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. Author manuscript; available in PMC: 2025 Sep 1.
Published in final edited form as: Couple Family Psychol. 2022 Sep 22;13(3):188–201. doi: 10.1037/cfp0000234

A Communal Coping Intervention for Couples Managing Chronic Illness: Proof-of-Concept Study

Melissa Zajdel 1, Vicki S Helgeson 2
PMCID: PMC11361721  NIHMSID: NIHMS1865347  PMID: 39220404

Abstract

Introduction.

Communal coping is an interpersonal coping strategy defined as the appraisal of a problem as shared and collaboration to manage it. Despite evidence establishing links of communal coping to health, few interventions have involved communal coping. This study seeks to establish proof of concept that an intervention rooted in communal coping theory can impact couple members’ communal coping and intermediary outcomes.

Methods.

Couples (n = 40) in which one person has type 2 diabetes were randomly assigned to intervention versus control in a parallel randomized trial with 1:1 allocation. The intervention consisted of a single session focused on discussion of shared stressors, communal coping education, and collaborative implementation intentions followed by 7 days of text message reinforcement. Couples were interviewed in-person, received the intervention or active control, and completed 7 daily questionnaires. Communal coping and intermediary outcomes associated with communal coping were assessed daily. Feasibility and acceptability were also assessed.

Results.

The intervention increased reports of both patient and partner shared appraisal and collaboration and impacted some intermediary outcomes of communal coping. Compared to control, intervention participants reported greater perceived partner responsiveness, patient support receipt, and partner confidence in patient illness self-efficacy.

Discussion.

This study provides initial proof of concept that an intervention based on communal coping theory can increase couples’ communal coping—both shared appraisal and collaboration. Additionally, the intervention was able to impact some intermediary outcomes that may be linked to downstream health outcomes for both patients and partners.

Keywords: interpersonal coping, chronic illness, social support

It has been increasingly recognized that there is an interpersonal context to coping. Stressors not only impact an individual but also the individual’s social network. Individuals can leverage resources from their network to more effectively manage stressors such as chronic illness by engaging in interpersonal rather than individual-focused coping strategies. There are a variety of interpersonal coping theories, including relationship-focused coping (Coyne & Smith, 1991), the systemic transactional model of coping (Bodenmann, 1997), and the developmental contextual model of coping (Berg & Upchurch, 2007).

The present study adopts the communal coping framework, which consists of the cognitive appraisal of a stressor as shared and collaborative behaviors to manage the stressor (Afifi et al. 2006; Helgeson et al., 2018; Lyons et al., 1998). Although most interpersonal coping theories include collaborative behaviors as a core component, the inclusion of a shared appraisal of the stressor is a unique aspect of communal coping that sets it apart from other theories. There is a growing literature documenting the relationship and health benefits of communal coping for couples coping with chronic illness (e.g., Zajdel & Helgeson, 2020), but there have not been empirical tests of a couples-based intervention rooted in both components of communal coping.

The primary goal of this study was to establish proof of concept that a brief, single-session intervention grounded in communal coping theory can increase couple members’ shared appraisal of an illness and collaboration to manage it. The second goal was to determine whether the communal coping intervention impacts intermediary outcomes—including social support, perceived responsiveness to needs, and self-efficacy—that are posited to impact distal health outcomes. Finally, we sought to determine whether this initial intervention is feasible and acceptable to couple members. Below we review communal coping theory, describe intervention research relevant to communal coping, and discuss intermediary outcomes of communal coping that may affect downstream health.

Communal Coping Theory

Communal coping has been consistently linked to better psychological and physical health across chronic illness contexts (e.g., Basinger et al., 2021). For example, among couples coping with type 2 diabetes, observed communal coping has been linked to enhanced problem solving, less psychological distress, and better self-care (e.g., Helgeson et al.., 2017; Van Vleet, et al., 2019), and daily reports of communal coping have been linked to better daily mood and self-care (Zajdel et al., 2018). Additionally, a meta-analytic review of we-talk—a marker of shared appraisal—showed links to enhanced illness outcomes, psychological well-being, and relationship quality across a range of disease contexts for both patients and spouses (see Karan et al., 2019 for a review). Collaborative behaviors have also been linked to better relationship quality and better mood for couples coping with prostate cancer (Berg et al., 2008) and diabetes (Zajdel & Helgeson, 2020). Finally, a construct similar to collaboration—common dyadic coping—has been linked to better self-care among couples in which one person has type 2 diabetes (Johnson et al., 2013), and a meta-analysis has linked common dyadic coping to enhanced relationship satisfaction (Falconier et al., 2015). Given the potential benefits of both shared appraisal and collaboration, we incorporated both aspects into the intervention and measured whether the intervention impacted both processes for couple members.

