The Association Between Cardiac Illness-Related Distress and Partner Support: The Moderating Role of Dyadic Coping

Rapelli, Giada; Donato, Silvia; Pagani, Ariela Francesca; Parise, Miriam; Iafrate, Raffaella; Pietrabissa, Giada; Giusti, Emanuele Maria; Castelnuovo, Gianluca; Bertoni, Anna

doi:10.3389/fpsyg.2021.624095

ORIGINAL RESEARCH article

Front. Psychol., 17 February 2021

Sec. Personality and Social Psychology

Volume 12 - 2021 | https://doi.org/10.3389/fpsyg.2021.624095

This article is part of the Research Topic Individual versus Dyadic Processes: Health and Relationship Outcomes View all 18 articles

The Association Between Cardiac Illness-Related Distress and Partner Support: The Moderating Role of Dyadic Coping

$\r\nGiada Rapelli,*&#x;$ Giada Rapelli^1,2*†

Silvia Donato^1†

Ariela Francesca Pagani¹

Miriam Parise¹

Raffaella Iafrate¹

Giada Pietrabissa^2,3

Emanuele Maria Giusti^2,3

Gianluca Castelnuovo^2,3

Anna Bertoni¹

¹Department of Psychology, Family Studies and Research University Centre, Università Cattolica del Sacro Cuore, Milan, Italy
²Psychology Research Laboratory, Istituto Auxologico Italiano, IRCCS, Milan, Italy
³Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy

Managing cardiac illness is not easy because it dramatically disrupts people’s daily life and both the patient and his/her spouse are at risk for experiencing distress, which, in turn, may affect the support provided by the partner as caregiver. The partner, in fact, is the main source of support, but his/her support may sometimes be inadequate. In addition, dyadic coping (i.e., the way partners cope together against stress and support each other in times of difficulty) could likely be a moderating factor. The main aim of the present study was to examine the role that dyadic coping (DC, in terms of positive, negative, and common dyadic coping responses) plays in moderating the link between patient and partner cardiac illness-related distress (in terms of anxiety and depression) and partner support (in terms of overprotection, hostility, and partner support for patient engagement). The study included 100 married couples faced with cardiac illness who completed a self-report questionnaire. We analyzed our data in PROCESS using multiple regressions in order to assess the moderating effects of DC responses in the relationship between the couple’s cardiac illness-related distress and partner support. With regard to patient distress, results showed that higher levels of patient anxiety and depression were linked with ineffective partner support (i.e., overprotection and hostility). With regard to partner distress, higher levels of partner depression were linked with hostility; higher levels of partner depression and anxiety were associated with less partner support for patient engagement. Moreover, the association between distress and partner support was moderated by the quality of DC. In particular, low positive DC represented a risk factor for both the patient and the partner during a cardiac illness, as low positive DC exacerbated the link between patient and partner distress and less effective partner support styles. Also, higher levels of negative DC were risky for couples: The association between distress and less adequate partner supportive behaviors was stronger in the case of higher negative DC. These results imply a need for psychosocial interventions for couples in cardiac illness, especially for couples lacking relational competences, such as positive dyadic coping.

