PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Rehabil Psychol. Author manuscript; available in PMC 2017 August 1.
Published in final edited form as:
PMCID: PMC4982855
NIHMSID: NIHMS770506

Validation of the Social Provisions Scale in People with Multiple Sclerosis

Abstract

Objective

This study examined the factorial and construct validity of the Social Provisions Scale (SPS) in a sample of people with multiple sclerosis (MS).

Method

Participants included 292 individuals with MS (83.9% women) recruited from the Greater Illinois, Gateway, and Indiana chapters of the National Multiple Sclerosis Society. Participants completed the SPS and pain, fatigue, depression, anxiety, MS self-efficacy, quality of life and satisfaction with life measures. Factorial validity was tested using confirmatory factor analysis (CFA), and construct validity was examined based on the strength of bivariate correlations with scores on related measures.

Results

Findings from the CFA indicated that a first-order, six-factor measurement model provided a good fit for the 24 items of the SPS (CFI = .94, TLI= .93, RMSEA = 0.07) and that the six factors could be described by a single, second-order factor of the overall social provisions (CFI = .93, TLI= .92, RMSEA = 0.08). Cronbach’s alpha was .89 for the global score and between .66 and .81 for the six subscales. The SPS global and subscale scores correlated significantly with satisfaction with life, depression, anxiety, MS self-efficacy, and quality of life measures.

Conclusions

Findings from this study support the factorial validity, construct validity, and reliability of the SPS as a measure of social provisions for use with people with MS.

Keywords: multiple sclerosis, social provisions, social support, factor analysis, measurement

Validation of the Social Provisions Scale in People with Multiple Sclerosis Multiple sclerosis (MS) is a chronic, unpredictable, and often debilitating disease that involves an immune system attack against oligodendrocytes in the central nervous system (Compston & Coles, 2008; National Multiple Sclerosis Society [NMSS], 2014). There are approximately 450,000 individuals living with MS in the United States, and most people are diagnosed between the ages of 20–50 years (Compston & Coles, 2008; Giesser, 2011; NMSS, 2014). People with MS experience many symptoms, including fatigue, pain, numbness, tingling, weakness, muscle stiffness or spasms, tremors, bladder and bowel dysfunction, visual problems, cognitive dysfunction, emotional changes, depression, slurred speech, difficulty walking, and problems with balance (Compston & Coles, 2008; Giesser, 2011; NMSS, 2014). These symptoms can lead to gradual declines in social functioning and interpersonal interactions, and ultimately, diminished social support (Krokavcova et al., 2008; McCabe, Ebacioni, Simmons, McDonald, & Melton, 2015). For example, the severity of MS has been shown to be associated with decreased social support, and those living longer with MS tend to experience greater unmet support needs (Krokavcova et al., 2008; Matti, McCarl, Klaer, Keane, & Chen, 2010; McCabe et al., 2015). This is particularly concerning given research indicating social support is vital for maintaining physical and mental health and promoting well-being and quality of life by modulating stress and protecting against health problems (Benito-León, Morales, Rivera-Navarro, & Mitchell, 2003; Buljevac, et al., 2003; Cohen, Gottlieb, & Underwood, 2000; Mitchell, Benito-León, Gonzalez, & Rivera-Navarro, 2005; Nurullah, 2012).

For people with MS, social support has been linked to improved coping with illness-related challenges, better physical and mental health, modulated perceptions of stress, and increased quality of life and well-being (Chronister, Chou, Frain, & Cardoso, 2008; Chronister, 2009; Haber, Cohen, Lucas, & Baltes, 2007; Matti et al., 2010; Mitchell et al., 2005; Stuifbergen, Seraphine, & Roberts, 2000; Suh, Weikert, Dlugonski, Sandroff, & Motl, 2012). In particular, stress is associated with MS recurrence and progression (Lovera & Reza, 2013), and social support plays a significant role in buffering the impact of stress (Thoits, 1982). In addition, social support increases self-esteem and self-efficacy, which are critical components for living a positive, healthy, and productive life with MS (Bandura, 1982; Cobb, 1976; Cutrona & Russell, 1987; Dlugonski & Motl, 2010). Further, Thoits (1986) reported that the way individuals mobilize and process social support reflects how they cope with stressful life events, such as MS. Hence, screening is an important first step in efforts to maintain or enhance social support for people with MS who are at increased risk for diminished social support over time.

The construct of social support is complex and multidimensional (Cobb, 1976; Lakey & Cohen, 2000). Although definitions of social support are numerous and varied (e.g., Cobb, 1976; Heaney & Israel, 2002; Thompson, 1995; Wallston, Alagna, DeVellis, & DeVellis, 1983), in general they highlight that social support involves a process of perceiving the availability of different types of support through interpersonal relationships among social ties. The various definitions of social support have resulted in the development of a number of social support measures. However, there are only a few measures based on sound theories of social support (Chronister, Johnson, & Berven, 2006; Chronister, 2009; Tawalbeh & Ahmad, 2013), and this adversely impacts the quality of social support measurement (Chronister et al., 2006; Chronister, 2009; Gottlieb & Bergen, 2010). Moreover, most definitions and measures of social support focus solely on an individual’s perception of received or available support, and fail to recognize the bidirectional nature of support by not considering the extent to which the individual is also responsible for providing support.

Use of a theory-driven social support measure is needed to better assist in social support intervention development and evaluation (Chronister et al., 2006; Krokavcova et al., 2008). Yet, at this point, the rehabilitation field is lacking such a measure validated for use with people with MS. The Social Provisions Scale (SPS), developed by Cutrona and Russell (1987) and based on Weiss’s (1974) social provisions theory, is one of the few theory-based social support measures available. The SPS has been used to a limited extent with people with disability and chronic illnesses. Scores on the SPS have been found to have a strong negative correlation with loneliness among people with severe traumatic brain injury (McLean, Jarus, Hubley, & Jongbloed, 2014) as well as significant correlations with psychosocial adjustment and symptom severity among women with breast cancer (Mallinckrodt, Armer, & Heppner, 2012). Two studies have used the the SPS in research with people with with MS. Motl et al. (2007) found a relationship between scores on the SPS and exercise self-efficacy, functional limitations, and quality of life among individuals with MS. Similarly, Jaracz et al. (2010) found that the SPS had a positive relationship with the physical and mental health composite scores on the MS Quality of Life measure (MSQOL-54; Vickrey, Hays, Harooni, Myers, & Ellison, 1995).