Couples-Based Interventions Relevant to Communal Coping

Family or couple-based interventions have shown beneficial effects on adjustment outcomes across cancer, type 2 diabetes, HIV, arthritis, and cardiovascular disease (see Berry et al., 2017; Martire et al., 2010 for reviews). It is also the case that these benefits from couple-based interventions are greater than those found from interventions that focus on the patient alone (Martire et al., 2010). While no interventions have been tested that incorporate both aspects of communal coping, some interventions have found benefits of collaboration. For example, one intervention that focused on partner communication, collaboration, and diabetes-related conflict resolution had positive effects on HbA1c, diabetes distress, and self-efficacy (Trief et al., 2016). A second intervention had couples in which one person had type 2 diabetes develop collaborative implementation intentions—or joint regulatory strategies to manage diabetes—and found links to increased exercise adherence and more spouse social support 6 weeks later (Wooldridge et al., 2019).

Other interventions have included communal coping as one component of a multi-faceted intervention. For example, an intervention called FAMCON is rooted in both family systems theory and communal coping theory and has been shown to be effective in the context of smoking cessation (Rohrbaugh et al., 2012) and alcohol use (Rentscher et al., 2017). Importantly, the intervention increased shared appraisal, as increased patient and spouse we-talk over the course of the 10-session intervention was observed (Rohrbaugh et al., 2012). Recently, a new communal coping and family systems intervention was introduced (Rohrbaugh, 2021). This 8-session intervention is rooted in communal coping theory (e.g., discussing past teamwork in overcoming adversity) using a nondirective approach (e.g., asking questions) rather than providing explicit suggestions for how couples should approach illness management. However, there are no empirical tests of this intervention to date.

Thus, this study provides a critical step in building on past communal coping work and family-based interventions by developing and testing an intervention grounded in communal coping theory, which addresses the concern that some family-based interventions for chronic illness lack theoretical grounding (Martire, 2013). We also targeted both the appraisal and collaboration components of communal coping in this intervention. Additionally, the intervention was tailored to the needs of the couple, a factor that increases the strength of family-based interventions (Martire et al., 2010).

Effects of Communal Coping on Intermediary Outcomes

The second study goal was to examine the impact of the intervention on intermediary outcomes hypothesized to mediate the effects of communal coping on health. There is recent, increased emphasis on the mechanisms of behavior change and designing interventions that identify, measure, and influence mechanisms to impact health (Nielsen et al., 2018). In this study, we tested whether the communal coping intervention impacted three intermediary outcomes that have been suggested as potential mediators of the link between communal coping and health: 1) support interactions, 2) perceived partner responsiveness, and 3) self-efficacy (e.g., Helgeson et al., 2018; Rentscher, 2019).

The first intermediary outcome examined is social support—both patient perceived support receipt and spouse perceived support provision. Social support has traditionally been defined as the resources one individual provides to another (Cohen & Syme, 1985), and there is a great deal of literature that indicates positive effects of social support on health outcomes such as cardiovascular and immune function (see Uchino, 2006 for a review) and adherence to medical regimens (see DiMatteo, 2004 for a review). Communal coping is likely to increase spouse supportive behavior because thinking of the problem as shared increases ownership over the problem—thereby prompting spouses to provide more support to the patient. Patients may also be more likely to request support when they view the illness as a shared problem and be more receptive to provided support. Indeed, there is some cross-sectional evidence that communal coping is linked to both enhanced spouse support provision and patient receptiveness to support (Van Vleet et al., 2019).

The second intermediary outcome examined is perceived partner responsiveness. Perceived partner responsiveness is the perception that one’s partner respects and understands the self and provides appropriate support (Reis et al., 2004). Perceived partner responsiveness has been linked to a variety of positive relationship and health outcomes, including higher marital intimacy (Laurenceau et al., 2005) and healthier cortisol patterns in healthy couples (Slatcher et al., 2015). Communal coping should foster health-related communication such that patients are able to communicate the type of support desired and partners are able to communicate the type of support they are capable of providing—both of which lead to the perception that partners are meeting each other’s needs. A previous study showed that perceived partner responsiveness mediated the links of daily communal coping to daily mood for both persons with diabetes and their partners (Zajdel et al., 2018).

