RESEARCH ARTICLE
Family Functioning, Marital Satisfaction and Social
Support in Hemodialysis Patients and their Spouses
Hong Jiang1, Li Wang2, Qian Zhang1, De-xiang Liu1, Juan Ding1, Zhen Lei1, Qian Lu3
& Fang Pan1*†
1
Department of Medical Psychology, Shandong University School of Medicine, Jinan, Shandong, China
Kidney Disease Centre, Jinan Central Hospital Affiliated to Shandong University, Jinan, Shandong, China
3
Department of Psychology, University of Houston, Houston, Texas, USA
2
ABSTRACT
A growing number of studies have demonstrated the importance of marital quality among patients undergoing
medical procedures. The aim of the study was to expand the literature by examining the relationships between
stress, social support and family and marriage life among hemodialysis patients. A total of 114 participants,
including 38 patients and their spouses and 38 healthy controls, completed a survey package assessing social
support, stress, family functioning and marital satisfaction and quality. We found that hemodialysis patients and
spouses were less flexible in family adaptability compared with the healthy controls. Patients and spouses had more
stress and instrumental social support compared with healthy people. Stress was negatively associated with marital
satisfaction. Instrumental support was not associated with family or marital outcomes. The association between
marital quality and support outside of family was positive in healthy individuals but was negative in patients and
their spouses. Family adaptability was positively associated with support within family as perceived by patients
and positively associated with emotional support as perceived by spouses. In conclusion, findings suggest that social
support may promote adjustment depending on the source and type. Future research should pay more attention to
the types and sources of social support in studying married couples. Copyright © 2014 John Wiley & Sons, Ltd.
Received 31 October 2012; Revised 12 August 2013; Accepted 12 September 2013
Keywords
family functioning; marital quality; hemodialysis; stress; social support
*Correspondence:
#
Professor Fang Pan, Department of Medical Psychology, Shandong University School of Medicine, 44 , Wenhua Xi Road, Jinan, Shandong,
250012, China.
†
Email: panfang@sdu.edu.cn
Published online 28 January 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/smi.2541
Introduction
A growing number of studies suggest the importance of
family function and marital adjustment among patients
with chronic diseases (Clare et al., 2012; Pereira, Daibs,
Tobias-Machado, & Pompeo, 2011; Tadros et al.,
2011). End-stage renal disease (ESRD) is one of the
chronic diseases causing a high level of disability in
different domains of the patients’ lives, leading to stress
reactions (Abraham, Venu, Ramachandran, Chandran,
& Raman, 2012; Edgell et al., 1996). Several studies
showed that ESRD had a negative impact on family
functioning (Anthony et al., 2010; Park et al., 2012),
but few link the stress reaction, social support and
patients’ family function and marital state (de Paula,
Nascimento, & Rocha, 2008; Watson, 1997). The goal
of this study was to investigate the family and marital
166
life of hemodialysis patients with ESRD using a stress
and social support framework.
The theoretical framework of stress and coping
proposes that stress is a two-way process; the environment produces stressors and the individual finds
ways to deal with them (Folkman, 1984; Folkman &
Lazarus, 1983). Stress occurs when environmental
demands exceed personal resources for coping with
the demand (Manne & Sandler, 1984; Coyne &
Downey, 1991; Ahlert & Greeff, 2012). Cognitive
appraisal is central to the stress and coping processes as it determines how an event is perceived
and, therefore, operates as an essential mediator
between the event and the outcome. It should be
noted that chronic disease and treatment can cause
stress, which will have a negative impact on family function and marital satisfaction (Myaskovsky et al., 2005).
Stress Health 31: 166–174 (2015) © 2014 John Wiley & Sons, Ltd.