Introduction

Cardiac illness is a stressful situation because it disrupts daily life and demands many lifestyle changes (e.g., diet, physical activity, smoking and alcohol consumption, medical check-ups, prescription drug compliance, etc.). Evidence supports the view that cardiac patients suffer from stress in managing their clinical condition (Jackson et al., 2018). Still, illness management does not happen in isolation, and successfully coping with a cardiac disease significantly depends on the individual’s perceived social support, particularly that of the partner (Donato et al., 2009; Iafrate et al., 2009; Rapelli et al., 2020c). The partner usually provides emotional and practical support to the cardiac patient by constantly monitoring the patient’s medication adherence, making appointments, accompanying the partner to the regular medical visits, and detecting signs of cardiac symptoms. The partner, moreover, is the main person responsible for the patient’s low-salt diet, takes charge of the tasks that previously were done with or by the patient, and contributes actively to making decisions on health care (Tulloch et al., 2015). According to Bertoni et al. (2015), when the partner is able to provide adequate support (i.e., balancing emotional and practical support, involving the patient in discussions, not substituting for the patient, but reinforcing the patient’s autonomous capacities), the patient is more engaged in his/her treatment with benefits in terms of psychological well-being (see, for a review, Bertoni et al., 2017), disease management, and quality of life (Greene et al., 2015; Shortell et al., 2017). The cardiac event has significant implications for both the patient and his/her partner after the diagnosis and during the recovery. In fact, following a cardiac event, both the patient and his/her spouse are at risk of experiencing distress and face a number of challenges, including the fear surrounding the patient’s health and illness progression, the novelty and unpredictability of the cardiac event, disruption of goals, caregiving demands, and decreased perceived control over the patient’s illness (Leigh et al., 2014). The support provided by the partner, however, may often be inadequate because of his/her burden and because the caregiver may not know how to effectively support the patient (Dekel et al., 2014; Bertoni et al., 2015; George-Levi et al., 2017). The literature on cardiac patients has actually highlighted that the caregiver may implement overprotective or hostile support styles, both of which are associated with worse patient health outcomes. In particular, an overprotective partner underestimates the patient’s capabilities, resulting in unnecessary help, excessive praise for accomplishments, or attempts to restrict activities, thereby resulting in worse outcomes for the patient (Bertoni et al., 2020), such as decreased quality of life and self-efficacy (Joekes et al., 2007; Zniva et al., 2017). Instead, partners’ hostile behaviors are not just unskillful, but openly unsupportive and characterized by criticism, coldness, and blame (Fiske et al., 1991). Hostility is associated with decreased patient engagement in his/her care (Rapelli et al., 2020a), increased psychological distress, and higher risk of relapses (Fiske et al., 1991). Evidence exists for the partner’s (un)supportive behaviors to be associated with (low) patient well-being and (low) self-efficacy, but whether and how patients’ and partners’ distress is associated with specific types of support has not yet been clarified. In addition, research is needed on factors that can reduce or exacerbate the negative interplay between the patients’ and partners’ cardiac illness-related distress and the partner’s unsupportive behaviors.

Recent studies of stress and coping that account for the importance of social relationships in the coping process have increasingly emphasized a dyadic perspective on illness management (Bertoni et al., 2015; Donato and Bertoni, 2018; Rentscher, 2019). In couples, mutual coping processes with external stressors, such as an illness, are covered by Bodenmann’s concept of dyadic coping (1997; 2005), that is, the process through which partners cope together, as a couple, with daily stressors. In fact, when one partner’s individual resources are insufficient for coping with a stressor, he/she may share the stressful situation with the partner, who then interprets the stress signals and responds to the shared information with a behavioral response that can be either positive or negative (Bodenmann, 2005). Bodenmann (2005) distinguished three forms of dyadic coping: Positive dyadic coping, which refers to one partner’s attempts to assist the other’s coping efforts, including delegated dyadic coping (one partner asks the other to take over certain tasks and duties in an effort to reduce his or her stress experienced in the situation); negative dyadic coping that is composed of superficial, ambivalent, or hostile reactions to the partner’s stress; and common dyadic coping, in which both partners participate in the coping process, more or less symmetrically (e.g., through shared problem solving or mutual encouragement). Abundant research has found that positive and common dyadic coping are associated with lower levels of stress and higher levels of couple satisfaction, while the opposite was found for negative dyadic coping (Hilpert et al., 2016; Parise et al., 2019). Good dyadic coping competences, therefore, should protect the partner against the negative effects of (one’s own and the patient’s) distress on his/her support behaviors, in at least three ways. First, couples showing good dyadic coping skills should be able to better cope with the stress caused by the illness and, therefore, should be less affected by its negative impact. Second, dyadic coping is generally associated with better relationship quality as it is an indicator of how much the partners jointly commit to each other’s relationship satisfaction, quality of life, and mutual well-being (Bertoni et al., 2018). Therefore, partners with a better relationship quality and higher relationship satisfaction should present more benevolent interpretations of the patient’s distress and negative behaviors and rely less than dissatisfied partners do on self-defensive reactions (Bradbury and Fincham, 1990). Finally, partners with good dyadic coping skills are especially able to appraise the illness as a couple, rather than individual, problem (Falconier and Kuhn, 2019); consequently, they are more prone to respond with positive behaviors to cope with an illness that is not only “yours,” but also “ours.” No studies, however, have examined the potential moderating effects of dyadic coping in the link between (patient’s and partner’s) cardiac illness-related distress and the quality of partner support in the context of cardiac illness.

