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Published in final edited form as: Psychol Health Med. 2022 Apr 3;28(4):831–842. doi: 10.1080/13548506.2022.2061720

The indirect influence of “invisible” support on pulmonary function among adults with chronic obstructive pulmonary disease

Aliza A Panjwani 1, Joel Erblich 2, Tracey A Revenson 2, Hoda J Badr 3, Alex D Federman 4, Juan P Wisnivesky 4,5
PMCID: PMC9527261  NIHMSID: NIHMS1796856  PMID: 35373659

Abstract

Individuals living with chronic obstructive pulmonary disease (COPD) often require support from family or friends. We examined whether invisible support – support that is provided but goes unnoticed – is related to pulmonary function, and whether this association is mediated by depressive symptoms and illness perceptions. Sixty-six dyads of individuals with COPD and their informal caregivers reported on receipt and provision of support, respectively. Those with COPD completed measures of depressive symptoms, illness perceptions and pulmonary function. Although invisible support was not directly related to pulmonary function, mediation analyses revealed a combined indirect effect through lower depressive symptoms and less negative illness perceptions. Interventions teaching skillful delivery of support to caregivers may reduce depressive symptoms and threatening illness cognitions, which may contribute to improvements in symptom burden among patients with COPD

Keywords: chronic obstructive pulmonary disease (COPD), caregivers, dyads, social support, illness perceptions, depressive symptoms

Introduction

Chronic obstructive pulmonary disease (COPD) is currently the third leading cause of death worldwide (World Health Organization, 2021). Responsible for over 15 million physician visits and at least 700 000 hospitalizations each year in the United States (Mannino et al., 2002), COPD is a chronic degenerative inflammatory illness with no known cure and long-term symptom management, in which patients experience impairment of lung function due to airflow obstruction. Given its significant economic and medical burden (Jinjuvadia et al., 2017), there is a need to consider the role of overlooked psychosocial factors such as social support in predicting indices of functional health.

As a result of the physical and psychological demands of COPD, individuals living with COPD often require and benefit from caregiver or familial support (Badr et al., 2017; Chen et al., 2017). The beneficial effects of social support on psychological well-being, physical functioning, and quality of life have been shown across multiple illnesses (Farrell & Stanton, 2019; Maki, 2020). Hoyt and Stanton (2018) lay out a framework of adaptation to illness in which support can have both direct and indirect effects on mental and physical health, and these effects may be positive or negative. Paradoxically, receipt of support from loved ones can, at times, increase psychological distress (Bolger et al., 2000; Zee & Bolger, 2019) or have no effect on health at all (Luszczynska et al., 2007; Uchino, 2006).

Social exchange theory posits that relationships are characterized by the both the costs of providing help and the benefits of receiving it (Chibucos et al., 2005). Positive health outcomes ensue if both partners feel neither under- or over-benefitted by the other, and there is a sense of equity or reciprocity (Revenson & Lepore, 2012). If the exchange is uneven, with one person providing more than the other, the recipient may feel a sense of indebtedness (Nadler, 2015), which can lead to increased guilt, conflict and distress (Sprecher, 2018).

Consistent with this process, research has examined social support in terms of its ‘visibility’ rather than solely on perceptions of ‘receipt’. In a daily diary study in which one member of a couple was preparing for the bar exam, Bolger and colleagues (2000) found that ‘invisible’ support transactions – times when providers reported giving emotional support, but recipients did not encode receipt of support – were more effective in reducing depressive symptoms than when support provision was visible or acknowledged by the recipient. Support can be invisible in two ways: the support provision occurred outside of the recipient’s awareness or support was delivered skillfully such that the recipient did not encode the transaction as support or ‘being helped’. The [in]visibility of support has been studied in different health contexts, such as cardiovascular reactivity (Kirsch & Lehman, 2015), smoking cessation (Lüscher et al., 2015) and breast cancer (Belcher et al., 2011).