H. Jiang et al.
Studies have shown that patients with ESRD
undergo serious stress experiences (Cukor et al., 2007;
Finkelstein & Finkelstein, 2000). Patients with ESRD
often go through hemodialysis therapy, an expensive
and time-intensive treatment requiring fluid and
dietary restrictions. Long-term dialysis therapy could
result in dependence on caregivers, a loss of freedom,
and family members and partners of patients having
to adjust the schedule of treatment and also experiencing stress symptoms (Lin, Lee, & Hicks, 2005). Hemodialysis impacts every life aspect of patients and their
spouses. Studies suggested that family members of
hemodialysis patients are faced with lower quality of
life, more mental health problems and potential complications and disruption of family life (AL-Jumaih,
Al-Onazi, Binsalih, Hejaili, & Al-Sayyari, 2011; Al Eissa
et al., 2010; Reynolds, Garralda, Jameson, & Postlethwaite,
1988; Sathvik, Parthasarathi, Narahari, & Gurudev, 2008).
Patients with ESRD and their spouses often have
stress reactions and complex adaptation in couple
relationships (Khaira et al., 2012). But, there are
few studies focused on the relationship between
stress and family and marital adjustment of patients
on dialysis and their spouses.
Increasing evidence addresses the role of social
support in the course of chronic disease as a protective
factor. Social support could reduce the level of negative
emotion and physiological response, improving the
health state of the body (Tavallaii et al., 2009). Social
support is defined as the perception that an individual
is a member of a network in which one can give and
receive affection, help and obligation (Untas et al.,
2011). It can be received from family members, friends,
colleagues and medical personnel. Greater social
support has been linked to better health outcomes in
community and clinical samples (Cohen et al., 2007).
Most of studies have examined the relationship between social support and patient adherence to medical
care as well as quality of life (Christensen et al., 1992;
Kara, Caglar, & Kilic, 2007; Thong, Kaptein, Krediet,
Boeschoten, & Dekker, 2007; Kutner, Zhang, McClellan,
& Cole, 2002; Helgeson, 2003; Tell et al., 1995). Those
studies showed a strong correlation between perceived
social support and several measures of health-related
quality of life in dialysis patients. However, there is less
information about the association between social
support and family and marital adjustment in dialysis
patients. Therefore, it is important to examine the
functioning of social support on family and marital life
among ESRD patients.
Previous studies indicated that individuals with
ESRD perceiving more social and family support have
been associated with lower mortality risks (Christensen,
Wiebe, Smith, & Turner, 1994; Kimmel et al., 1998).
Seeking social support during stressful times could
expand the family bond and enhance the relationship between family members and their relatives (McLean &
Hales, 2010; Tezel, Karabulutlu, & Sahin, 2011). For
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Family and Marital Life in Hemodialysis Patients
example, parents in one study reported increased closeness with family and greater bonding between the child
and his or her mother when social support was sought
(de Paula et al., 2008). Therefore, it has possibility that
patients on dialysis and spouses would receive increased
social support; this social support in turn would be
associated with better adjustment in family and marital
life according to stress theory.
Family function and marital satisfaction play an
important role in quality of life amongst hemodialysis
patients (Anthony et al., 2010; Park et al., 2012).
Assessments of both family function and quality of
marriage can yield basic information for psychological
family intervention. The circumflex model of family
functioning characterizes families on two orthogonal
dimensions: cohesion and flexibility (adaptability)
(Olson, 1986). Cohesion refers to the emotional bonds
between family members; flexibility refers to the quality
and expression of the family’s leadership, organization,
roles and relationship rules. Well-functioning families
are considered balanced and fall mid-range on each
dimension. Poorly functioning families are considered
unbalanced on these dimensions, falling either low (e.g.
disengaged and rigid) or high (enmeshed and chaotic)
on these characteristics. Over the family life cycle and
in response to stress, families are expected to shift along
these dimensions in predictable ways (Cervera, 1994;
García-Huidobro, Puschel, & Soto, 2012). Therefore, in
the current study, in addition to assessing marital
satisfaction and quality, we assessed family functioning
factors (i.e. family cohesion and adaptability) as indicators of adjustment.