Given the serious stress experienced by both patients and partners when facing cardiac illness, the crucial role played by the quality of partner support for the patient’s physical and psychological outcomes, and the potential for dyadic coping to function as a protective factor in this context, the main aim of the present study was to examine the role that dyadic coping plays in moderating the relation between patient’s and partner’s cardiac illness-related distress and partner support in 100 married couples faced with cardiac illness. This is the first study, to our knowledge, to analyze the above associations and to do so within a dyadic framework, which may help gain a deeper understanding of the role of the quality of interpersonal relationships in shaping cardiac disease management processes. In particular, positive, negative, and common dyadic coping were examined as moderators of the links between patient’s and partner’s distress (in terms of anxiety and depression) and the quality of partner support (Figure 1). In addition, the quality of partner support was assessed in terms of three (un)supportive behaviors already investigated in the cardiac population: Hostility (openly unsupportive behaviors; Coyne and Smith, 1994; Rapelli et al., 2020a), overprotection (well-intended, but unskillful support; Vilchinsky et al., 2010), and support for patient engagement (positive and skillful form of partner support aimed at increasing the patient’s autonomous skills in treatment; Bertoni et al., 2015).

FIGURE 1

Figure 1. The moderation model used in this study. DC = Dyadic Coping.

In light of the literature reviewed above, we tested the following hypotheses:

Hypothesis 1: Patient cardiac illness-related distress (Hp1a) and partner cardiac illness-related distress (Hp1b) will be positively associated with partner hostility and partner overprotection and negatively associated with partner support for patient engagement;

Hypothesis 2: These associations will be stronger for patients (Hp2a) and partners (Hp2b) who perceive themselves and/or their partners to display low positive dyadic coping, high negative dyadic coping, and low common dyadic coping.

Materials and Methods

Participants and Procedure

One hundred and fifty patients were originally recruited within a larger research project on cardiovascular patients’ well-being: One hundred thirty-three of them were in a committed couple relationship. Only couples in which both patients and partners completed the questionnaire were selected for the current study, which resulted in a final sample composed of 100 heterosexual couples.

The socio-demographic characteristics of the sample are shown in Table 1. Patients (N = 100; 83% male) ranged in age from 34 to 85 years (M = 62.97, SD = 11.25); partners (N = 100; 83% female) were slightly younger on average, ranging in age from 31 to 87 years (M = 59.85; SD = 11.36). The couples were married or in a committed relationship for 3 to 60 years (M = 36.99; SD = 13.45). The main diseases for which patients were hospitalized were ischemic heart disease including angina pectoris and acute coronary syndrome (ST-segment elevation myocardial infarction–STEMI; non-ST-segment elevation myocardial infarction–NSTEMI) (75%), and acute heart failure (25%).

TABLE 1

Table 1. Socio-demographic characteristics of couples (N = 100).

Participants were contacted and interviewed during the patient’s hospitalization for an acute cardiac event. A set of two questionnaires (one for the patient and one for the partner) was administered 2 days before discharge. Signed informed consent was obtained from all participants. Criteria for study inclusion were as follows: (1) Admission for acute cardiac illness (e.g., Ischemic heart diseases like myocardial infarction and acute coronary syndrome); (2) no mental disability, assessed with a short version of the Mini Mental State Examination (MMSE); and (3) ability to understand Italian and complete the questionnaire autonomously. The Psychology Research Ethic Committee of the Institution approved the study (cod. 37-18).