The SPS constitutes a potentially useful theory-based assessment tool for examining social support among people with MS, but further research is needed to provide support for the use of the SPS with this population. Moreover, this measure captures Weiss’s conceptualization of dimensions of support that include both perceived availability of support as well as the indivdual’s perceived responsibility as a provider of support, making it especially useful for understanding the bidirectional nature of social support for people with MS. Thus, the purpose of this study was to test the factorial validity of the SPS using confirmatory factor analysis (CFA) and to examine its construct validity based on correlations with related measures among people with MS.

Social Provisions Theory

According to Weiss’s (1974) social provisions theory, social support is defined in terms of its function, namely, social provisions. This theory considers the functions of social relationships across specific social roles (e.g., romantic partner, spouse, family members, friends, colleagues, etc.), especially when individuals face critical life-changing events. Weiss (1974) proposed that social ties provide social support and that specific social ties might meet individuals’ different social support needs or might influence individuals to offer social support. Specifically, he analyzed social roles and their specific functions among adults who experienced a major disruption in their lives, such as a change in health status, death of a spouse, or retirement (Weiss, 1974). Based on his analysis of various social functions among interpersonal relationships, he proposed six types of social provisions. Attachment refers to feelings of intimacy, peace, and security (similar to emotional support); social integration denotes sense of belonging to a group with whom one shares common interests and social activities; opportunity for nurturance represents the support receiver providing care to others, such as children or senior family members; reassurance of worth refers to having others validate one’s competence and value; reliable alliance has to do with perceived access to assistance in times of need from others; and finally, guidance refers to having people available who can provide suggestions, solutions, and advice when needed (Cobb, 1979). According to Weiss’s theory, each type of support provision is embedded in a network of social connections, and multiple types of social provisions may occur through a single connection. Weiss further posited that people need all six types of social provisions, and if one type is deficient, people are at risk for experiencing social and/or emotional loneliness. This loneliness could subsequently lead to poor concentration, distress, tension, disturbed sleep, and disengagement, along with depression and generalized dissatisfaction (Weiss, 1974).

Weiss’s social provisions theory has application to understanding social support and well-being for people with MS. Research suggests that people with MS rely on a number of individuals in their social network to provide different forms of support as posited by this theory. Evidence supports that people who comprise the social networks of people with MS, such as professionals, family, friends, and partners, do indeed provide different forms of social support to serve a number of supportive functions (Costa, Sa, & Calheiros, 2012; Kouzoupis, Paparrigopoulos, Soldatos, & Papadimitriou, 2010). At the same time, the literature recognizes the benefits individuals derive as providers of social support (Plow, Finlayson, Gunzler, & Heinemann, 2015). For people with MS, the ability to offer social provisions through performing social roles (e.g., parenting, working, volunteering) is associated with greater self-esteem, better quality of life, and higher levels of coping self-efficacy related to living well with MS (Plow et al., 2015).

Much of the research applying and evaluating Weiss’s (1974) theory of social provisions uses the 24-item SPS developed by Cutrona and Russell (1987). The SPS has six subscales that align with Weiss’s six types of support provisions. In addition to evaluating perceived social support, the SPS takes into account social support that is offered by the individual. This scale’s emphasis on the bidirectional nature of social support makes it idiosyncratic among the many other measures of social support. This feature is important because reciprocal support is necessary for living together well, particularly in family relationships with an individual with chronic illness (Ek, Ternestedt, Andershed, & Sahlberg-Blom, 2011). Moreover, the provision of support by people facing challenges is also essential for mutual-aid and self-help support groups (Gottlieb & Bergen, 2010). Importantly, being able to offer social support stimulates individuals’ self-esteem and self-efficacy (Cutrona & Russell, 1987; Weiss, 1974).

Although there is support for the factorial and construct validity of the SPS (e.g., Cutrona & Russell, 1987), this scale has not been thoroughly validated for use with people with MS. Specifically, researchers have not yet examined the extent to which the six latent variables correspond with an overall, higher-order latent factor of social provisions for people with MS. Although some research has supported the relationship between the SPS global scale and quality of life and health indicators for people with MS (Motl, McAuley, & Snook, 2007; Vickrey et al., 1995), more research is needed to understand the relationship between the SPS subscales and measures of physical and psychological well-being. For this study, we hypothesized that the six factor structure of the SPS would be supported and that the SPS overall and subscale scores would have moderate to strong correlations with measures of life satisfaction, mental health, and self-efficacy, but small to moderate correlations with physical health status, including fatigue and pain, as measures of social support generally are found to have higher correlations with mental rather than physical health indicators (Chronister et al., 2008). Findings have the potential to support the use of the SPS with people with MS and provide a foundation for more focused examination and tailored intervention efforts involving social provisions among this population.

Method

Participants

This study involved a secondary analysis of existing baseline data from a previously completed study investigating changes in quality of life over time among people with MS (Motl, McAuley, Snook, & Gliottoni, 2009). Participants came from a convenience sample recruited through the Greater Illinois, Gateway, and Indiana chapters of the National MS Society. Recruitment occurred through (a) research announcements mailed to past study participants, (b) advertisements placed in each chapter’s MS Connection quarterly publication, and (c) email messages that were distributed to all registered members of the chapters. To be included in the study, individuals had to (a) have an established definitive diagnosis of MS, (b) be relapse free for the past 30 days, and (c) be ambulatory with minimal to no assistance. Initially, 511 people expressed interest in participating and 387 of them underwent screening. Twenty-seven individuals did not satisfy the inclusion criteria and 16 individuals declined participation. Informed consent documents and verification letters were sent to the remaining 344 individuals, and 300 consent forms were received. The response rate was 87.2% at this point. Eight additional individuals dropped out for unknown reasons, yielding a final sample of 292 individuals with MS.

The majority of the participants (n = 245) were female. Most (n = 246) reported relapsing-remitting MS, followed by secondary progressive MS (n =34) and primary progressive MS (n = 12). The mean age of the sample was 48.0 years (SD = 10.3, range = 20 – 69 years) and the average time since definitive diagnosis of MS was 10.3 years (SD = 7.9, range = 1 – 35 years). The sample was mostly Caucasian (94%), married (68%), and employed (53%). Over half (57.7%) were college graduates and another 28.0% reported some college education. Approximately two-thirds (67.7%) reported a median annual household income of greater than $40,000.