According to Hoyt and Stanton’s (2019) theoretical framework of psychosocial adaptation to chronic illness, social support affects adjustment through multiple mechanisms such as cognitive and affective pathways that may act in parallel to influence outcomes (see also Uchino, 2006; Lepore, 2001). Perceptions of support may influence the cognitive representations of illness, or illness perceptions, that can be formed around several features of an illness, such as timeline, cure, and controllability. Poorer illness perceptions held by individuals with COPD have been related to lower quality of life, greater functional impairment, and increased medication use and hospitalization beyond the influence of objective disease severity and COPD duration (Scharloo et al., 2000; Scharloo et al., 2007; Zoeckler et al., 2014).

An affective pathway through which social support may impact functional health in COPD is depressive symptoms. Rates of depression are approximately 2.5 times higher among those with COPD than those without (Schane et al., 2008), with prevalence rates up to 80% (Smith & Wrobel, 2014). Depression can worsen the symptom burden of COPD (Yohannes et al., 2017). COPD patients with depressive symptoms experience an approximate three-fold increase in having at least one illness exacerbation compared to those without depressive symptoms (Jennings et al., 2009). Baseline depressive symptoms in COPD have predicted lower physical functioning, more symptom burden, and poorer survival, even after accounting for illness severity and socioeconomic status (Ng et al., 2007; Panagioti et al., 2014).

To broaden the literature on the benefits of support in the context of chronic illness, a stressor where support is often inequitable (i.e., the chronically ill partner generally requires more support than the healthy partner), the current study examined direct and indirect pathways between invisible support and functional health among individuals with COPD. We evaluated (1) whether there was a positive relationship between invisible support and pulmonary functioning; and (2) if this relationship was explained through positive illness representations (cognitive pathway) and/or lower depressive symptoms (affective pathway).

Method

Recruitment

Patients.

Individuals with COPD were recruited from three urban outpatient clinics between December 2011 and June 2013, as part of a larger study on associations between cognition, health literacy, and self-care among individuals with COPD (Kale et al., 2015). Patients were eligible if they had a medical diagnosis of COPD, spoke English or Spanish, and were ≥ 55. This age cut-off was selected as COPD prevalence increases in middle age and later life, with one in four men and one in six women free of COPD developing it at age 55 (van Durme et al., 2009). Participants were excluded if they had respiratory, neurological, or psychiatric illness that could affect cognition.

Caregivers.

Caregivers over the age of 18 years were eligible if they were informal caregivers—defined as unpaid relatives or friends—who by patient report were most involved in assisting with their healthcare, were. Formal caregivers were excluded, as one would expect support from paid caregivers to be largely visible as they receive payment for services.

Procedures

Informed consent and Health Insurance Portability and Accountability Act (HIPPA) documentation was obtained prior to interviews. Patient and caregiver interviews were conducted separately, followed by the patient’s pulmonary function assessment (see below). Patient interviews lasted approximately 90 minutes and caregiver interviews 30 minutes. At the conclusion of the interview, participants received $50 for their time. As this was a secondary analysis, the research staff responsible for data collection were unaware of this study’s hypotheses. Study procedures were reviewed and approved by the Institutional Review Boards of the Icahn School of Medicine at Mount Sinai and the Feinberg School of Medicine at Northwestern University.

Measures

Demographic variables.

Patients and informal caregivers independently reported age, gender, and race/ethnicity. Patients also reported highest educational level and marital status. Caregivers described their relationship to the patient (e.g., spouse, child).

Social support.

The Positive Support subscale of the Contextual Illness Support Scale, (CISS) includes 16 items assessing emotional, informational, and practical support Revenson et al., 1991). Patients completed the measure regarding receipt of support from their informal caregiver (support receipt). Caregivers completed the same items regarding provision of support to the patient (support provision). The CISS has been validated in studies of adults with chronic illness and their caregiving partners (Frick et al., 2005; Revenson et al., 1991). Cronbach’s alpha was 0.78 for patients’ support receipt and 0.80 for caregivers’ support provision.

Illness perceptions.