The final proposed intermediary outcome is self-efficacy, or the confidence in one’s ability to engage in the behaviors necessary for successful management of diabetes (Bandura & Adams, 1977). Communal coping should provide patients with additional resources that increase their self-efficacy and ultimately improve their self-care (Helgeson et al., 2018). Communal coping may not only increase the patient’s self-efficacy in managing diabetes but also the spouse’s perception of the patient’s efficacy in disease management. Past research indicates that spouse confidence in the patient’s ability to take care of illness management was more predictive of successful adaptation to heart failure than the patient’s own self-efficacy (Rohrbaugh et al., 2004).

Introduction to the Current Study

We examined whether a brief, single-session intervention grounded in communal coping followed by a week of daily text reinforcement increased communal coping—both shared appraisal and collaboration—and enhanced intermediary outcomes: social support, perceived partner responsiveness, and self-efficacy. This study was conducted among couples in which one person had type 2 diabetes. Type 2 diabetes is a prevalent chronic illness, affecting approximately 30.3 million people in the United States (Centers for Disease Control and Prevention, 2017) and one that requires patients to engage in a complex self-care regimen consisting of diet, exercise, and medication adherence to avoid serious health complications (Hunter, 2016). Because these behaviors often involve partners, type 2 diabetes is an ideal context in which to test a communal coping intervention. We view this study as a proof of concept study to determine whether this intervention can impact communal coping, whether the intervention can impact intermediary outcomes, and whether the intervention is feasible and acceptable to couples. If these aims are met, the intervention is easily delivered to a larger population and easily translated to other illness contexts.

Method

This study is a parallel assignment intervention design and is pre-registered on clinicaltrials.gov, identifier number: NCT04014582. The IRB at Carnegie Mellon University approved all procedures.

Participants

Participants were eligible if they met the following inclusion criteria: 1) only one person in the couple had type 2 diabetes, 2) the person with diabetes was married or living with a partner for at least one year, 3) both couple members had access to a cell phone to receive text messages, and 4) both couple members were able to complete a daily questionnaire either via the internet or cell phone. Demographics are presented in Table 1 for intervention and control groups.

Table 1:

Demographic Characteristics of the Sample

Patient Partner
Control Intervention Control Intervention
Gender:
 Male 71.4% 63.2% 33.3% 31.6%
 Female 28.6% 36.8% 66.7% 68.4%
Race:
 White 66.7% 68.4% 66.7% 68.4%
 Black 33.3% 31.6% 33.3% 31.6%
Education:
 Less than high school 0% 5% 0% 0%
 High school grad 28.5% 31.6% 9.5% 31.6%
 Some college 23.8% 10.5% 28.6% 26.3%
 2 year college grad 19.0% 15.8% 9.5% 21.1%
 4 year college grad 14.3% 21.1% 38.1% 15.8%
 Postgraduate 14.3% 15.8% 14.3% 5.3%
Age; mean (SD); range 55.33 (14.09); 24-76 57.53 (7.60); 43-66 54.33 (14.69); 24-74 58.64 (8.67); 42-71
Marital Status (Married) 85.7% 84.2% 85.7% 84.2%
Income
 < 20,000 a year 4.8% 15.8% 0% 5.3%
 20,000-29,999 4.8% 0% 9.5% 5.3%
 30,000-39,999 4.8% 5.3% 14.3% 0%
 40,000-49,999 14.3% 0% 4.8% 10.5%
 50,000-59,999 9.5% 5.3% 4.8% 5.3%
 60,000-69,999 14.3% 15.8% 19.0% 5.3%
 70,000-79,999 4.8% 10.5% 19.0% 10.5%
 80,000-89,999 0% 10.5% 0% 15.8%
 90,000-99,999 4.8% 10.5% 9.5% 5.3%
 > 100,000 28.6% 21.1% 19.0% 21.1%
 Prefer not to answer 9.5% 5.3% 0% 15.8%
Years Since Diagnosis (mean, SD, range) 6.65 (1.87); 1.08-10.33 7.56 (2.80); .83-13.83 -- --
Diabetes Medication
 Insulin 23.8% 31.6% -- --
 Pills only 76.2% 52.6% -- --
 None 0% 15.8% -- --
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Participants consisted of 40 couples; 85% were married (n = 34) and 15% were living together in a marital-like relationship (n = 6), with an average relationship length of 26 years (SD = 13.92). More patients were male (67.5%) than female (32.5%), and more patients were White (67.5%) than Black (32.5%). Average age was 56 years for both patients (SD = 11.39) and partners (SD = 12.25). Patients had been diagnosed with type 2 diabetes an average of 7 years ago (SD = 2.35).