Furthermore, previous studies regarding social support
and adjustment have revealed mixed findings. One study
showed a strong correlation between perceived social
support and several measures of health-related quality of
life in dialysis patients (Helgeson, 2003), whereas a crosssectional study of black and white women and men did
not find such results (Tell et al., 1995). These findings
suggest the importance of conducting additional studies
among non-white samples.
In this study, we planned to investigate the relationships between stress, social support, family functioning
and marital quality among Chinese dialysis patients.
We also investigated whether the level of stress, perceived
social support, family functioning and marital quality
among patients and their spouses differ compared with
healthy individuals. Because long-term dialysis is a stressful event, we hypothesized that hemodialysis patients
would experience higher levels of stress than their
spouses, who would experience higher levels of stress
than healthy controls (hypothesis 1). Because stress
may elicit social support and extended family members
were more likely to provide social support to patients,
we also hypothesized that patients and their spouses
would receive more social support than healthy controls
(hypothesis 2). Because families under stress may have
limited resources for maintaining family and marital
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Family and Marital Life in Hemodialysis Patients
life, patients and spouses would have lower family life
and marriage quality compared with healthy controls
(hypothesis 3). We also hypothesized that lower levels
of stress and higher levels of social support would be
associated with higher family and marital quality
(hypothesis 4). Furthermore, because social support
could be given financially, emotionally, by spending
time with the patient and so on, and social support
could be from family and outside of the family, we
would also explore whether the type and sources of
social support mattered.
Method
Participants
Patients were recruited from dialysis centre of Medical
College Hospital in Jinan, China from May, 2010 to
July, 2011. The criteria for inclusion were: ESRD
patients over 22 years of age and of either sex; regular
hemodialysis twice a week for at least 6 months; able
to speak or read the local language and able to consent
to participate in the study. In addition, their spouses
agreed to participate in the same study. Patients were
excluded if they had malignant tumours or multiple
organ system failure, major hearing impairment
(inability to hear loud speech even with a hearing aid),
rejection episodes or underwent any major surgical
interventions in the previous 3 months. Healthy individuals in the control group were matched based on major
demographic factors and were recruited from the general
population by conducting a survey in health centre of the
same hospital and on a voluntary basis, excluding those
with major diseases such as hypertension, coronary heart
disease and diabetes. The control group served as a control for both the patients group and spouses group. The
residing area of all subjects was in Jinan City (urban population). Approval for the study was obtained from the
Institutional Ethics Committee of Medical College of
Shandong University. Written consent was obtained
from each subject. The purpose of the study, voluntary
participation, confidentiality and freedom to discontinue
at any time without being left untreated, were understood by patients prior to their participation. Standardized questionnaires were used to obtain data. Figure 1
showed the sampling and flow of the study.
Measurements
Family functioning: family cohesion and
flexibility
The Chinese version of the family adaptability and
cohesion evaluation scales (FACES II-CV) was used
to rate actual experience of family function (Phillips,
Zheng, & Zhou, 1993). There are two subscales of
FACES II-CV in evaluating family cohesion and flexibility, respectively. Test-retest reliability ranged from
0.84 to 0.91 and Cronbach’s alpha coefficients are
0.85 and 0.73, respectively. Family cohesion is the emotional bonding that family members have with each
other; the dimension includes items such as ‘family
members try to support each other when the family
faces difficulty’ and ‘family members enjoy free time
Figure 1. Sampling and flow of study
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H. Jiang et al.
together’. Family flexibility is the ability of the family
system to adjust its rules, provide structure and adjust
relationship patterns in response to changes; the
subscale included such items as: ‘Each family member
is involved in making major family decisions’ and ‘we
like to use a new method to solve the problem’. The
items were rated on a five point scale. Moderate scores
in cohesion and flexibility sub-dimensions indicate a
balanced family. Extreme lower or higher scores indicate an imbalanced family. Family cohesion is divided
into four types, including loose, free, intimate and
entangled, and family flexibility is divided into four
types as well: irregular, flexible, regular and inflexible,
according to the determination point of the mean and
one standard deviation score.