Instruments

Social Provisions Scale (SPS)

The SPS assesses the degree to which an individual perceives his or her social relationships to provide various dimensions of social support, including opportunities for the individual to provide support (Cutrona & Russell, 1987). It is a self-report questionnaire requiring approximately five minutes to complete. It includes 24 items rated on a four-point Likert-type scale with anchors of strongly disagree (1) and strongly agree (4). The scale includes six subscales based on Weiss’s (1974) social provisions theory: reliable alliance, attachment, nurturance, social integration, reassurance of worth, and guidance. Each subscale has four items: two positively-worded items describing the presence of a type of support and two negatively-worded items assessing the absence of a type of support. For example, on the attachment subscale two items are “I have close relationships that provide me with a sense of emotional security and well-being” and “I feel that I do not have close personal relationships with other people.” Cutrona and Russell (1987) used CFA to support the validity of the six factor structure of the SPS among college students, teachers, and nurses. They also recorded test-retest reliability coefficients ranging from .37 to .66 over a six-month period. The Cronbach’s alpha coefficients of the six factors ranged from .67 to .76, and items loaded on the respective factors supporting the construct validity of the scale (Cutrona & Russell, 1987). In addition, moderate to high correlations between the SPS and other measures of support provided evidence for the construct validity of the scale (Cutrona & Russell, 1987). Subsequent studies have further supported the internal consistency of the global scale and subscales of the SPS in a range of populations (e.g., Green, Furrer, & McAllister, 2007; McLean et al., 2014; Ribas & Lamb, 2010; Vogel & Wei, 2005). Additionally, a number of studies documenting correlations between the SPS and measures of well-being and physical health provide further evidence of the construct validity of the scale (e.g., Cutrona & Russell, 1987; Dlugonski & Motl, 2010; Jaracz et al., 2010; Mallinckrodt et al., 2012; Motl et al., 2007).

Satisfaction With Life Scale (SWLS)

The SWLS was designed to measure an individual’s perceived global life satisfaction across different life domains based on his/her values and standards (Diener, Emmons, Larsen, & Griffin, 1985; Pavot, Diener, Colvin, & Sandvik, 1991). The SWLS has five items (e.g., “In most ways my life is close to my ideal.”) rated on a seven-point Likert-type scale from one (strongly disagree) to seven (strongly agree). The SWLS has good internal consistency, test-retest reliability, and evidence of score validity (Diener et al., 1985; Pavot et al., 1991). The Cronbach’s alpha coefficient for the SWLS was .89 in the present study.

Short Form 12 (SF-12)

The SF-12 was used to measure perceived health-related quality of life (Ware, Kosinski, & Keller, 1996). The scale consists of twelve items, and depending on the item, response options range from a dichotomous “yes” or “no” response, to three-, and five-point rating scales (e.g., 1 = excellent to 5 = poor). Items include: “In general, would you say your health is excellent, very good, good, fair or poor?” and “Does your health now limit you a lot, limit you a little or not limit you at all?”. Ratings on the 12 items are summed to calculate a Physical Component Summary Scale (PCS) and a Mental Component Summary Scale (MCS) that range from 0 to 100. Scores are standardized from the general population (M = 50, SD = 10). Test-retest reliability estimates based on a two-week interval were .89 and .76 for the PCS and the MCS, respectively (Ware et al., 1996). Cronbach’s alpha coefficients for the PCS and MCS were .80 and .78, respectively.

Hospital Anxiety and Depression Scale (HADS)

The HADS is a subjective measure of anxiety and depressive moods (Zigmond & Snaith, 1983). The HADS contains two subscales measuring self-reported anxiety (e.g., “Worrying thoughts go through my mind.”) and depression (e.g., “I have lost interest in my appearance.”). Each subscale has seven items. This scale has been used in previous studies examining quality of life for people with MS (Janssens et al., 2003), and there is evidence of its score reliability and validity (Zigmond & Snaith, 1983). For the present study, the Cronbach’s alpha for the anxiety and depression components of the HADS were .83 and .82, respectively.

Multiple Sclerosis Self-Efficacy Scale (MSSE)

The MSSE was developed to assess perceived self-efficacy among people with MS. The measure has two subjective subscales related to function and control; each subscale has nine items rated on a scale of 10 (“very uncertain”) to 100 (“very certain”) (Schwartz, Coulthard-Morris, Zeng, & Retzlaff, 1996). The function subscale assesses an individual’s confidence with functional abilities (e.g., “walk 100 feet on flat ground.”); while the control subscale measures confidence with managing symptoms and coping with the demands of illness (e.g., “how certain are you that you can control your fatigue?”). In the present study, the Cronbach’s alpha for the function and control subscales were .79 and .95, respectively.

Fatigue Severity Scale (FSS)

The FSS was used to measure perceived fatigue (Krupp, LaRocca, Muir-Nash, & Steinberg, 1989) rated on a seven-point Likert type scale (1 = disagree to 7 = agree). The FSS has nine items that are combined to form an overall measure of a person’s severity of fatigue symptoms (e.g., “Fatigue interferes with my work, family, or social life.”). There is support for the internal consistency, test-retest reliability, and score validity of this scale (Krupp et al., 1989). The Cronbach’s alpha for the FSS was .93 in the present study.

Short-Form McGill Pain Questionnaire (SF-MPQ)

The SF-MPQ scale is comprised of a 15-item adjective checklist that captures subjective sensory and affective dimensions of pain (e.g., throbbing, sharp; Melzack, 1987). It is rated on a four-point Likert type scale (0 = none to 3 = severe). The scores from the items are summed to form a pain rating index. The SF-MPQ is internally consistent, appears to be reliable across time, and has evidence of score validity (Melzack, 1987). The Cronbach’s alpha for the SF-MPQ was .88 in the present study.

Patient Determined Disease Steps (PDDS )

The PDDS is a self-report measure based on response to a single item on a nine-point ordinal scale describing level of perceived disability (e.g., 0 = normal, 8= bedridden; Hadjimichael, Kerns, Rizzo, Cutter, & Vollmer, 2007). Scores from the PDDS have been found to be linearly and strongly correlated with physician-administered Expanded Disability Status Scale (EDSS) scores, providing evidence for the scale’s validity (Hadjimichael et al., 2007).

Procedure

After initial contact and screening, an informed consent document and a form-letter for verifying the participant’s diagnosis of MS were sent to all participants through the U.S. Postal Service (USPS), along with pre-stamped and pre-addressed envelopes for return postal service. The researchers called to ensure the participants received the documents, understood the directions, and signed the informed consent. Once the informed consent and MS verification were returned, the battery of questionnaires was sent to all participants through the USPS, along with a pre-stamped and pre-addressed envelope for return postal service. The researchers called to make sure the participants received the package and understood the directions. Participants then returned the study materials through the USPS. All questionnaires were checked for completeness. In the event of missing data, participants were contacted by a member of the research team to collect the data over the phone. All participants received $20 after returning the questionnaire battery.