Recruitment

The study began in August 2019, and the sample was recruited from two sources (see Figure 1 for CONSORT flow diagram). First, 61 couples who had previously participated in a study of type 2 diabetes at Carnegie Mellon University (Helgeson et al., 2017) were re-contacted to see if they were interested in the present study. Of these couples, 13 were reached and deemed ineligible, largely because they did not have access to the internet to complete the daily questionnaires. An additional 5 couples declined to participate (2 due to health problems and 3 because they did not want to travel to the university). Six couples expressed verbal interest in participating but were not able to be scheduled or participate before the study was closed due to COVID-19 on March 12th, 2020. Thus, 37 couples from the prior study were contacted, deemed eligible, and participated in the study. Second, the study was advertised on the University of Pittsburgh Pitt + Me research registry. From this site, 15 participants were assessed for eligibility. Of these, 5 were ineligible, 5 expressed verbal interest but were unable to be scheduled or participate before the study was closed due to COVID-19 on March 12th, 2020, and 5 couples completed the study.

Figure 1:

Figure 1:

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Consort Diagram

A total of 42 couples completed the in-person session and were randomized to condition in a 1:1 allocation to group by simple randomization at study start. Because cell sizes were determined to be unbalanced due to gender halfway through the study and gender has been linked to communal coping (Helgeson et al., 2020), randomization was switched to stratified randomization by gender. The first author served as the recruiter and interventionist but was blind to condition until the in-person session. A research assistant revealed group assignment immediately prior to the session from a randomly generated list stored on a secure server. After the in-person session, two couples were removed from the study: one couple (intervention group) was unable to complete the daily diary portion of the study because they did not have access to cell phones or a computer, and one couple (control group) was determined not to be eligible because both members had type 2 diabetes. Thus, the final sample consisted of 40 couples: 19 intervention and 21 control.

A priori power analyses were conducted to determine sample size from studies assessing the collaboration component of the intervention. Effect sizes for two collaborative intentions studies ranged from d = .63-.84 (Prestwich et al., 2005; Prestwich et al., 2012). The recruitment goal was 30 couples per group based on this power analysis. However, the study was stopped in March, 2020 due to the COVID-19 pandemic. Thus, we chose to focus our analyses on the impact of the intervention on daily indicators of communal coping and intermediary outcomes (e.g., support) rather than more distal outcomes (e.g., self-care).

Procedure

There were three parts to the study. Unless otherwise noted, couples in both the intervention and control groups completed the procedure.

First, participants attended an in-person session at Carnegie Mellon University. This session consisted of 1) a questionnaire that assessed demographics and baseline measures (e.g., communal coping) that was orally administered to patients and partners in separate rooms, 2) a diabetes education video shown to both patients and partners separately, 3) the intervention (described in further detail below) for those in the intervention condition only, and 4) an implementation intentions protocol that differed by condition (described below). The diabetes education video was developed from the Association of Diabetes Care and Education Specialists (Association of Diabetes Care and Education Specialists, 2019) and was approximately 15 minutes long. It consisted of education regarding diet, exercise, and blood glucose monitoring. The entire in-person session was about 2 hours in total.

After the in-person session, patients and partners completed a 7-day daily diary protocol. Patients and partners were asked to complete a brief questionnaire at the end of the day for 7 consecutive days starting the day after the in-person session. The questionnaire assessed communal coping and intermediary outcomes (support, perceived responsiveness, and self-efficacy). Patients completed an average of 6.8 of the 7 daily diaries, and partners completed an average of 6.5 of the 7 daily diaries. The completion rate did not differ between groups. Finally, couples completed a questionnaire over the phone one month after the end of the diary period.

Intervention

The intervention consisted of five modules, each of which is described below (see Supplementary Materials for full text). In all modules we allowed time for both individuals to answer the prompt, and if only one responded, we asked to hear from both persons’ viewpoints.

Module 1: Past shared stressor (shared appraisal).

First, couples were asked to identify a stressor from their past that they viewed as a shared problem. Couples were asked to describe the situation and a series of questions to prime the past example of shared appraisal. For example, they were asked to provide examples of how they worked together to handle the problem and ways they thought it was easier to work on this problem together rather than alone.

Module 2: Communal coping education (shared appraisal and collaboration).