The 8-item Brief-Illness Perceptions Questionnaire (B-IPQ) was used to assess patients’ cognitive and emotional representations of COPD (Broadbent et al., 2006). Five items examine cognitive representations of the illness (consequences, timeline, personal control, treatment control, and identity of the illness), two items assess emotional representations of illness, and one assesses illness coherence. Items are answered on 10-point scales. Higher composite scores indicate more threatening illness perceptions (Broadbent et al., 2015). Cronbach’s alpha for the B-IPQ was 0.56.

Depressive symptoms.

Depressive symptoms were assessed with the Patient-Health Questionnaire (PHQ-9; Spitzer et al., 1999), which measures the presence and chronicity of nine self-reported symptoms over the past two weeks using a 0–3 response format (not at all to nearly every day). PHQ-9 scores ranged from (M = 8.1, SD = 6.0; alpha = .82).

Pulmonary functioning.

Significant airway obstruction was operationalized as FEV1 <70% of predicted (Miller et al., 2005). This assessment was performed in the absence of bronchodilator use in accordance with American Thoracic Society criteria using a Midmark IQspiro Digital Spirometer (MidMark Diagnostics Group, Gardena, CA). FEV1 values ranged from 0.15 to 1.5 (M = 0.59, SD = 0.27).

Data Analysis

We tested a parallel mediation model in which illness perceptions (cognitive pathway) and depressive symptoms (affective pathway) mediated relationships between invisible support and pulmonary function (FEV1). Parallel mediation allows for testing each proposed mediator while accounting for the shared variance between them and is preferable to conducting two separate simple mediation models (Hayes, 2018). As outlined by Hayes (2018), we conducted a series of regression analyses that calculated both direct and indirect effects of invisible support on pulmonary function. Variables were converted to z-scores, yielding standardized parameter estimates. Invisible support was calculated as the residual score of caregiver support provision regressed on patient support receipt. Bootstrapped confidence intervals to test the significance of indirect effects were estimated using the PROCESS program in SPSS (Hayes, 2018).

Results

Sample Characteristics

Of the 89 patient-informal caregiver dyads that met inclusion criteria, 66 had complete data. These 66 dyads did not differ significantly on sociodemographic variables from the 23 excluded. Patients were middle-aged or older with an average age of 66.9 years (SD = 8.4). About half (54%) were married and approximately 60% were women. Nearly 75% of caregivers were women, with an average age of 54.1 years (SD = 16.6). Caregivers tended to be spouses (50%), followed by adult children (26%), other family members (17%), or friends (7%). Participants were from diverse ethnic and socioeconomic backgrounds. Sample characteristics are reported in Table 1.

Table 1.

Patient and Caregiver Demographics

Patient Caregiver
n % n %
Gender
 Male 26 39 15 23
 Female 40 61 51 77
Age
 18–39 - - 13 20
 40–54 - - 17 26
 55–64 30 46 14 21
 65–74 24 36 15 23
 74+ 12 18 7 10
Race
 White 20 30 19 29
 Black 29 44 27 41
 Hispanic 16 24 17 26
 Other 1 2 3 4
Married/Partnered
 Yes 36 54 - -
 No 30 46 - -
Education
 Some or less than high school 13 20 12 18
 High school graduate 15 23 15 23
 Some college 12 18 21 32
 College graduate or more 7 11 18 27
 Missing 19 29 - -
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Effects of Invisible Support on Illness Perceptions and Depressive Symptoms

Higher invisible support was marginally related to less threatening illness perceptions, r2 = 0.05, b = −0.21 (SE = 0.12), p = 0.09. Invisible support was not a significant predictor of depressive symptoms, r2 = 0.04, b = 0.19 (SE = 0.12), p = 0.12.

Effects of Illness Perceptions and Depressive Symptoms on Pulmonary function

A multiple regression analysis with invisible support, illness perceptions, and depressive symptoms as predictors of FEV1 found that the overall model was significant, accounting for 20% of the variability in pulmonary function, R2 = 0.20, F(3,62) = 5.16, p = 0.003. At the predictor level, only illness perceptions were related to FEV1, b = −0.48 (SE = .14), p = 0.0002, with more threatening illness perceptions related to worse lung function. Neither depressive symptoms nor invisible support were directly predictive of FEV1.