Data Analysis

The data were analyzed with Mplus 7.0 (Muthén & Muthén, 2012) and the Statistical Package for the Social Sciences (SPSS, version 22.0). The measurement structure of the SPS was analyzed using CFA with the robust maximum likelihood (MLR) estimator in Mplus. The MLR estimator estimates standard errors and a chi-square test statistic that are robust to non-normality (Muthén & Muthén, 2012). Two models for the SPS were tested using CFA: (1) six, correlated first-order factors with four items per factor, and (2) one, second-order factor for describing the correlations among the six first-order factors from the previous model. Model-data fit was assessed using the chi-square goodness-of-fit test, chi-square/degree-of-freedom ratio, the comparative fit index (CFI), and the root mean square error of approximation (RMSEA) following guidelines presented by Weston, Gore, Chan, and Catalano (2008). A non-significant chi-square, a relative chi-square (χ2/df ) in the range of 1 to 3, and values greater than 0.90 for the CFI are considered an acceptable model fit, with a value of 0.95 or higher considered an excellent fit. For RMSEA, a value of less than 0.05 indicates a close fit and values of up to 0.08 indicate reasonable errors of approximation in the population (Weston et al., 2008). The critical ratio, which operates as a z-statistic in testing the significance of parameter estimates, was examined to determine if any SPS items could be deleted and modification indices were examined to determine whether additional model parameters could be estimated to provide a better model fit. Descriptive statistics were computed for all study variables using SPSS. Cronbach’s coefficient alphas were computed to evaluate the internal consistency reliability of the SPS and its subscales using SPSS. Pearson product-moment correlations were computed using SPSS to determine the relationships among SPS global scores and subscale scores with SWLS, HADS-Depression, HADS-Anxiety, MSSE, MCS, PCS, FSS, SF-MPQ, and PDDS.

Results

SPS Reliability and Factorial Validity

The first-order model with six correlated factors adequately described the pattern of variances and covariances for the 24 items of the SPS (χ2 = 610.04, p < .001, df = 230, CFI = .94. TLI = .93, RMSEA = 0.07). The factor loadings ranged from .45 to .94. The second-order model indicated that the variances and covariances among the six first-order factors were explained by a single, second-order factor of the overall social provisions construct (χ2 = 676.81, p < .001, df = 246, CFI = .93. TLI = .92, RMSEA = 0.08). The factor loadings for the second order factor ranged between .65 and .90. Table 1 summarizes the standardized factorial loadings and internal consistency coefficients of the SPS. The Cronbach’s alpha coefficients ranged from .66 to .81 for the six subscales (Table 1). The Cronbach’s alpha coefficient of the overall SPS was .89. There were no large modification indices suggesting model parameters that should be freely estimated.

Table 1
Factor Loadings for Items in the Specified Six-Factor Model

Given that the CFA analyses supported the original six-factor model, we calculated a global SPS score and the six subscale scores for our subsequent analyses. The bivariate correlations between the SPS global score and six subscale scores are provided in Table 2. The correlations among the subscales ranged from .30 to .63. The correlation coefficients between the global SPS and each subscale ranged from .63 to .78. The means, standard deviations, and ranges of scores are reported in Table 3.

Table 2
Bivariate Correlations between the SPS Total Scores and SPS Subscale Scores
Table 3
Descriptive Statistics for the Study Measures (N = 292)

Construct Validity of the SPS

Table 4 provides the correlations between the construct validity scales and the SPS scale. As hypothesized, the SPS total score had moderate to strong correlations with psychosocial outcomes, whereas the correlations with physical health outcomes, although statistically significant, were low to moderate in magnitude. This general pattern of higher correlations with psychosocial outcomes held for the subscales of the SPS as well. All SPS subscales, with the exception of the social integration subscale, were most strongly correlated with the SWLS and HADS-depression scale, suggesting that higher scores on most social provisions dimensions were most strongly associated with greater overall satisfaction with life and with lower symptoms of depression. For the social integration subscale, the highest correlations were with the HADS-depression and HADS-anxiety scales. There were only three correlations between SPS subscales and validation scales that were not statistically significant, and these were related to physical health outcomes. Specifically, the social integration subscale was not correlated with the SF-12 physical component score or with the PDDS; and the reliable alliance subscale was not correlated with the PDDS.

Table 4
Bivariate Correlations between the Social Provisions Scale Global Score and Subscales with Other Measures

Discussion

This study was the first to examine the utility of the SPS in a sample of people with MS. Our findings provide support for the psychometric strength of the SPS. We sought to investigate the construct validity of the SPS and its subscales by comparing them with measures of physical and psychosocial health commonly used with people with MS. Findings support the six-factor structure of the SPS based on Weiss’s (1974) theory. Additionally, the global social provisions score correlated strongly with the six subscales, thereby supporting that the SPS is consistent with Weiss’s social provisions theory. The correlation coefficients among the six subscale scores were not as high as those reported by Cutrona and Russell (1987) and the moderate correlation coefficients among the six subscale scores suggested that each social provisions factor represents related yet distinct types of social provisions. Furthermore, consistent with prior research (Chronister et al., 2006, 2008; Chronister, 2009; Cutrona & Russell, 1987; Haber et al., 2007), our findings showed the SPS global score and subscale scores had moderate to strong correlations with mental and psychosocial health indicators, and small to moderate correlations with measures of physical health. Additionally, the present study raises important considerations for clinical practice and future research.

Factorial Validity of the SPS

Results of the first and second order factor analysis validated that the SPS represents Weiss’s theoretical framework. This is consistent with Cutrona and Russell’s (1987) prior findings. The model fit index values in their study indicated that the six-factor oblique model fit the data well. The authors assumed the possibility of a second-order overall social provisions factor based on high correlation coefficients between six factors and then conducted a six-factor, second-order CFA. This second-order model fit the data well and they concluded that the SPS assesses six distinct types of social provisions and one overall construct of social provisions. However, this six-factor structure has not been consistently supported in the research. Mancini and Blieszner (1992) studied the factorial validity of the SPS among seniors aged 65 years and older, finding only four factors: intimacy, social integration, reassurance of worth, and opportunity for nurturance (the original SPS factors of attachment, guidance, and reliable alliance were collapsed into one factor labelled intimacy). Participants in the present study were 20 to 69 years old, while participants were all over 65 years old in Mancini and Blieszner’s study. As people age, the variety, quantity, quality, needs, and functions associated with individuals’ social networks likely change over time. Future studies to validate the SPS with people with MS over 65 years old is needed to examine if the six-factor structure is maintained.