Next, the interventionist briefly educated couples on the concept of communal coping using the shared stressor identified above. The interventionist described the two components of communal coping and provided examples from the literature as to why communal coping may be helpful in type 2 diabetes.

Module 3: Transition of type 2 diabetes from individual management to shared management (shared appraisal and collaboration).

The goal of the third module was to encourage couples to think of diabetes as a shared stressor and to consider ways they could collaborate to manage diabetes. To foster the perception of diabetes as a shared problem, couples were asked to identify ways in which diabetes affects the partner. After both individuals provided their perspective, we connected both parts of communal coping to the previous shared stressor through a series of prompts.

Module 4: Collaborative implementation intentions (collaboration).

Couples in both conditions completed a series of implementation intentions, which are plans for when and how individuals will engage in a set of goals following an “if X, then Y” format (Gollwitzer & Sheeran, 2006). Full descriptions of the intentions can be seen in Supplementary Materials. Couples in the intervention group were asked to use we-talk to construct a set of five collaborative implementation intentions together, which are implementation intentions adapted to focus on the couple’s joint behaviors (Prestwich, 2005). An example is: “If we have extra time in the evening, then we will take a walk.” In contrast, couples in the control group completed these five intentions individually and focused on their own goals. Patients in the control group focused on diabetes related goals, for example, “If I sit for more than one hour, then I will get up and do exercises for 5 minutes.” Partners in the control group were asked to focus on whatever goals they may have that are not health-related, for example, “If the girls are home this weekend, then we will decorate for fall.”

Module 5: Daily text messages (shared appraisal and collaboration).

The final component of the intervention was a series of text messages only sent to couples in the intervention group. Both patients and partners each received two text messages a day. The first was sent in the morning and was a general reminder about communal coping (e.g., “Thinking of diabetes as a shared problem can help both you and your partner!”). The second was sent in the afternoon and was a reminder of a specific collaborative implementation intention they created during the in-person session. Couples in the control group did not receive text messages.

Measures

Communal coping.

Shared appraisal was measured on a daily basis with questions adapted from Zajdel and Helgeson (2020) to reflect the current day. Patients responded to three items that showed good within-person reliability via variance component analysis (λ00 = .80), and partners responded to one item each day (“When you thought about problems related to diabetes, to what extent do you view those as ‘our problem’ or mainly your partner’s problem?”).

Collaboration was measured with three questions on a daily basis adapted from Zajdel and Helgeson (2020) to reflect the current day (e.g., “When a problem related to your diabetes arises, to what extent do you and your partner work together to solve it?”). Reliability was good for patients (λ00 = .77) and partners (λ00 = .63).

Social support.

Three emotional support and three instrumental support items were administered on a daily basis (Helgeson et al., 2017). Patients were asked how often partners engaged in these behaviors (e.g., “My partner was there for me by giving his/her undivided attention”), whereas partners were asked how often they performed these behaviors (e.g., “I was there for my partner by giving my undivided attention”). Reliability analyses for patient emotional support (λ00 = .61) and partner emotional support (λ00 = .46) were acceptable given the brief nature of the scales (Iacobucci & Duhacek, 2003). One item from the instrumental support scale detracted from the reliability; therefore two items were retained and were moderately related to each other (patient regression coefficient = .53; partner regression coefficient = .55).

Perceived partner responsiveness.

Perceived partner responsiveness was measured on a daily basis by asking patients and partners to think about how their partner responded to them with respect to diabetes management each day. These 7 items (e.g., accepted, understood) adapted from Fekete et al. (2007) were measured on 1 (none of the time) to 4 (all of the time) scale, and showed good reliability (patients λ00 = .83; partners λ00 = .72).

Illness specific self-efficacy.

Illness specific self-efficacy was measured with three items on a daily basis from the self-efficacy subscale from the Multidimensional Diabetes Questionnaire on a 0-100 scale (Talbot et al., 1997). Patients were asked how confident they were that they could complete a series of tasks (e.g., “How confident are you in your ability to exercise regularly?”), whereas partners were asked how confident they were in the patient’s abilities to complete those tasks (e.g., “How confident are you in your partner’s ability to exercise regularly?”). This scale had acceptable reliability for both patients and partners (λ00 = .53 and .45, respectively).

Acceptability & feasibility.

Feasibility was assessed by daily diary completion rate and attrition. Acceptability was assessed by asking couples at the end of the audio-taped intervention whether they would be able to view diabetes as more of a team problem when they left the session. The first author listened to the audiotaped recordings and rated responses on a yes/no scale. A subset of 10 couples (n = 4 intervention, 6 control) were also asked how satisfied they were with participation in the study on a 1-10 scale one-month after the daily diary period.

