Full Research Report
Interpersonal variables and
caregiving partners’ burden in
cardiac illness: A longitudinal
study
Journal of Social and
Personal Relationships
2023, Vol. 0(0) 1–25
© The Author(s) 2023
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/02654075231177259
journals.sagepub.com/home/spr
Eran Katz1 , Eran Bar-Kalifa2, Paula Pietromonaco3 ,
Hodaya Wolf1, Robert Klempfner4,5, Hanoch Hod4,5 and
Noa Vilchinsky1 
Abstract
The literature on coping with illness has for many years viewed only the patients as the
focal point of attention and support, and only recently have the needs of patients’
caregivers been acknowledged as well. In addition, studies that have focused on factors
contributing to caregiving partners’ burden in the context of chronic illness have assessed
mostly intrapersonal variables of either the patient or the partner, thus overlooking the
dyadic and interpersonal nature of caregiving. In the current longitudinal study, we
examined the contribution of interpersonal factors, such as patients’ and partners’ relationship satisfaction and social support perceptions, to caregiving partners’ burden in
the context of cardiac illness. Couples comprising male patients and female caregiving
partners (N = 131) completed measures of relationship satisfaction, provided support,
and received support upon patients’ admission to a cardiac rehabilitation program after an
acute cardiac event (Time 1), and 3 months later (Time 2), upon program completion.
Caregiving partners also completed a measure of burden at both measurement times.
Path analyses revealed that partners’ relationship satisfaction, provided support, and
received support, were all associated with lower levels of different dimensions of burden
at both timepoints, as well as over time. Patients’ contribution to their partners’ burden
was salient cross-sectionally but not over time. The findings shed light on the substantial
1
Bar-Ilan University, Israel
Ben-Gurion University of the Negev, Israel
3
University of Massachusetts, USA
4
Chaim Sheba Medical Center, Israel
5
Tel Aviv University, Israel
2
Corresponding author:
Eran Katz, Department of Psychology, Bar-Ilan University, Ramat-Gan 52900, Israel.
Email: erankatz@gmail.com
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role played by interpersonal factors in the caregiving process. Our findings suggest that
both patients and partners should be regarded as caregivers and care receivers to each
other.
Keywords
ACE, burden, family caregivers, partners, relationship satisfaction, social support
Introduction
Illness introduces one of the major challenges for any interpersonal relationship, especially among couples. In the United States alone, one in two adults is diagnosed with at
least one chronic health condition, such as diabetes, cancer, or coronary heart disease
(Boersma et al., 2020). Coping with a life-endangering chronic health condition is a
lifelong process. After the initial diagnosis, patients usually must make considerable
lifestyle changes to improve their quality of life, reduce illness burden, and prevent
deterioration (Martire & Helgeson, 2017). Adopting new habits and relinquishing old
ones can be challenging, and for adults, the patient’s romantic partner tends to be the main
source of support (Knoll et al., 2018; Smith & Baucom, 2017).
Healthy partners’ caregiving efforts can take a heavy toll on themselves (George-Levi
et al., 2017; Revenson et al., 2016). Taking care of an ill person consists of providing
emotional and tangible support, potentially exerting an emotional and/or physical strain
on the caregiving partner and resulting in caregiving burden. Caregiving partners engage
less than non-caregiving partners in self-care activities (Bouchard et al., 2019) and are at a
higher risk of developing physical ailments, such as elevated cardiovascular reactivity,
metabolic syndrome, and coronary heart disease (Bouchard et al., 2019; Durante et al.,
2021; Vitaliano et al., 2003). Prior studies have detected that caregiving partners in the
context of cardiac illness, for example, show both mental and physical health risks such as
higher levels of anxiety, depression, and even cardiac-disease-induced post-traumatic
stress disorder (CDI-PTSD) (Fait et al., 2017; Randall et al., 2009; Van Wijnen et al.,
2017; Vilchinsky et al., 2015).