Indirect Effects of Invisible Support on Pulmonary function

To test the mediational model, we calculated three possible indirect effects of invisible support on FEV1: 1) effects mediated by illness perception alone [i.e., a1*b1]; 2) effects mediated by depressive symptoms alone [i.e., a2*b2]; and 3), the total indirect effect of the model [i.e., Σ(ai*bi)]. Bias-corrected confidence intervals for indirect effects were calculated using 10,000 bootstrapped samples.

The total effect of the mediation model was not significant. Indirect effects were estimated irrespective of the total effect, given that competing effects (i.e., indirect and direct effects in opposing directions) such as those found in our study can suppress each other and result in a zero or near zero total effect. Thus, the presence of a total effect is not required for estimation of indirect effects, and may be absent (Hayes, 2018; Rucker et al., 2011; Zhao et al., 2010; Agler & De Boeck, 2017). The findings of the mediation model are reported in Figure 1 and summarized below.

Figure 1.

Figure 1.

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Standardized regression coefficients from the analysis of direct and indirect effects of invisible support on pulmonary function.

*p <0.05, based on bootstrapped confidence intervals

The direct effect of invisible support on pulmonary function was not significant; b = −0.15, [CI: −.39, .10], the total indirect effect was significant, b = 0.15 [CI: 0.03, 0.35], suggesting an indirect relationship between invisible support and better pulmonary function mediated by the collective influence of illness perceptions and depressive symptoms. Examined individually, neither the indirect effect through illness perceptions, b = 0.10 [CI: −0.01, 0.27] nor through depressive symptoms, b = 0.05 [CI: −0.01, 0.18] was significant. These results suggest that the indirect effects were driven by the combined contribution of depressive symptoms and illness perception.

Discussion

A support transaction involves not just the patient’s perception of support receipt but also the provider’s perception of support provision. In this regard, the concept of invisible support can provide a novel perspective on how support from others affects well-being during chronic illness. Among illnesses related to breathing difficulty, overprotectiveness – though intended to support the patient – can increase patient burden (Schokker et al., 2010). Another characteristic of these overprotective behaviors is that they are overt and, thus, highly visible to patient. What if the support provided was more covert and less visible to the patient?

This study is the first to explore the influence of invisible support among individuals with COPD. We found a small yet significant indirect influence of invisible support on FEV1, an index of pulmonary function, through the combined effect of greater positive illness perceptions and lower depressive symptoms. The effect of interpersonal relationships on physical, physiological, or immune health is likely mediated by co-occuring intrapersonal processes such as emotional dysregulation and cognitive appraisals (Pietromonaco & Collins, 2017).

In line with this reasoning, social support, an oft-studied aspect of interpersonal relationships, may exert its influence on individuals’ internal milieu through both cognitive and affective mechanisms (Hoyt & Stanton, 2018; Pietromonaco & Collins, 2017). Although one mechanism alone may be insufficient to impact physical health, these processes taken together may very well impact outcomes such as pulmonary function (Farrell & Stanton, 2019; Pietromonaco & Collins, 2017; Uchino, 2006). For example, receiving ‘invisible’ or skillfully-delivered support—support that is provided but not salient to recipient—can provide the benefits of overt or visible support without generating costs to appraisals of self-efficacy or feelings of indebtedness, sadness, guilt (Bolger, 2000).

Skillfully provided support may aid patients in reframing illness perceptions to be less threatening (Benyamini, 2007), affecting various health outcomes. In longitudinal studies, less threatening illness perceptions lead to faster recovery from surgery or injury, remittance of physical symptoms, and quicker healing from burns (Broadbent et al., 2015). Although we did not test self-efficacy in this model, increased self-efficacy among patients with COPD improves quality of life (Kar & Zengin, 2020) and functional capacity (Jackson et al., 2014). Invisible support may ameliorate depressive symptoms by circumventing emotions related shame or guilt. In turn, prospective research shows that lower depresssive symptoms predict decreased hospital re-admissions, length of stay, and symptom burden among patients with COPD (Ng et al., 2007).