Overview of Analyses

First, demographic and baseline variables were examined to ensure randomization was effective. Baseline variables were not different across groups (see Table 1). Thus, no covariates were included. Because days are nested within-persons, we used mixed-modeling to address the primary aims. Time was a within-person variable, and condition (intervention vs. control) was a between-person variable. For each outcome, the first set of models included the effect of condition and time. Condition assesses whether those couples in the intervention group differ from those in the control group on the outcome of interest one day after intervention delivery, because time is centered at day 1;1 this is the primary effect in which we are interested. Time assesses whether the variable of interest increases or deceases over the seven-day daily diary period. After the main effects models were conducted, condition by time interactions were included to determine if individuals in the two conditions differed in the rate of change in the outcome of interest across the seven days. All models included a random intercept (with no other random effects) and used restricted maximum likelihood.

Results

Effects of Intervention on Communal Coping

There were condition effects for both patient and partner shared appraisal, indicating more patient and partner shared appraisal in the intervention group compared to the control group (Table 2). There was a condition by time interaction for patient appraisal but not partner appraisal. Patients in the intervention group increased their shared appraisal over the week (estimate = .05, SE = .02, p < .01), while patients in the control group did not (estimate = .00, SE = .01, p = .85).

Table 2:

Effects of Condition, Time, and Condition by Time for Patient and Partner Outcomes

Intercept Time Condition
(Intervention)		 Condition
(Intervention)*Time
Patient Communal Coping
 Appraisal −1.86*** (.36) .02+ (.01) 1.19*** (.23) .05* (.02)
 Collaboration −1.20** (.35) .01 (.02) .79*** (.22) .02 (.03)
Partner Communal Coping
 Appraisal −1.43*** (.38) .04** (.01) .83** (.24) −.04 (.03)
 Collaboration −.89* (.40) .03* (.03) .50+ (.25) −.02 (.03)
Patient Support
 Instrumental 1.23*** (.37) −.01 (.02) .65** (.23) −.03 (.03)
 Emotional 1.51*** (.36) .02 (.02) .60* (.23) .02 (.03)
Partner Support
 Instrumental 1.71*** (.36) .01 (.02) .10 (.22) −.03 (.03)
 Emotional 2.07*** (.37) .00 (.01) .31 (.24) −.04 (.03)
Patient Perceived Responsiveness 2.89*** (.26) .01 (.01) .37* (.17) .04 (.02)
Partner Perceived Responsiveness 2.68*** (.23) .03** (.01) .37* (.15) −.04 (.02)
Patient Illness Self-Efficacy (ISE) 64.23*** (9.07) .54 (.41) .69 (5.72) −.62 (.82)
Partner Confidence in Patient ISE 52.00*** (13.53) −.31 (.62) 10.41 (8.64) 3.15* (1.23)
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Note: Unstandardized estimates and standard errors are reported. The control group is the baseline, thus the beta coefficients in the condition column represent the intervention scores relative to the control group.

+

p = .05

*

p < .05

**

p < .01

***

p < .001.

There was a significant condition effect on patient collaboration and a trend for partner collaboration, indicating more collaboration in the intervention group compared to control group (Table 2). There were no condition by time effects on patient or partner collaboration.

Effects of Intervention on Intermediary Outcomes

Social support.

There were condition effects on patient instrumental and emotional support receipt, indicating patients reported receiving more instrumental support and more emotional support from partners in the intervention group compared to the control group (Table 2). There were no condition by time interactions on patient support. There were no condition or condition by time effects for partner reports of emotional or instrumental support provision.

Perceived partner responsiveness.

There were condition effects on both patient and partner perceived partner responsiveness, indicating more perceived partner responsiveness in the intervention compared to control group for both patients and partners (Table 2). There were no condition by time interactions.

Patient illness self-efficacy.

There were no condition or condition by time effects on patient self-efficacy (Table 2). There was a condition by time interaction for partner confidence in patient illness self-efficacy. Partners in the control group decreased their confidence in patient illness self-efficacy over time (estimate = −1.85, SE = .86, p < .05), whereas partners in the intervention group maintained their confidence in patient illness self-efficacy over time (estimate = 1.31, SE = .88, p = .14).