Reliability of the SPS

The internal consistency findings of the overall SPS and its subscales were generally similar to previous internal consistency coefficients reported in the literature (Cutrona & Russell, 1987; Green et al., 2007; McLean et al., 2014; Ribas & Lamb, 2010; Vogel & Wei, 2005), suggesting that the individual items comprising each factor measure the same function of social provisions. Although Cutrona and Russell (1987) found support for the test-retest reliability of the SPS, the reserchers were unable to determine whether social provisions vary over time. Motl and Dishman (2004) however determined through a longitudinal study with adolescent females that the SPS had good cross-validity, stationarity, and stability over time. In terms of reliability over time for individuals with MS, when the disease progresses or disability increases, the dynamics of social provisions may change. Therefore, it would likely be valuable in clinical practice to periodically assess the status of social provisions for individuals with MS.

Construct Validity of the SPS

Similar to findings reported in existing studies (Chronister, 2009; Cutrona & Russell, 1987; Dlugonski & Motl, 2010; Jaracz et al., 2010; Mallinckrodt et al., 2012; Motl et al., 2007), our results indicate that the global SPS and its subscales have moderate to high correlations with mental and psychosocial health indicators and small to moderate correlations with physical health measures. Of the psychosocial measures used in the study, the SPS and its subscales were correlated most strongly with life satisfaction and depression. The results also suggest stronger associations between the global SPS scores and life satisfaction and depression than previously documented in the literature (Chronister, 2009; Cutrona & Russell, 1987; Dlugonski & Motl, 2010; Jaracz et al., 2010; Mallinckrodt et al., 2012; Motl et al., 2007), suggesting that for people with MS, the global social provisions construct may be particularly important for promoting life satisfaction and mitigating depression symptoms.

The reliable alliance and guidance subscales were strongly correlated positivly with life satisfaction and negatively with depression and moderately negatively correlated with fatigue and pain. According to Weiss (1974), guidance is regarded as informational/instrumental support, while reliable alliance is similar to tangible/material support. Some studies have found that informational/instrumental support helps manage physical health for people with chronic illnesses because such support usually comes directly from health professionals (Gottlieb & Bergen, 2010; Luszczynska, Sarkar, & Knoll, 2007; Nurullah, 2012). Similarly, our findings suggest that receiving informational or instrumental guidance appears to help people with MS cope with fatigue and chronic pain more effectively. Importantly, our findings show that perceiving more guidance is associated with lower levels of depression. This is particularly important for persons with MS because approximately half of those living with MS will experience major depression at some point (Sadovnick, Eisen, & Ebers, 1991; Siegert & Abernathy, 2005).

Notably, severity of disability was independent of reliable alliance. This indicates that reliable alliance from a core social tie (e.g., close family members, trustworthy friends) represents a basic social need, regardless of the level of disability severity. In addition, the uncertainty of MS and unpredictability of flare-ups may lead individuals with MS to seek out support to manage the condition despite disability severity. When individuals with MS relapse, they may need tangible or material support from the reliable alliance provision to get their immediate needs met.

Our findings show that attachment and social integration were strongly associated with life satisfaction, depression, and anxiety. Attachment and social integration provide individuals with comfort, security, happiness, and group identity oftentimes through social ties with their spouses/partners, family members, and friends (Weiss, 1974). Consistent with the existing literature (Chronister et al., 2006, 2008; Chronister, 2009; Cobb, 1979), we found that perceiving stronger attachment is correlated with higher life satisfaction and lower levels of depression. Attachment, a form of emotional support, is fundamental to individuals’ mental health (Chronister et al., 2006, 2008; Chronister, 2009; Cobb, 1979). As individuals with MS age and their level of disability increases, they express more needs related to family and desire opportunities for relationship counseling to maintain or improve their relationships with spouses/partners or other close ties (McCabe et al., 2015). Studies have shown that spouses/partners and family members report stress and frustration when they help individuals with MS cope with the condition, and that they feel anger and/or grief when they observe the progression of MS affecting their loved ones (Devins, Seland, Klein, Ebworthy, & Saary, 1993). When individuals with MS perceive a deteriorated relationship with their family members, they are more likely to become depressed and angry and experience perceived loss of control (McCabe & McKern, 2002). Conversely, healthy attachments with their spouses/partners (e.g., establishing friendly and comfortable relationships) help individuals with MS cope with the disease and maintain functioning (Ghafari, Khoshknab, Norouzi, & Mohamadi, 2014).

Social integration had the strongest negative correlations with depression and anxiety and was not associated with disability and physical health. These findings suggest that belonging, social identity, and peer-support play an important role in the mental health of persons with MS, regardless of the severity level of disability. This aligns with the literature reporting that people with MS attending MS support groups report learning how to cope with MS from peers in similar situations (Jean, Paul, & Beatty, 1999). Interestingly, compared to seniors with MS, young adults with MS have been found to more often seek out peer support groups to address a greater variety of needs (e.g., job, MS treatment), meeting times, and modes of communication (e.g., Skype, phone, social media; Krokavcova et al., 2008). Additionally, Krokavcova and colleagues (2008) noted that individuals with MS had fewer friends and less contact from social networks. Yet, belonging to a peer cohort is considered an important component for helping persons with MS adjust to living with a disability (Rudick, Miller, Cough, Gragg, & Farmer, 1992).

The reassurance of worth subscale was strongly related to life satisfaction and depression, and was moderately related to self-efficacy for MS management. It is noteworthy that reassurance of worth had small to moderate effect sizes with fatigue, chronic pain, severity of disability, and general physical health. This suggests that individuals’ confidence in executing daily role functions may be correlated with their perception of self-worth or self-esteem. Weiss (1974) stated that reassurance of worth can be beneficial for individuals experiencing either low or high levels of stress, because it increases individuals’ self-efficacy and self-esteem, and can moderate the process of causal attributions. Self-esteem, defined as an individual’s perceived worth, is developed in part from opportunities to perform daily roles and social functions (e.g., being a worker, partner, friend, family member, parent, etc.; Rosenberg, 1989).

However, MS can present challenges to performing social functions and consequently may reduce self-esteem. Low self-esteem has been correlated with depression, unhappiness, and poor quality of life among people with MS (Dlugonski & Motl, 2012; Kirana, Rosen, & Hatzichristou, 2009). Importantly, perceived self-worth moderates the impact of diseases, like MS, and facilitates positive coping (Lazarus, 1966). Persons with MS reporting higher self-esteem have been shown to employ more problem-focused coping, which is associated with positive adjustment to disability and well-being (Lazarus & Folkman, 1984; O’Brien, 1993). Hence, it is important for health-related professionals to inquire whether individuals with MS have difficulties performing their life roles and responsibilities in order to reassure or improve their perception of self-worth. Health-related professionals may also need to provide education to family members and co-workers about reasonable expectations and potential accommodations to assist individuals with MS to fulfill their role functions or work duties.