Measures

The description of measures and internal consistency reliability coefficients (Cronbach’s alpha) for patients and partners are shown in Table 2.

TABLE 2

Table 2. Measures and alpha’s coefficients.

Cardiac Illness-Related Distress

Cardiac illness-related distress of both the patient and the partner was measured by a 25-item version of the Hopkins Symptom Checklist (HSCL-25; Mattsson et al., 1969). The scale consisted of 25 items measuring symptoms of anxiety, depression, and somatization. Both patients and partners were asked to rate the symptoms they experienced during the past week as ranging from 1 = never to 4 = often [e.g., Item # 1 for anxiety: (In the past week, to what extent did you worry or stress for this symptom…) “Suddenly scared for no reason.”; Item # 25 for depression: (In the past week, to what extent did you worry or stress for this symptom…) “Difficulty in falling asleep and in sleeping?”]. The total score of the subscales (anxiety and depression) are computed by averaging the items: Higher scores indicated more psychological distress. The cut-off clinical score was set at 1.70, according to the validation study (Mattsson et al., 1969).

Partner Hostility

The partner’s hostile attitude toward the patient was measured by the Spouse Hostility Scale from the Michigan Family Heart Questionnaire (Fiske et al., 1991). It consisted of five items which were included in the questionnaire filled in by the partner (e.g., Item # 5: “My spouse doesn’t try hard enough to help himself/herself.”). All responses were coded on a 5-point Likert-type scale ranging from 1 = never to 5 = very often. The total score of the scale was computed by averaging the five items: A higher score indicated a higher level of hostility.

Partner Overprotection

The partner unrequired protection and interference with the patient’s behaviors and decisions was measured by the Spouse Overprotection Scale from the Michigan Family Heart Questionnaire (Fiske et al., 1991). It consisted of four items which were included in the questionnaire filled in by the partner (e.g., Item # 4: “I find myself stepping in and doing things that my spouse can do for himself.”). All responses were coded on a 5-point Likert-type scale ranging from 1 = never to 5 = very often. The total score of the scale was computed by averaging the five items: A higher score indicated a higher level of overprotection.

Partner Support for Patient Engagement

The partner’s supportive behaviors aimed at promoting the patient’s active engagement into his/her treatment was measured with 11 hoc items on a 5-point Likert-type scale ranging from 1 = strongly disagree to 5 = strongly agree (e.g., Item # 11: “I help my partner to recognize when he/she needs medical care and when he/she can manage the problem on his/her own.”). The total score was created by averaging the items after reverse coding negatively keyed items: A higher score indicated a higher level of support for patient activation by the partner.

Patient and Partner Dyadic Coping

Dyadic coping of both the patient and the partner was measured with the Italian version of the Dyadic Coping Inventory (Fragebogen zur Erfassung des Dyadischen Copings als Tendenz FDCT-N; Bodenmann, 1997; Donato et al., 2009). This 41-item questionnaire measures the propensity of each partner to offer help, emotional support, and empathy in response to the other’s expression of stress together with the couple’s joint attempts to cope with common stressors. The scale considers the three forms of dyadic coping: Positive (e.g., “My partner is on my side and tells me that he/she knows how it feels to be stressed and that he/she cares about me.”), negative (e.g., “My partner helps me, but does so unwillingly and unmotivated.”), and common (e.g., “We try to cope with the problem together and search for practical solutions.”). For positive and negative dyadic coping, we considered both self-perceptions (from now on “dyadic coping self-perceived”) (e.g., “When my partner is stressed, I communicate my understanding to him/her.”) and the perceptions of the other (from now on “dyadic coping other-perceived”) (e.g., “When I’m stressed, my partner gives me the feeling that he/she understands me.”). The items were administered on a 5-point Likert-type scale from 1 = never to 5 = very often.

