagh et al., (2017) on patients withepilepsy, confirmed that patients with lower emotional
intelligence used more emotion-centered strategies andimproving the emotional intelligence of these patients
can help them to use more adaptive coping skills [20].
Additionally, Sarabia et al., (2017) found that coping
styles were increased significantly by emotional intelligence workshop and emotional intelligence training canpromote adaptive coping strategies [32]. These findings
are in agreement with our study demonstrated that
applying emotional intelligence components improvethe coping strategies of patients and help them to cope
better with stressful situations.
Contrary to our findings, Kovaþeviü et al., (2018)
reported that emotion-oriented strategies had no
meaningful relationship with emotional intelligence andits subscales [17]. It can be attributed to the differencein the research community; they conducted researchon patients with schizophrenia between the ages of 18
and 55 and these patients have endured many complications of the disease and its treatments over the years,
so it is not easy to change coping strategies in thesepatients and changing coping skills requires long-term
intervention [17]. The study of Manicacci et al., (2019)
on the relationship between emotional intelligence andcoping strategies in Mothers of Autistic Children also
indicated no significant correlation between emotional
intelligence and coping strategies. It can be attributed
to the difference in the research community and dataAhmadian et al. BMC Pediatrics(2024) 24:591

collection method; they conducted the study on mothers of autistic children aged 23–61 years and outcomes
show what they were thinking and feeling when theyanswered. Besides that, data collection method wasanonymous and online, therefore researcher cannot
confirm the children’s diagnoses indicated by the mothers, nor the degree of autism severity [22].
Moreover, the results reveal that the effect of time andgroup on all coping strategies is significant (P < 0.001).
Considering that the two groups were homogenous interms of all the demographic characteristics, thus, themain effect of time and group on the average of coping
strategies in adolescents with beta-thalassemia major
in the two groups can be attributed to the effect of theresearch intervention including the applying of emotional intelligence components.
In conclusion, emotional intelligence training can
improve coping strategies in adolescents with betathalassemia major. Emotionally intelligent people think
differently about the stressful situation and they see it asan opportunity instead of a threat, they have better ability and more skills to control their emotions to cope withwork-related problems and daily life challenges [33].

Limitations
The present study has some limitations, including thesmall sample size, which limits the generalizability of theresults. Moreover, because of the coronavirus pandemic,
the most training sessions were held virtually. Moreover,
our results show what the teenagers were thinking andfeeling when they answered the questionnaires.
Conclusions
Overall, the findings of the present study demonstrated
that applying components of emotional intelligence canpromote problem-focused (problem-solving and cognitive evaluation) and positive emotion-focused (comprising social support) coping strategies and reduce
negative emotion-focused (comprising emotional inhibition and somatic inhibition) coping strategies. In
other words, applying emotional intelligence enabledadolescents with beta-thalassemia major to use adaptive coping skills and deal better with complications of
the disease.
Health care providers are often the first point of contact with children and adolescents, in meeting withadolescents with chronic illness and their families,
they can identify and evaluate coping strategies used
and then apply methods to improve them. Promoting
positive coping can play an important role in decreasing stress, ameliorating therapeutic outcomes and thequality of life. As a result, we strongly recommend that

Page 13 of 14

health professionals consider educating and applying emotional intelligence as part of psychological andnon-pharmacological treatments in health centers.
Acknowledgements
We would like to express our gratitude for the support of the nurses ofThalassemia and Hemophilia Clinic Center (Sarvar) and the adolescents who
participated in our study.
Authors’ contributions
BA, MR, ZB and SV made contributions to conception and design of the study,acquisition of data, analysis and interpretation of data. They all drafted themanuscript or revised it critically for important intellectual content. All authorsof the manuscript have read and approved the final version of the manuscript.
Funding
This study is the result of a master thesis in pediatric nursing with the codeof grant 991978. The work was supported by the Research Administration of
Mashhad University of Medical Sciences.
Availability of data and materials
The datasets generated and/or analyzed during the current study are notpublicly available due to individuals’ privacy but are available from the corresponding author on reasonable request.

Declarations
Ethics approval and consent to participate
This study was awarded ethical approval by Mashhad University of Medical
Sciences (with the code of ethics IR.MUMS.NURSE.REC.1400.017) on May 31,
2021. All methods were performed in accordance with the Declaration of
Helsinki. The written informed consent form from all adolescents and theirparents were obtained by researcher.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1
MSc Student, Department of Pediatric Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran. 2 Associate
Professor, Nursing and Midwifery Care Research Center, Mashhad Universityof Medical Sciences, Mashhad, Iran. 3 Associate Professor, Department of Pediatric Nursing, School of Nursing and Midwifery, Mashhad University of Medical
Sciences, Mashhad, Iran. 4 Associate Professor, Specialist in Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Mashhad
University of Medical Sciences, Mashhad, Iran. 5 Instructor, MSc, Departmentof Mental Health, School of Nursing and Midwifery, Mashhad Universityof Medical Sciences, Mashhad, Iran.
Received: 26 February 2023 Accepted: 4 September 2024

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