Being able to provide nurturance, or being able to help others, is one of the ways to build self-worth. The opportunity for nurturance subscale had moderate to high correlations with life satisfaction and depression and small to moderate correlations with fatigue. This opportunity for nurturance factor was also adopted in the Personal Resources Questionnaire (PRQ; Brandt & Weinert, 1981), which has five subscales—namely, intimacy, social integration, worth, assistance, and nurturance. Brandt and Weinert (1981) studied 149 spouses of individuals with MS, and because the nurturance subscale had only small correlations with the other four subscales of the PRQ, authors concluded that nurturance seemed to be an independent dimension. By contrast, the participants in the present study were individuals with MS as opposed to family members.

The opportunity of nurturance subscale had moderate to high correlations with the other five subscales of the SPS, indicating that there was some level of overlap among the six subscales in this sample. Further, this suggests that when individuals with MS are able to provide support to their loved ones, they not only perceive more self-value but also indicate perceptions of receiving more support provisions. Although social support is typically considered as an individual’s perceived availability or receipt of support, these findings highlight the importance of conceptualizing social support as bidirectional. In other words, the positive benefits associated with opportunities to provide support to others should not be overlooked by clinicians and intervention strategies to improve well-being for people with MS.

Limitations

The following limitations of this study should be considered. First, the sample may not be generalizable to all people with MS. The participants in this study primarily consisted of Caucasian women with relapsing-remitting MS. Although this is generally consistent with the national demographics of MS (NMSS, 2014), we recommend that future research engage a more diverse sample which would allow for a broader generalization of the findings among less representative groups of individuals with MS (e.g., men, minority populations). A prior study found different factors of the SPS in seniors aged 65 years and above (Mancini & Blieszner, 1992), while the majoriy of the participants in our stud were younger than ages 65 years. We recommend that future research recruit seniors with MS to assess the extent to which the six factor structure holds. Further, the recruited participants in the present study were all able to walk. Including only participants with walking ability may limit the range of disability severity. Overall, the majority of participants were middle class. It is possible that lower social economic status and education levels may influence opportunities to receive and/or offer social provisions. Research focusing on validation of this scale in heterogeneous groups of individuals with MS will provide further support for the measurement structure and applications. Second, all measures in the study were based on self-report collected at the same time; results might therefore be subject to response bias and overestimation of validity coefficients. Further, assumptions regarding causality cannot be made given the cross-sectional nature of the study. Additionally, we recommend the use of longitudinal CFA to examine pattern invariance, metric invariance, and intercept invariance of the SPS over time, especially across human developmental stages. Finally, participants in this study were self-selected rather than being randomly selected, which is another source of potential bias that should be considered.

Conclusions & Future Directions

The SPS is a useful instrument based on Weiss’s theory that assesses six types of social provisions, incorporating both provisions that are perceived to be supportive and provisions provided by the support receiver. In this study, results supported the factorial and construct validity of the SPS in a sample of individuals with MS. Findings of the current study demonstrate the potential utility of the SPS in clinical practice as a screening tool to assess social support for people with MS. Findings also highlight the importance of recognizing the functional specificity of interpersonal relationships embedded in social ties. If an individual experiences a deficiency in one type of social provision, he or she may not be able to compensate with other kinds of social provisions based on Weiss’s theory (1974). Moreover, clinicians should recognize that building and maintaining various social ties may be more helpful than securing limited types of social ties. Therefore, it is important to screen for the social provisions status of individuals with disabilities, like MS, by using a scale with sound psychometric characteristics. Our results support the SPS as a valid reflection of Weiss’s six dimensions of social provisions and support the validity of its use with people with MS.

Although correlations cannot explain causal effects, our findings suggest that distinct types of social provisions may be more effective at mitigating physical impairments, symptoms, and secondary health and mental health conditions (e.g., depression, anxiety, and chronic pain) due to MS. Future research is needed to examine the directionality of these relationship more closely. Additionally, our results indicate that social provisions may directly and/or indirectly affect health and quality of life. Future research is needed to better understand the extent to which distinct social provision types mediate associations among biopsychosocial interventions, self-efficacy of MS self-management, and rehabilitation outcomes. Future research should also examine the external validity of the SPS in more diverse samples of people with MS with regard to age, severity of disability, gender, and minority status. Further validation of a short-form of the SPS for people with MS would be beneficial and allow for more comprehensive research and screening strategies through the inclusion of more measures in a single study or clinic when time, participant, or resource constraints need to be considered. Finally, there is also a need for future research to incorporate longitudinal designs to examine the predicative validity, pattern invariance, metric invariance, and intercept invariance of the SPS.

Impact

  • This study was the first to examine the factorial validity of the Social Provisions Scale (SPS) in a sample of people with MS.
  • Results support the six-factor structure of the SPS, namely attachment, social integration, reassurance of worth, reliable alliance, guidance, and opportunity for nurturance, and demonstrate that social support can be conceptualized as bidirectional in nature—i.e., individuals perceive and provide support. Findings also provide evidence for the construct validity of the SPS for people with MS.
  • Clinicians can use the SPS as a screening tool for people with MS to assess specific social support needs and capabilities.

Acknowledgments

This research was supported from the United States Department of Health and Human Services, National Institutes of Health, National Institute of Neurological Diseases and Stroke (Grant NS054050).

Contributor Information

Chung-Yi Chiu, University of Illinois at Urbana-Champaign.

Robert W. Motl, University of Illinois at Urbana-Champaign.

Nicole Ditchman, Illinois Institute of Technology.