Implications for Clinical Practice

“Invisible”—or skillfully-provided—support has important clinical implications in the context of a chronic degenerative disease such as COPD, where support provision and receipt is often inequitable. Along with management of illness perceptions and depressive symptoms through tailored health-focused cognitive behavioral interventions (e.g., Jonsbu et al., 2013), psychoeducation or skills-based training on effectively providing support to maintain patient autonomy or self-efficacy may prove helpful, both at home and hospital settings. Consistent with our findings, coping strategies that aid individuals in altering both emotional responses (affect) and appraisals (cognition) are likely to be most effective in improving health outcomes (Denson, Spanovic, & Miller, 2009).

Limitations

Participation in the study was voluntary, so the sample may not be representative of the population of people with COPD. Even with this caveat, the sample was diverse in terms of participants’ race and socioeconomic background. The analyses were cross-sectional and, as such, we cannot make statements of causality about the indirect effects of invisible support on pulmonary function. The low internal consistency reliability for B-IPQ (Cronbach’s alpha = 0.56) is a further limitation. However, reliabilities as low as 0.50 do not generally attenuate validity coefficients and when measures have other desirable properties such as meaningful content coverage, low alphas need not deter their use (Schmitt, 1996). In Bolger and colleagues’ studies, invisibility of support was operationalized as a dichotomous variable in experimental laboratory work conducted with student populations (Bolger, 2000; Bolger & Amarel, 2007). To apply the concept of invisible support within our COPD population and observational design, residual scores were employed to calculate invisible support. Use of residual scores have shown to provide better reliability than simple change scores (Fitzmaurice et al., 2012). We were limited by sample size and were thus unable to conduct analyses by relationship of caregiver or type of support size. Replication studies with larger sample sizes are needed and would allow for meaningful moderation analyses to examine whether invisible support is more helpful for certain subgroups or at particular points in the illness trajectory.

Conclusions

Most research on social support and physical health has centered on individual perceptions of support receipt rather than patient-provider based transactions of support (Uchino et al., 2012; Uchino, 2006). This theoretically-grounded study of dyads managing COPD is among the few to test the relationship between invisible social support, accounting for patient and partner perceptions of support receipt and provision, respectively, and functional health through cognitive (illness perceptions) and affective (depressive symptoms) mechanisms. Among older adults, social support has predicted markers of physical and physiological health, including lower blood pressure (Creaven et al., 2013), salivary cortisol levels (Turner-Cobb et al., 2000), and pain and inflammation (Hughes et al., 2014). The current study sought to add to this area of research by identifying possible mechanisms of the relationship between support and health affecting COPD patients’ lung function. This direction of research is critical for developing effective behavioral interventions for patients and their informal caregivers to improve management of COPD and quality of life.

Acknowledgements:

The authors would like to thank Rachel O’Conor, Michael S. Wolf, Melissa Martynenko, Tianyun Sheng, Fernando Caday, Jose Morillo, Allison Russell, who assisted with recruitment, project coordination, and data management.

Funding:

This study was funded by a grant from the National Heart, Lung, and Blood Institute (R01 HL105385).

Declaration of Interests

Dr. Wisnivesky has received honorarium from EHE International, Merck, Quintiles, AstraZeneca and research grants from Sanofi and Quorum. The other authors have no conflicts to report. The study was funded by a grant from the National Heart, Lung, and Blood Institute (R01HL105385).

Footnotes

Declaration of Interests: Drs. Wisnivesky and Revenson have received past honorarium from EHE International. Dr. Wisnivesky has also received honorarium from Merck, Quintiles, AstraZeneca and research grants from Sanofi and Quorum. The other authors have no conflicts to report.

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