Statistical Analyses

Descriptive statistics were obtained from the sample in terms of socio-demographic data. Pearson’s correlations were used to calculate the relationship between study variables. In order to test for differences between patients and partners on study variables, paired sample t-tests were calculated.

To examine the moderating effects of partners’ dyadic coping responses (moderators) in the link between patients’ and spouses’ distress (independent variables) and their partners’ support (dependent variable), we used PROCESS, a freely available computational tool for SPSS and SAS developed by Hayes (2017). To examine moderation effects in this study, we performed the analyses corresponding to PROCESS Model 1. A moderated model was tested in which patient and partner distress in terms of anxiety and depression were hypothesized to be associated with the quality of partner support in terms of overprotection, hostility, and support for patient engagement, as well as the moderating role of dyadic coping responses (positive, negative, and common) in these associations. Prior to model analyses, all predictors and moderators were mean-centered to reduce collinearity between the interaction term and its constituents (Aiken et al., 1991). Regression analyses were conducted in which coefficients were bootstrapped using 5,000 bootstrap samples. The coefficients were tested for statistical significance by means of the percentile confidence intervals, and a significant effect is said to occur if the 95% confidence interval excluded 0.

Results

Descriptive Statistics

Table 3 shows the means and correlations for the selected psychological variables. Anxiety was high and above the clinical cut-off score (1.70) for both patients (M = 1.72; SD = 0.56) and their partners (M = 1.83; SD = 0.58); depression was lower than the clinical cut-off score (1.70) (Patients: M = 1.66; SD = 0.51; Partners: M = 1.69; SD = 0.56). Of the three support styles, hostility and overprotection were moderate compared to the scale range (Hostility: M = 2.14; SD = 0.75; Overprotection: M = 2.85; SD = 0.86), partner support for patient engagement was high (M = 3.79; SD = 0.66) compared to the scale range. Positive dyadic coping self-perceived (Patients: M = 3.67; SD = 0.68; Partners: M = 3.69; SD = 0.63) and other-perceived (Patients: M = 3.88; SD = 0.79; Partners: M = 3.37; SD = 0.88) were high. Furthermore, partners reported receiving significantly less positive dyadic coping responses from the other than patients did [t(95) = 4.12; p = 0.008]. Negative dyadic coping self-perceived (Patients: M = 1.83; SD = 0.82; Partners: M = 1.96; SD = 0.95) and other-perceived (Patients: M = 1.88; SD = 0.69; Partners: M = 1.95; SD = 0.69) were low. Common dyadic coping was high (Patients: M = 3.47; SD = 0.76; Partners: M = 3.40; SD = 0.89).

TABLE 3

Table 3. Means and intercorrelations among study variables.

Table 3 also shows the correlation analysis among study variables. For patients, anxiety and depression were negatively correlated with partner support for patient engagement and hostility showed a weak positive association with depression. The associations between the support styles and dyadic coping were low to moderate in size.

For partners, anxiety was weakly and positively correlated with overprotection and hostility; depression was weakly and positively correlated with hostility and weakly and negatively correlated with partner support for patient engagement. The associations between the support styles and dyadic coping were low to moderate.

Testing Moderating Effects

To test whether dyadic coping (i.e., self and other-perceived positive dyadic coping, self and other-perceived negative dyadic coping, and common dyadic coping) moderated the association between the patient’s and the partner’s cardiac illness-related distress and the partner’s support quality (i.e., overprotection, hostility, and partner support for patient engagement), we conducted several hierarchical regression analyses. To test whether these effects varied significantly across the levels of the moderators, the differences in the effects for high and low levels of the moderator were computed and tested for significance by determining the bootstrapped confidence limits of the difference. As suggested by Aiken et al. (1991), low and high levels of the moderators were defined as minus one standard deviation and plus one standard deviation of the moderators, respectively. The results for patients and for partners were presented separately. We reported only significant interaction effects.

Results for Patients’ Distress (Hp1a and Hp2a)