References

  • Bandura A. Self-efficacy mechanism in human agency. American Psychologist. 1982;37(2):122–47.
  • Benito-León J, Morales JM, Rivera-Navarro J, Mitchell A. A review about the impact of multiple sclerosis on health-related quality of life. Disability and Rehabilitation. 2003;25(23):1291–1303. [PubMed]
  • Brandt PA, Weinert C. The PRQ—a social support measure. Nursing Research. 1981;30(5):277–280. [PubMed]
  • Buljevac D, Hop WC, Reedeker W, Janssens AC, van der Meché FG, van Doorn PA, Hintzen RQ. Self reported stressful life events and exacerbations in multiple sclerosis: Prospective study. British Medical Journal. 2003;327(7416):646–650. [PMC free article] [PubMed]
  • Chronister J. Chronister J. Social support and rehabilitation. In: Chan F, Cardoso E, Chronister J, editors. Understanding psychosocial adjustment to chronic illness and disability. New York, NY: Spring Publishing Company; 2009. pp. 149–174.
  • Chronister JA, Johnson EK, Berven NL. Measuring social support in rehabilitation. Disability and Rehabilitation. 2006;28(2):75–84. [PubMed]
  • Chronister J, Chou CC, Frain M, Cardoso E. The relationship between social support and rehabilitation related outcomes: A meta-analysis. Journal of Rehabilitation. 2008;74:16–32.
  • Cobb S. Social support as a moderator of life stress. Psychosomatic Medicine. 1976;38(5):300–314. [PubMed]
  • Cobb S. Social support and health through the life course. In: Riley MW, editor. Aging from birth to death: Interdisciplinary perspectives. Boulder, C: Westview Press; 1979. pp. 93–106.
  • Cohen S, Gottlieb BH, Underwood LG. Social relationships and health. In: Cohen S, Underwood L, Gottlieb BH, editors. Social support measurement and intervention: A guide for health and social scientists. New York, NY: Oxford University Press; 2000. pp. 3–25.
  • Compston A, Coles A. Multiple sclerosis. Lancet. 2008;372:25–31. [PubMed]
  • Costa DC, Sa MJ, Calheiros JM. The effect of social support on the quality of life of patients with multiple sclerosis. Arquivos de Neuro-Psiquiatria. 2012;70:108–113. [PubMed]
  • Cutrona CE, Russell DW. The provisions of social relationships and adaptation to stress. Advances in Personal Relationships. 1987;1:37–67.
  • Devins GM, Seland TP, Klein G, Ebworthy SM, Saary MJ. Stability and determinants of psychological well-being in multiple sclerosis. Rehabilitation Psychology. 1993;38:11–26.
  • Diener E, Emmons RA, Larsen RJ, Griffin S. The satisfaction with life scale. Journal of Personality Assessment. 1985;49(1):71–75. [PubMed]
  • Dlugonski D, Motl RW. Possible antecedents and consequences of self-esteem in persons with multiple sclerosis: Preliminary evidence from a cross-sectional analysis. Rehabilitation Psychology. 2012;57(1):35–42. [PubMed]
  • Ek K, Ternestedt BM, Andershed B, Sahlberg-Blom E. Shifting life rhythms: Couples' stories about living together when one spouse has advanced chronic obstructive pulmonary disease. Journal of Palliative Care. 2011;27(3):189–197. [PubMed]
  • Ghafari S1, Khoshknab MF, Norouzi K, Mohamadi E. Spousal support as experienced by people with multiple sclerosis: A qualitative study. The Journal of Neuroscience Nursing. 2014;46(5):15–24. [PubMed]
  • Giesser BS. Diagnosis of multiple sclerosis. Neurologic Clinics. 2011;29(2):381–388. [PubMed]
  • Gottlieb BH, Bergen AE. Social support concepts and measures. Journal of Psychosomatic Research. 2010;69:511–520. [PubMed]
  • Green B, Furrer C, McAllister C. How do relationships support parenting? Effects of attachment style and social support on parenting behavior in an at-risk population. American Journal of Community Psychology. 2007;40(1–2):96–108. [PubMed]
  • Haber MG, Cohen JL, Lucas T, Baltes BB. The relationship between self-reported received and perceived social support: A meta-analytic review. American Journal of Community Psychology. 2007;39(1–2):133–144. [PubMed]
  • Hadjimichael O, Kerns RB, Rizzo MA, Cutter G, Vollmer T. Persistent pain and uncomfortable sensations in persons with multiple sclerosis. Pain. 2007;127:35–41. [PubMed]
  • Heaney CA, Israel BA. Social support and social networks. In: Glanz K, Rimer B, Lewis F, editors. Health Behavior and Health Education: Theory, Research, and Practice. 3. San Francisco, CA: Jossey-Bass; 2002. pp. 185–209.
  • Janssens AC, van Doorn PA, de Boer JB, Kalkers NF, van der Meche FG, Passchier J, Hintzen RQ. Anxiety and depression influence the relation between disability status and quality of life in multiple sclerosis. Multiple Sclerosis Journal. 2003;9(4):397–403. [PubMed]
  • Jaracz K, Pawlak M, Górna K, Kołcz B, Wołoszyn D, Kozubski W. Quality of life and social support in patients with multiple sclerosis. Neurologia i Neurochirurgia Polska. 2010;44(4):358–365. [PubMed]
  • Jean VM, Paul RH, Beatty WW. Psychological and neuropsychological predictors of coping patterns by patients with multiple sclerosis. Journal of Clinical Psychology. 1999;55:21–26. [PubMed]
  • Kirana PS, Rosen R, Hatzichristou D. Subjective well-being as a determinant of individuals’ responses to symptoms: A biopsychosocial perspective. International Journal of Clinical Practice. 2009;63:1435–1445. [PubMed]
  • Kouzoupis AB, Paparrigopoulos T, Soldatos M, Papadimitriou GN. The family of the multiple sclerosis patient: a psychosocial perspective. Internation Review of Psychiatry. 2010;22(1):83–89. [PubMed]
  • Krokavcova M, van Dijk JP, Nagyova I, Rosenberger J, Gavelova M, Middel B, Gdovinova Z, Groothoff JW. Social support as a predictor of perceived health status in patients with multiple sclerosis. Patient Education and Counseling. 2008;73(1):159–165. [PubMed]
  • Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale: Application to patients with multiple sclerosis and systemic lupus erythematosus. Archives of Neurology. 1989;46(10):1121–1123. [PubMed]
  • Lakey B, Cohen S. Support theory and measurement. In: Cohen S, Underwood L, Gottlieb BH, editors. Social support measurement and interventions: A guide for health and social scientists. New York, NY: Oxford University Press; 2000. pp. 29–52.
  • Lazarus RS. Psychological stress and the coping process. New York, NY: McGraw- Hill; 1966.
  • Lazarus RS, Folkman S. Stress, appraisal, and coping. New York, NY: Springer; 1984.
  • Lovera J, Reza T. Stress in multiple sclerosis: Review of new developments and future directions. Current Neurology and Neuroscience Reports. 2013;13:398–406. [PubMed]