Martial satisfaction and quality
The Chinese version of the marital inventory ENRICH
(Evaluating & Nurturing Relationship. Issues, Communication & Happiness) was used to judge the degree of
satisfaction in marriage (Cao, Jiang, Li, Hui Lo, & Li,
2013). ENRICH included 12 factors: marital satisfaction, personality compatibility, the couple exchange,
conflict resolution, economic arrangements, leisure
activities, sexual life, children and marriage, the relationship between friends and relatives and the role of
equality and belief consistency. The validity and reliability of ENRICH shows internal consistency (alpha)
ranges from 0.68 to 0.86 in every dimension and testretest correlation coefficients ranges from 0.77 to
0.96. The discrimination reliability is from 85%–90%.
Global measurement of 12 factors and marital satisfaction is used in this study, with a higher score indicating
better marital quality and marital satisfaction (Fowers
& Olson, 1989).
Stress reaction
The Chinese version of the Stress Responses Questionnaire consisted of 28 items on a 1–5 rating scale,
including psychological response, physical response
and behavioral response based on the stress response
model. Total scores indicate intensive stress reaction.
Cronbach’s alpha coefficient of Stress Responses Questionnaire is 0.902, correlation coefficient with Self-Rating
Anxiety Scale (SAS) and Self-Rating Depression Scale
(SDS) are 0.585 and 0.574, respectively (Zhong, Jiang,
Wu, & Qian, 2004).
Social support
The Chinese versions of the Social Support Rating Scale
and Perceived social support scale (PSSS) were used in
the study. Social Support Rating Scale has three dimensions, including instrumental support, emotional
support and utilization of social support. Instrumental
support comes from objective and visible help, including material assistance, financial support and social
networks. Such support is independent of individual
feelings. Emotional support is the social state of the
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Family and Marital Life in Hemodialysis Patients
individual’s emotional experiences and satisfaction, it
is closely related to the individual’s subjective feelings
(Xiao, 1999). PSSS emphasizes the individual’s
perceived social support from various sources, such as
family members and friends. There are two dimensions
in PSSS: family support within family and support
outside family (Jiang, 2001).
Statistical analysis
Statistical analyses were carried out using SPSS version
18.0 (SPSS Inc., Chicago, USA). Univariant relationships were determined between sociodemographics
(gender, education, working status and family members); X2 test was used to analyze the degree of family
flexibility, and mental scales scores were analyzed with
one-way ANOVA and least significant difference test.
Pearson’s correlation was used to determine the correlation between stress reaction, social support, family
functioning and marital satisfaction. All statistical tests
were two-tailed, and P < 0.05 was regarded as being
statistically significant.
Results
Demographic characteristics of the subjects are documented in Table I. There were no significant differences
in gender, education, working status or number of family
members among the three groups.
Family functioning and marital quality and
satisfaction
The comparison of the FACES II-CV and ENRICH
scores of hemodialysis patients and spouses with the
control group did not yield any significant differences
in family cohesion, family flexibility and marital quality
or marital satisfaction. Types of family flexibility analyses showed that 13.15% of non-patients thought their
family was inflexible, whereas 36.8% of patients and
31.57% of spouse rated their family as inflexible. These
results indicate that there were more inflexible family
types in the patient group compared with families in
the control group (Table II; X2 = 6.343, P < 0.05).
Comparison of stress reaction and social
support
Stress reaction and social support differed significantly
in three groups (Table III). Hemodialysis patients and
their spouses had higher scores in stress reaction than
the control group (P < 0.01, P < 0.05) and more instrumental social support than the control group
(P < 0.01).