Despite the abundant literature attesting to the negative implications of caregiving for
partners, the medical world still adheres strongly to the view that patients are the sole focal
point of attention and the exclusive recipients of care, thus overlooking the needs and
suffering of the partner (Revenson et al., 2016). The caregiving theoretical framework, on
the contrary, highlights the fact that the healthy partner is also in need of care and attention
(Cipolletta et al., 2021; Revenson et al., 2016; Vilchinsky, 2017). In the same vein, the
dyadic coping model in psychology offers a paradigmatic shift in the way coping with a
major stressful event such as illness should be conceptualized, viewing it as a dyadic
process rather than merely an individual one (Acitelli & Badr, 2005; Berg & Upchurch,
2007; Coyne & DeLongis, 1986; Kayser et al., 2007; Vilchinsky & Dekel, 2018). This
view suggests that patients and partners are interdependent in their coping efforts and that
they mutually affect each other’s outcomes. Accordingly, in our study we focused on the
Katz et al.
3
healthy partners and specifically on variables such as provided and received support,
which may moderate caregivers’ burden when coping with their partners’ illness.
In the context of chronic illness, studies on factors contributing to caregiving partners’
burden have focused mostly on intrapersonal variables of either the patient or the partner,
such as the patient’s level of adherence (Durante et al., 2019), but have overlooked
interpersonal variables, such as perceptions of social support (Durante et al., 2019).
Neglecting the potential effects of interpersonal variables on caregiving partners’ burden
is a major limitation in the field of relational health psychology, especially in light of the
vast literature on the relevance of interpersonal processes in the context of coping with
illness (Pietromonaco & Collins, 2017; Pietromonaco & Overall, 2021; Uchino et al.,
2018). Thus, in the current study, we focused on the caregiving partner as the target of care
and assessed the contribution of interpersonal variables (specifically relationship satisfaction and provided and received support of both partners) to their level of burden
over time.
Understanding Caregiving Partners’ Burden From an Interpersonal Perspective
Caregiver burden is defined as the extent to which caregivers perceive their emotional
or physical health, social life, or financial status to be affected by their caring for an ill
relative (Adelman et al., 2014; Zarit et al., 1986). Most studies focusing on factors
contributing to caregiving partner burden in the context of chronic illness have applied
an individual approach, in that they have focused on individuals’ own characteristics
(Rodrı́guez-González et al., 2021). Examples include individuals’ own lack of choice
in being a caregiver (Adelman et al., 2014), attachment orientations (Tsilika et al.,
2014; Vilchinsky et al., 2010), neuroticism (Revenson et al., 2016), age and gender
(Durante et al., 2019), dispositional anxiety (Jaracz et al., 2014), and the caregiver’s
health status (Bekdemir & Ilhan, 2019). All of the above have been found to contribute
to elevated levels of burden. However, the dyadic nature of caregiving has been
overlooked in previous studies, including those just mentioned. Caregiving is not a
unilateral act that occurs in isolation, but a reciprocal process of transactions between
the caregiver and care receiver (Bodenmann et al., 2005; Revenson et al., 2016). A
dyadic investigation takes into account both the effect of the caregiver on the patient
and that of the patient on the caregiver (Revenson et al., 2016). Indeed, recent studies
have incorporated patients’ individual variables as possible contributors to caregivers’
burden, such as type of illness (Rodrı́guez-González & Rodrı́guez-Mı́guez, 2020) or
level of patients’ dependency (C. Y. Lin et al., 2019).
Even these studies, however, have neglected the relationship between the caregiver
and the care receiver, which includes the contribution of interpersonal-related variables
(e.g., relationship satisfaction or perceptions of social support) to caregiver burden. This
gap is of special relevance in the psycho-cardiology literature because, at the average age
of cardiac illness onset, most people rely primarily on their romantic partners for support
(Rapelli et al., 2021). In fact, Bennett (1999) described the response of couples to an acute
cardiac event as a systematic transactional response by both partners and suggested that
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recovery should be considered a dyadic rather than an individual process, highlighting the
importance of both patient and partner responses.