  • Luszczynska A, Sarkar Y, Knoll N. Received social support, self-efficacy, and finding benefits in disease as predictors of physical functioning and adherence to antiretroviral therapy. Patient Education and Counseling. 2007;66(1):37–42. [PubMed]
  • Mallinckrodt B, Armer JM, Heppner PP. A threshold model of social support, adjustment, and distress after breast cancer treatment. Journal of Counseling Psychology. 2012;59(1):150–160. [PMC free article] [PubMed]
  • Mancini JA, Blieszner R. Social provisions in adulthood: Concept and measurement in close relationships. Journal of Gerontology. 1992;47:14–20. [PubMed]
  • Matti AI, McCarl H, Klaer P, Keane MC, Chen CS. Multiple sclerosis: Patients' information sources and needs on disease symptoms and management. Patient Preference Adherence. 2010;4:157–161. [PMC free article] [PubMed]
  • McCabe MP, McKern S. Quality of life and multiple sclerosis: Comparison between people with MS and people from the general population. Journal of Clinical Psychology in Medical Settings. 2002;9:287–295.
  • McCabe MP, Ebacioni KJ, Simmons R, McDonald E, Melton L. Unmet education, psychological and peer support needs of people with multiple sclerosis. Journal of Psychomatic Research. 2015;78(1):82–87. [PubMed]
  • McLean AM, Jarus T, Hubley AM, Jongbloed L. Associations between social participation and subjective quality of life for adults with moderate to severe traumatic brain injury. Disability and Rehabiliation. 2014;36(17):1409–1418. [PubMed]
  • Melzack R. The short form McGill Pain Questionnaire. Pain. 1987;30:191–197. [PubMed]
  • Mitchell AJ, Benito-León J, Gonzalez JMM, Rivera-Navarro J. Quality of life and its assessment in multiple sclerosis: Integrating physical and psychological components of well-being. The Lancet. Neurolology. 2005;4:556–566. [PubMed]
  • Motl RW, McAuley E, Snook EM, Gliottoni RC. Physical activity and quality of life in multiple sclerosis: Intermediary roles of disability, fatigue, mood, pain, self-efficacy and social support. Psychology Health and Medicine. 2009;14(1):111–124. [PMC free article] [PubMed]
  • Motl RW, Dishman RK. Measuring social provisions for physical activity among adolescent black and white girls. Educational and psychological measurement. 2004;64(4):682–706.
  • Motl R, McAuley E, Snook E. Physical activity and quality of life in multiple sclerosis; possible roles of social support, self-efficacy, and functional limitations. Rehabilitation Psychology. 2007;52(2):143–151.
  • Muthén LK, Muthén BO. Mplus user’s guide. 7. Los Angeles, CA: Muthén & Muthén; 2012.
  • National Multiple Sclerosis Society. What is MS? 2014 Retrieved from: http://www.nationalmssociety.org/What-is-MS.
  • Nurullah AS. Received and provided social support: a review of current evidence and future directions. American Journal of Health Studies. 2012;27(3):173–188.
  • O'Brien MT. Multiple sclerosis: The relationship among self-esteem, social support, and coping behavior. Applied Nursing Research. 1993;6(2):54–63. [PubMed]
  • Pavot W, Diener E, Colvin CR, Sandvik E. Further validation of the Satisfaction with Life Scale: Evidence for the cross-method convergence of well-being measures. Journal of Personality Assessment. 1991;57(1):149–161. [PubMed]
  • Plow MA, Finlayson M, Gunzler D, Heinemann AW. Correlates of participation in meaningful activities among people with multiple sclerosis. Journal of Rehabilitation Medicine. 2015;47(6):538–545. [PMC free article] [PubMed]
  • Ribas A, Lam C. Social support and quality of life among latinos with mental illness. The Journal of Nervous and Mental Disease. 2010;198(2):137–143. [PubMed]
  • Rosenberg M. Society and the adolescent self-image. Middletown, CT, England: Wesleyan University Press; 1989.
  • Rudick RA, Miller D, Cough JD, Gragg LA, Farmer RG. Quality of life in multiple sclerosis: Comparison with inflammatory bowel disease and rheumatoid arthritis. Archives of Neurology. 1992;49:1237–1242. [PubMed]
  • Sadovnick A, Eisen K, Ebers G. Cause of death in patients attending MS clinics. Neurology. 1991;41:1193–1196. [PubMed]
  • Schwartz CE, Coulthard-Morris L, Zeng Q, Retzlaff P. Measuring self-efficacy in people with multiple sclerosis: A validation study. Archives of Physical Medicine and Rehabilitation. 1996;77(4):394–398. [PubMed]
  • Siegert RJ, Abernathy DA. Depression in multiple sclerosis: A review. Journal of Neurology, Neurosurgery, and Psychiatry. 2005;76(4):469–475. [PMC free article] [PubMed]
  • Stuifbergen AK, Seraphine A, Roberts G. An explanatory model of health promotion and quality of life in chronic disabling conditions. Nursing Research. 2000;49:122–129. [PubMed]
  • Suh Y, Weikert M, Dlugonski D, Sandroff B, Motl RW. Physical activity, social support, and depression: Possible independent and indirect associations in persons with multiple sclerosis. Psychology, Health and Medicine. 2012;17(2):196–206. [PubMed]
  • Tawalbeh LI, Ahmad MM. Personal resource questionnaire: A systematic review. Western Journal of Nursing Research. 2013;21(3):170–177. [PubMed]
  • Thoits PA. Conceptual, methodological, and theoretical problems in studying social support as a buffer against life stress. Journal of Health and Social Behavior. 1982;23(2):145–159. [PubMed]
  • Thoits PA. Social support as coping assistance. Journal of Counseling and Clinical Psychology. 1986;54:416–423. [PubMed]
  • Thompson RA. Preventing child maltreatment through social support: A critical analysis. Thousand Oaks, CA: Sage; 1995.
  • Vickrey BG, Hays RD, Harooni R, Myers LW, Ellison GW. A health-related quality of life measure for multiple sclerosis. Quality of Life Research. 1995;4(3):187–206. [PubMed]
  • Vogel D, Wei M. Adult attachment and help-seeking intent: The mediating roles of psychological distress and perceived social support. Journal of Counseling Psychology. 2005;52(3):347–357.
  • Wallston B, Alagna S, DeVellis B, DeVellis R. Social support and physical health. Health Psychology. 1983;2:367–392.
  • Ware J, Jr, Kosinski M, Keller SD. A 12-item short-form health survey: Construction of scales and preliminary tests of reliability and validity. Medical Care. 1996;34(3):220–233. [PubMed]
  • Weiss RS. The provisions of social relationships. In: Rubin Z, editor. Doing unto others. Englewood Cliffs, NJ: Prentice-Hall; 1974. pp. 17–26.
  • Weston R, Gore P, Chan F, Catalano D. An introduction to using structural equation models in rehabilitation psychology. Rehabilitation Psychology. 2008;53(3):340–356.
  • Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica. 1983;67(6):361–370. [PubMed]