Correlation analysis between stress
reaction, social support, family
functioning and marital satisfaction
Stress was negatively associated with marital satisfaction across the three groups (P < 0.001). Subjective
support was positively related with family cohesion
in the control group (P < 0.005) and with family
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Family and Marital Life in Hemodialysis Patients
Table I. Demographic characteristics of the subjects (n = 114)
Items
age (years) ± SD
male/female
education
high school graduate
college graduated
post graduated
employment
employment
retired
family numbers
control group (n = 38) %
patient group (n = 38) %
spouse group (n = 38) %
F
P
56.5 ± 12.1
19/19
55.9 ± 12.4
20/18
55.8 ± 12.9
18/20
1.781
0.442
1.661
0.173
0.657
0.195
14 (36.8%)
15 (39.5%)
9 (23.7%)
14 (36.8%)
16 (42.1%)
8 (21.0%)
14 (36.8%)
16 (42.1%)
8 (21.0%)
1.561
0.214
22 (57.9%)
16 (42.1%)
3.49 ± 1.14
22 (57.9%)
16 (42.1%)
3.51 ± 1.17
23 (60.5%)
15 (39.5%)
3.46 ± 1.14
0.020
0.980
No significant differences in demographic characteristics of the subjects (One-way ANOVA and LSD-test).
Table II. Comparison of types of family flexibility
Items
un-regulation
flexible
regulation
inflexible
2
control group (n = 38) %
patients group (n = 38) %
spouse group (n = 38) %
X
10 (26.31)
13 (34.21)
10 (26.31)
5 (13.15)
6 (15.78)
8 (21.05)
10 (26.31)
14 (36.81) *
5 (13.16)
9 (23.68)
11 (28.94)
13 (34.21) *
2.428
1.877
0.330
6.343†
*P < 0.05 difference compared with control group (chi-square test).
†
P < 0.05.
Table III. Comparison of stress reaction and social support (Mean ± SD)
Items
Stress Reaction
Instruments Support
Emotional Support
Support utilization
Support within family
Support outside family
control group (n = 38)
patients group (n = 38)
spouse group (n = 38)
F
47.79 ± 15.53
8.17 ± 2.97
16.00 ± 4.24
7.69 ± 2.04
16.00 ± 4.24
28.02 ± 7.57
63.97 ± 28.25*
10.13 ± 2.98*
16.75 ± 3.94
7.62 ± 2.16
16.57 ± 3.59
28.83 ± 8.22
59.02 ± 22.76†
10.20 ± 3.09*
16.75 ± 3.94
7.49 ± 2.07
16.75 ± 3.94
29.48 ± 8.46
5.111‡
4.570‡
0.385
0.089
0.385
0.312
*P < 0.01; †P < 0.05 difference compared with control group (one-way ANOVA and LSD-test); ‡P < 0.01.
flexibility in the spouse group (P < 0.005). Instrumental support was not related with family functioning or
martial quality in any of the groups. Support outside
family was positively related to marital quality and satisfaction in healthy individuals (P < 0.001) and negatively related to marital quality in patients (P < 0.001)
and their spouses (P < 0.001). Support within family
was associated positively with family cohesion and adaptability among patients and healthy individuals (P < 0.001,
respectively) but not among spouses (Table IV).
Discussion
Previous studies have demonstrated the role of stress
and social support on quality of life among patients
with chronic illnesses. However, few investigated the
relationships between stress, social support and family
170
and marital life. This study used a case control method
to test the differences in stress, social support, family
and martial life, and their relationships among patients,
spouses and healthy controls. We hypothesized that
patients and spouses would have higher stress and
social support and worse family and marital adjustment compared with healthy people; and family
and marital adjustment would be negatively associated with stress and positively associated with social
support. Our hypotheses were only partially supported.
Unexpected findings about martial quality and stress
reaction of patients and spouses also appeared and
revealed a complex picture of the adaptation and
relevant risk and protective factors among patients
and spouses.
Consistent with our hypotheses, we found that
hemodialysis patients and spouses were less flexible in
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H. Jiang et al.
0.330*
0.164
0.048
0.032
0.092
0.343*
0.100
0.177
0.069
0.383*
0.469*
0.210
0.079
0.301
0.261
0.471*
0.071
0.080
0.191
0.512*
0.307
0.057
0.171
0.001
0.336*
0.604*
0.225
0.045
0.466*
0.392*
0.317
0.334**
0.159
0.016
0.003
0.099
0.099
0.251
0.386*
0.001
0.280
0.226
0.054
0.490*
0.290
*P < 0.001; **P < 0.005 (Pearson’s correlation test).