Feasibility and Acceptability

Patients completed an average of 6.8 daily surveys (97%), and partners completed an average of 6.5 daily surveys (93%). All patients and all partners were retained over the 7 days of the study. Additionally, 100% of intervention couples said they would be able to view diabetes as more of a shared problem. Finally, couples reported high satisfaction with the study: patient average = 9.90 (SD= .32, range 9-10), partner average = 9.10 (SD = 1.10, range 7-10).

Discussion

There is a sizeable literature—largely correlational—that demonstrates communal coping is related to positive relationship and health outcomes. This study provides a critical step in building upon that work by developing and testing an intervention grounded in communal coping theory. We developed an intervention aimed at increasing the appraisal of diabetes as a shared stressor and increasing collaboration to manage diabetes. We assessed a series of intermediary outcomes connecting communal coping to health to see if this intervention impacted those outcomes and whether this intervention was acceptable to participants. First, we discuss the preliminary findings of this study. Next we discuss the strengths and weaknesses of our approach to translating communal coping theory into a brief intervention format. Finally, we conclude with recommendations for future research.

Effects of Communal Coping Intervention

Results showed that the intervention impacted both aspects of communal coping—shared appraisal and collaboration. Both patients and partners in the intervention group reported a greater shared appraisal compared to those in the control group. Although past research suggests it is possible to foster a shared appraisal of a stressor through family systems-based interventions (Rohrbaugh et al., 2012) and through a laboratory intervention with healthy dyads (Zajdel & Helgeson, 2021), this is the first study to show that a directive communal coping-based intervention can increase shared appraisal among couples coping with a chronic illness. Importantly, patients in the intervention group continued to increase their shared appraisal over the week following the intervention compared to those in the control group, indicating a cumulative effect of the intervention. It is not clear whether that increase was the result of the initial in-person session or the daily text message reinforcements of the intervention over the course of the week. Both patients and partners in the intervention group also reported greater collaboration the following week compared to those in the control group. Thus, the results of this brief intervention suggest that it is possible to impact both the shared appraisal and collaboration components of communal coping over the course of one week.

There was also evidence that the intervention impacted some intermediary outcomes of communal coping. Patients in the intervention group reported greater instrumental and emotional support receipt from partners compared to those in the control group. Interestingly, partners in the intervention group did not report providing more support compared to those in the control group. There are two possible interpretations of these findings. It is possible that spouse behavior did not change, and patients instead were more likely to recognize the support attempts after engaging with the intervention. It is also possible that patients were more receptive to support attempts from their spouses and therefore reported more support receipt after the intervention, consistent with theory (Helgeson et al., 2018).

The intervention also impacted couples’ reports of partner responsiveness. Both patients and partners in the intervention group reported that their partners were more responsive to their needs compared to those in the control group. Because the intervention encouraged communication among couple members regarding diabetes management, couple members may have been better able to articulate their needs and the types of support desired. Regardless of whether the intervention affected partner behavior, the intervention appears to have led patients and partners to perceive that their partners were responding to their needs. Perceived partner responsiveness is an important relational process, as it has been linked to healthier diurnal cortisol patterns 10 years later (Slatcher et al., 2015), fewer depressive symptoms (Fekete et al., 2007) and better sleep quality (Selcuk et al., 2017). Thus, the impact of the intervention on couple members’ perceptions of responsiveness holds important implications for relationship and health outcomes.

Finally, although patient self-efficacy was not impacted by the intervention, partners in the intervention group maintained their confidence in the patient’s ability to manage diabetes, while partners in the control group reported a decline in confidence. This finding is important as previous research has shown that partner confidence in the patient’s illness management is more impactful than patient’s own self-confidence (Rohrbaugh et al., 2004). In this instance, partner confidence in patients’ self-efficacy may have been preserved because the intervention facilitated enhanced communication between partners or enabled partners to play a greater role in diabetes management, which in turn augmented the spouse’s confidence in the patient’s management.

Feasibility and Acceptability

Findings also suggested that the intervention was feasible and acceptable to couples. The intervention was well-received by participants, as indicated by high recruitment rates, high daily completion rates, and zero attrition. Acceptance of the communal coping intervention is also supported by the fact that all couples in the intervention group agreed that they could envision viewing diabetes as shared after the in-person session. Given the prevalence of type 2 diabetes and the complex medical regimen associated with it, brief communal coping interventions may be particularly well-suited to improve couples’ daily diabetes management. Notably, there were no couples lost to attrition, indicating a high rate of acceptability in a community-based sample of participants with type 2 diabetes and their spouses. These results are particularly important because past literature examining the dissemination of interventions into community-based settings suggests it is beneficial to examine implementation strategies and acceptability during initial stages of research (e.g., Glasgow et al., 2012).