The few studies that have taken into account the interpersonal nature of caregiving,
and examined variables tapping interpersonal processes, have pointed to the added
contribution of these variables to caregiver burden (Rodakowski et al., 2012; Shiba
et al., 2016). For example, in the context of spinal cord injury, caregiving partners’ sense
of reciprocity (i.e., perceiving equal and fair give-and-take in the relationship) was
associated with lower levels of caregiving burden, whereas caregiving partners’
negative perceptions of their relationship quality were associated with higher levels of
burden (Tough et al., 2017).
In the current study, we assessed two interpersonal variables that are well-established
as highly relevant in the context of coping with illness: relationship satisfaction and
support perceptions (provided and received). Relationship satisfaction captures global
feelings and likely incorporates many recent and past aspects of the relationship prior to
the onset of the illness (Karney & Bradbury, 2020; Tavakol et al., 2017; Tong et al., 2021).
Having a satisfying relationship is associated with higher rates of happiness, better health,
and greater longevity for both spouses (Karney & Bradbury, 2020; Kiecolt-Glaser &
Wilson, 2017). In the specific context of burden, having a better relationship with one’s ill
partner is associated with less burden for the caregiving partner (Hooker et al., 2015;
Tough et al., 2017). Yet these prior studies assessed the contribution of relationship
satisfaction to partner burden only from an individual perspective (i.e., caregivers’ own
perceptions of relationship satisfaction as contributing to their own appraisals of burden)
(Springate & Tremont, 2014; Tough et al., 2017). In the current work, we also examined
the possible effect of patients’ relationship satisfaction on the caregiving partner as the
patient’s relationship satisfaction is a key feature of the context in which the caregiving
partner must operate.
In addition, it is important to consider the relationship variables that are most salient
when one partner is ill and in need of care and attention after a sudden major medical
event. For this reason, we also focused on how relationship factors that are more illnessrelated, namely the perceptions of support provided and received by both members of
the dyad, were related to caregiver burden. Prior work has shown that low levels of
social support are associated with greater caregiver burden (del-Pino-Casado et al.,
2018; Kim et al., 2005), whereas receiving support from family members can serve as a
protective buffer against caregiver burden (Isac et al., 2021). Yet support is a complex
variable that must be viewed from multiple perspectives. For instance, a differentiation
must be made between provided support, meaning the support that is being perceived by
the provider (usually the caregiver) and received support, meaning support as it is being
perceived by the recipient (usually the patient). A recent meta-analysis underscored the
importance of support perception by showing that the association between social
support and caregiver burden was a function of the way social support was measured,
and revealing that the association between received support and burden had a higher
effect size than that of provided support and burden (del-Pino-Casado et al., 2018; Shieh
et al., 2012). Thus, in the current study we assessed the contribution of partners’ and
patients’ provided and received support to caregiver burden.
Katz et al.
5
The Current Study
The current study extends past work by focusing on the healthy partner as the target of
attention and support, and on interpersonal factors that might be associated with their
burden in the context of cardiac illness. Cardiovascular disease is a chronic illness that
is considered the global leading cause of death (World Health Organization, 2022).
Coping with cardiac illness can be particularly challenging because it requires lifelong
adaptations from both patients and their families (Rapelli et al., 2021). Such adaptations include adherence to exercise routines, dietary changes, smoking cessation,
strict medication regimens, and medical check-ups (Dalal et al., 2015). To adjust to
these necessary life changes, patients are usually assisted by their close family
members, most often their romantic partners (Maunder et al., 2015; Randall et al.,
2009).
Specifically, we focused on the extent to which relationship satisfaction, provided
and received support, are linked with caregiving partner burden. It is reasonable to
suggest that the more satisfied one is with one’s relationship, and the more support one
receives in the relationship, the less burdened one feels. At the same time, it is also
reasonable to suggest that the more support one provides, the more burdened one
becomes. To gain a comprehensive understanding of these dynamics, we assessed the
study variables from both partners’ and patients’ perspectives at two timepoints along
the illness timeline: upon patients’ admission to the cardiac rehabilitation program
(Time 1) and upon completion of the program, 3 months later (Time 2). In addition, we
measured caregiving partners’ burden at both measurement times (see Figure 1 for a
theoretical model of the study). These measurement timepoints allowed us to detect the
interpersonal dynamics associated with caregiver burden before any formal intervention
took place, as well as over time.