0.303
0.201
0.140
0.199
0.111
0.017
0.037
0.151
0.443*
0.053
0.373**
0.384**
0.189
0.597*
0.224
Stress reaction
Emotional support
Instrument support
Support within family
Support outside family
patient
patient
patient
Items
control
patient
spouse
control
family flexibility
family cohesion
Table IV. Correlation between family functioning, martial quality, stress reaction and social support
spouse
control
marital quality
spouse
control
marital satisfaction
spouse
Family and Marital Life in Hemodialysis Patients
Stress Health 31: 166–174 (2015) © 2014 John Wiley & Sons, Ltd.
family adaptability. However, they did not differ in
marital quality and satisfaction compared with the
healthy controls. Consistent with our hypothesis,
patients and their spouses exhibited higher levels of
stress reactions than healthy people. However, patients
and spouses did not differ in stress levels. Consistent
with our hypothesis, stress was negatively associated
with marital satisfaction across the three groups. Our
results supported the argument that dialysis and stress
reaction both decreased the family functioning.
Furthermore, we found that patients and spouses
received more instrumental social support compared
with healthy people; however, instrumental support
was not associated with family or marital outcomes.
Emotional support was positively related with family
flexibility in spouses and in family cohesion in healthy
people, but patients, spouses and healthy people did
not differ on perceived emotional support. Although
support outside family was positively related to marital
quality and satisfaction in healthy individuals, it was
negatively related to marital quality in patients and
their spouses. Support within family was associated
with family cohesion and adaptability among patients
and healthy individuals but not among spouses. These
findings revealed a complex picture of the health implications of social support among patients. We discuss
the findings and their implications in more detail in
the succeeding text.
The present study showed that patients in dialysis
and their spouses had more serious stress reactions
than non-patients, suggesting that the diagnosis of
ESRD and treatment with hemodialysis might destroy
the balance of mental and physical states in both
patients and their spouses. Previous studies have shown
that patients with ESRD encountered serious stress
experiences and negative emotion, and depression was
the main factor influencing quality of life (Cukor
et al., 2007; Finkelstein & Finkelstein, 2000). One study
reported that ESRD could affect the well-being of
spouses as well as the patients (Davila, Bradbury,
Cohan, & Tochluk, 1997). Couples in which one partner has ESRD and is on hemodialysis must adjust to an
illness that requires patients to adhere to a strict treatment schedule (Devins, Hunsley, Mandin, Taub, &
Paul, 1997). Our results support the conclusion that
both patients in dialysis and their spouses have serious
stress reactions.
A previous study suggested that patients in dialysis
had to face unpredictable health crises, which would
impact their marital satisfaction (Daneker, Kimmel,
Ranich, & Peterson, 2001). In this study, no differences
in the levels of family functioning and martial quality
were found among hemodialysis patients, their spouses
or the control group. It seems that dialysis and stress
reactions induced by disease and diagnosis did not
impact the family functioning and marital quality at
first glance, but we think that patients and their spouses
had a complex adaptation to the period of disease. As
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H. Jiang et al.
Family and Marital Life in Hemodialysis Patients
results further showed, there was a greater incidence of
inflexible families in patients than non-patients,
indicating that patients regarded their families as inflexible
in adaptations to life changes. Dialysis is a time-intensive
therapy (Al Eissa et al., 2010; Reynolds et al., 1988; Sathvik
et al., 2008). One study showed that male patients
reported more negative effects of dialysis on family life,
social life, energy and appetite than female patients; longer
dialysis duration was associated with adverse effects on
finances, energy and living arrangements (Al Eissa et al.,
2010). Our findings point out that although the family
and marital functioning are good among patients and
their family members, more attention should be paid to
adaptation to change.