Implications and Applications

This initial proof of concept intervention fills a number of gaps in the literature. Most critically, this is the first empirical test of a theory-driven approach to incorporate communal coping into an intervention for couples managing chronic illness. Second, the intervention takes a positive approach to the management of chronic illness. Rather than focus on problematic interactions and couple conflict (which could be helpful in its own right), we try to capitalize on the couples’ past history of positive coping to approach and frame managing chronic illness. The incorporation of tailored text messages as an intervention component—a strategy known as ecological momentary intervention (EMI)—is also a study strength, as EMIs have been shown to be particularly effective in initiating behavior change (Heron & Smyth, 2010). We also sought to enhance participant diversity in this study, as this is a noted limitation in couples research (see Williams et al., 2021 for a review), and 33% of patients were non-White. A final strength of the intervention protocol is that it is designed to be flexibly adapted to other chronic illness populations. The brevity of the intervention and the manualized nature of the intervention ensures that the approach is easily delivered and cost effective in community-based settings.

Despite these strengths, there are a number of study limitations and potential opportunities for future research. First, the sample size fell short of projections because of the COVID-19 pandemic. Thus, we were underpowered to test effects of communal coping on distal health outcomes—an initial study goal. Second, we used brief measures to reduce participant burden and some reliabilities were lower than ideal. However, measurement error generally reduces one’s ability to detect significant effects, and we found a number of significant effects on these measures. Third, daily diary follow-up only lasted one week. Thus, the extent to which these effects persist over time has yet to be determined. Finally, after reviewing the collaborative intentions created by couples, it appears that some couples did not always follow instructions. For example, some intentions were off topic (e.g., discussed household chores) or did not follow the “if, then” structure of the exercise. Future studies may benefit from further guidance by the interventionist when couples create the intentions.

We also suggest several additional ways to increase the impact of the intervention to foster lasting effects. For example, future iterations of the intervention may benefit from a longer discussion of what each couple member feels they need in regard to diabetes management and types of support or communication they desire. Additional contact with the interventionist to review or reinforce the intervention components may also be helpful. The interventionist could contact participants by phone to review the components of communal coping, discuss progress on planned collaborative actions, and address barriers to communal coping that may have arisen. However, we note that increasing the complexity of the intervention may detract from cost-effectiveness and enhance the burden to participants.

Another important direction for future research is to more directly assess the communication that occurs between patients and partners following the intervention. Although we hypothesize that the increase in perceived partner responsiveness is due to enhanced communication, we do not have the evidence to support this theory. Additionally, we do not know whether patient reports of greater partner support are a result of changes in partner behavior or changes in patient perceptions. Future research could answer these questions by observational assessments of patient-partner interactions or with unobtrusive technologies such as the electronically activated recorder that captures communication in the natural environment (Mehl et al., 2001).

Overall, the development and initial test of this communal coping intervention in the context of couples coping with type 2 diabetes is an important step in extending the existing correlational research on communal coping. Strengths of the intervention include its grounding in theory, tailoring of the intervention to couples, a text-messaging component, and brevity. The intervention successfully impacted couple members’ perceptions of diabetes as shared and induced collaborative behavior over the next week. The intervention affected perceptions of support and increased perceptions that partners were mutually responsive to one another—intermediary outcomes that may serve as mechanisms for downstream health effects. Future research should continue to leverage communal coping theory in the development of interventions to impact relationship and health outcomes in chronic illness.

Supplementary Material

Supplemental Material

Acknowledgments

We would like to thank Ilan Schwell, Geneva Oke, and Rachael Liu for their help conducting the sessions as well as Jeanean Naqvi and Fiona Horner for reading earlier versions of this manuscript. We acknowledge the support of NIH R01DK095780 as well as the University of Pittsburgh’s Pitt+Me research registry funded by grant UL1TR001857. Portions of this study were presented at the 2021 Annual Meeting of the Society for Behavioral Medicine. This research was conducted when all authors were affiliated with the Psychology Department at Carnegie Mellon University. Melissa Zajdel is now a post-doctoral scholar and was supported in part by funding from the Intramural Research Program of the National Human Genome Research Institute (ZIAHG200395).

Footnotes

Trial registration: Clinical Trials NCT04014582.

1

We repeated the analytic procedure with time centered at day 7 and results were largely the same.

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