Figure 1. The theoretical model of the current study.
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Specifically, we hypothesized that:
1. Patients’ and partners’ relationship satisfaction at Time 1 and Time 2 would be
negatively associated with partners’ burden both at the same time point and from
one time point to the next.
2. Partners’ provided support and patients’ received support at Time 1 and Time
2 would be positively associated with partners’ burden both at the same time point
and from one time point to the next.
3. Patients’ provided support and partners’ received support at Time 1 and Time
2 would be negatively associated with partners’ burden both at the same time point
and from one time point to the next.
As burden is a multidimensional concept, we also conducted exploratory analyses to
examine these hypotheses for each of the different dimensions of burden.
Method
Participants and Procedure
This study was part of a large-scale study focusing on patients and their caregiving
partners in the context of a first acute coronary syndrom (ACS). Members of different-sex
couples completed the study questionnaires. All participants were recruited from the
Cardiac Prevention and Rehabilitation Center (CPRC) of the Sheba Medical Center,
Israel, the week they began their cardiac rehabilitation program. After receiving approval
from Sheba Medical Center’s institutional review board (IRB), all medical files of patients
admitted to the CPRC between November 2017 and March 2020 were screened. Inclusion
criteria comprised all male patients, aged 35 and over, who underwent their first ACS
[manifested as myocardial infarction (MI) or severe unstable angina (UA)], and their
married or cohabiting partners. According to Heart Disease and Stroke Statistics (Tsao
et al., 2022), there is a higher chance (approximately 34% higher), that men will undergo a
cardiac event than that women will across almost all age groups. Among women who
have an acute cardiac event, there is a greater likelihood that they will be older and have
more medical complications; they are also more likely to be widowed than men who have
an acute cardiac event are (Tsao et al., 2022). Therefore, given the likelihood that it would
be difficult to detect female cardiac patients who were also receiving social support from a
living partner, in the current study we focused on male patients and their female partners.
Patients had to be cohabiting with a romantic partner for a period of at least 1 year to be
eligible for the study. We excluded patients with a history of a previous cardiac event;
patients with a diagnosis other than ACS; patients with comorbid illnesses; and patients
under 35 years of age (i.e., to include only patients with a first-time coronary event which
was not related to a congenital disease and who were in a long-standing relationship; the
initial registry of all admitted patients included only 2.62% of people under 35 years of
age). In addition, patients or partners who were coping with additional cognitive or
physical ailments were excluded. As interviews were conducted in Hebrew, dyads in
which one or both partners were not fluent in Hebrew were excluded.
Katz et al.
7
Supplemental Figure 1 in the online supplementary material presents the study recruitment process. Out of 3,318 patients referred to the CPRC during the study period,
2,569 were excluded for various reasons (see Supplemental Figure 1 in the online
supplementary material for more detailed information). The study coordinator contacted
the remaining 749 patients by phone to validate their details and coordinate a meeting at
the CPRC. Of those, 341 were excluded for additional reasons (detailed in Supplemental
Figure 1 in the online supplementary material). The remaining 408 patients consented to
meet in person with our research team at the rehabilitation center. The research team met
with all 408 patients to explain the study in more detail and to request signed informed
consent including patients’ approval for the research team to recruit their partners
(i.e., sending partners the link to the study’s information sheet and questionnaires). During
this meeting, the eligibility of both partners was assessed, and as a result, an additional
49 patients were excluded for various reasons (see Supplemental Figure 1 in the online
supplementary material for more detailed information). Of the remaining 359 eligible
dyads, 228 (either patient or partner) declined to participate in the study. Thus,
131 couples participated in the first phase of the study (Time 1; participation rate: 36.5%).
Out of this sample, 88 couples also completed the follow-up phase (Time 2; 32.8%
attrition rate). Reasons for attrition were, for example, no interest in continuing or declining to begin the CPRP program. No significant differences were found between the
43 patients who provided data only at Time 1 and the 88 who also provided Time 2 data
with regard to age, illness severity, relationship duration, or socioeconomic status (SES).