Our findings also contributed to the vast literature
on social support and suggest the importance of examining the types and sources of social support. In this
study, instrumental support is the objective support,
such as material and financial assistance. Emotional
support is the individual’s emotional experiences and
satisfaction related to the social state. It is common
for Chinese people to receive instrumental support
but not necessarily emotional support from relatives
when they are sick. This may explain our results that
patients and spouses receive more instrumental but
not emotional support compared with healthy controls.
However, despite the widespread belief in Chinese societies that instrumental support is helpful, we did not find
that instrument social support was beneficial to family
functioning and marital quality. Western scholars have
argued that received support may not be beneficial
because it is associated with a threat to self-esteem or
one’s sense of independency, which in turn offset any
benefits of received support (Bolger & Amarel, 2007;
Uchino, 2009). This study also suggests that receiving
instrumental support may offset benefits of received
support in collective cultures. Furthermore, in Chinese
cultures, receiving instrumental support often implies
an obligation to reciprocate and thus may add a burden
to those who feel that they could not return instrumental
support. Future studies should further investigate the
distinct mechanisms linking instrumental support to
welling and linking emotional support to well-being.
Our findings suggested that support within family
was more important to patients’ family functioning
and marital quality, whereas support outside of family
was an interferential factor to marital satisfaction of
patient and spouse. In other words, the function of
social support also depends on the source of social
support and who is receiving it. We found that support
within family was associated with greater family
cohesion and flexibility for both patients and healthy
people. This is consistent with the idea that social
support could decrease the stress reaction and improve
well-being, including family functioning. In contrast,
support outside family was associated with better marital quality among healthy people, but worse marital
quality and satisfaction among patients and spouses.
172
There are two possible explanations. A previous study
using a laboratory stress paradigm (Uno, Uchino, &
Smith, 2002) showed that under stress situations women
receiving support from supportive close friend had lower
cardiovascular reactivity, but having support from ambivalent female friends resulted in higher cardiovascular
reactivity. Perhaps, the support received from outside
of family during non-stressful times may come from
close friends with high quality relationship, whereas support received from outside of family during stressful
times, such as acute or chronic illness, may come from
those who feel obligated to help but may not really want
to, thus resulting in ambivalence from the support provider. Our results support the idea that the quality of
one’s relationship with the support provider is an important aspect when explaining the effect of social support
on the physical health outcomes (Birmingham, Uchino,
Smith, Light, & Sanbonmatsu, 2009). It is also possible
that patients and their spouses may believe that support
outside family would interfere with marriage and family
life, or that obtaining support would lower their self-esteem, threat their sense of control or intensify their guilt
of not being able to reciprocate. Our finding suggests that
psychological interventions should focus on utilizing social support coming from family members, which could
promote family quality in patients with chronic diseases.
Future studies are needed to examine how and why the
different sources of social support have opposite impacts
on well-being.
This study has several limitations, including selfreport and relatively small sample sizes. Future
studies should test the conclusions in a larger sample
size. Future research should also include family life as
an additional domain for studying married couples and
pay attention to more variables such as gender, age and
dialysis duration and the ways in which these affected
family and marital quality (Anthony et al., 2010; Eton,
Lepore, & Helgeson, 2005).
In conclusion, our findings suggest that stress poses
challenges for family and marital life among patients
and spouses. Despite the stress that patients and spouses
experience, their family and marital lives appear to
adapt well. Although social support coming from
within the family may promote family quality among
patients, social support outside of the family may interfere with marital life for both patients and spouses and
emotional support is important for spouses to improve
family life.
Authors’ contributions
Fang Pan devised the concept for the study, developed the
study design, supervised data collection and analysis,
drafted the manuscript, and was involved in study coordination and manuscript revision. Hong Jiang and Li Wang
collected data. De-xiang Liu, Juan Ding and Zhen Lei
performed the analyses. Qian Lu revised the manuscript.
All authors read and approved the final manuscript.
Stress Health 31: 166–174 (2015) © 2014 John Wiley & Sons, Ltd.
H. Jiang et al.
Family and Marital Life in Hemodialysis Patients
Conflict of interest
The authors have declared that no conflict of interests
exists.
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