After receiving both partners’ agreement to participate in the study (for patients, by
signing the informed consent form during the meeting; the partners were exempted by the
IRB from signing, and their agreement to answer the study’s questionnaires after reading
the explanation sheet online was accepted as their informed consent to participate), both
patients and partners were added to the study’s online platform (Qualtrics.com). They
were sent the study’s questionnaires during the week of the patients’ admission to the
formal cardiac rehabilitation program (around 2–4 months after the cardiac event) and
during the week of program completion, 3 months after admission.
Questionnaires were completed via use of the online platform, and each participant and
dyad were assigned a unique code to preserve confidentiality. Participants were required to
answer each online question to avoid missing data, but they were free to withdraw from
participation at any point. In the few cases (n = 9) where participants did not have internet
access, we provided both partners with hard copies of the questionnaires, and they were asked
to complete them separately. Couples were compensated with gift cards valuing $220 in total.
Measures
Caregiver Burden. Partners completed the Hebrew version of the Multidimensional
Caregiver Burden Inventory (CBI; Novak & Guest, 1989) both at Time 1 and Time 2. This
version was validated among an Israeli sample of wives of war veterans with post-traumatic
stress disorder and brain injuries (Ben Arzhi et al., 2000). The CBI is a 24-item multidimensional questionnaire that measures the experience of burden across five dimensions:
time-dependence burden, developmental burden, physical burden, social burden, and
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emotional burden. It is widely used and has been validated both for the total scale and its five
dimensions (Cohen et al., 2021; Merlo et al., 2020). Each dimension consists of five items
(except for the physical burden dimension, which has four items). Participants rated each
statement on a scale ranging from not at all (0) to very much (4), and scores were later
transformed into a scale of 1–5 for clarity. The overall burden score was calculated by
averaging all items. We also calculated the specific dimensions of the questionnaire:
Time-dependent burden describes burden that is more tangible and occurs due to
restrictions on the caregiver’s time, as the caregiver must devote time and energy to
helping the patient with daily tasks. This factor includes items such as “I have to watch my
care receiver constantly” or “I have to help my care receiver with many basic functions.”
Developmental burden describes feelings of being out of sync with age-appropriate
benchmarks of personal development when compared to caregivers’ peers of the same
age. This factor includes items such as “I feel that I am missing out on life” or “I expected
that things would be different at this point in my life.”
Physical burden describes feelings of fatigue or harm to the caregiver’s physical
health. Example items are “I’m not getting enough sleep” or “Caregiving has made me
physically sick.”
Social burden describes caregivers’ feelings of conflict about their roles, especially
regarding the lack of appreciation they might feel from those around them. Example items
are “My caregiving efforts are not appreciated by others in my family” or “I feel resentful
of other relatives who could but do not help.”
Finally, emotional burden describes caregivers’ negative feelings toward the care receiver, or toward themselves for having such negative feelings. Items in this factor include
“I resent my care receiver” or “I feel angry about my interactions with my care receiver.”
In the current study, the Pearson correlations among the different burden dimensions
ranged from .34 to .66 at Time 1, and from .24 to .71 at Time 2. Exploratory factor analysis
with the Promax method revealed the existence of one factor which explained 70% of the
variance (eigenvalue = 4.19). McDonald’s omegas for reliability are presented in Table 1.
Relationship Satisfaction. Patients’ and partners’ relationship satisfaction was measured at
both Time 1 and Time 2 via the use of the shortened, 4-item version of the Couple
Satisfaction Index (Funk & Rogge, 2007). The Hebrew version of this questionnaire was
validated by Sened et al. (2020). Participants rated the extent to which they agreed with
each item, such as “I have a warm and comfortable relationship with my partner” on a
scale ranging from not at all true (0) to completely true (5), for items 2–4, and unhappy (0)
to perfect (6) for item 1 only (“Please indicate the degree of happiness, all things
considered, of your relationship”). The final score was calculated by summing all items.
McDonald’s omegas for reliability are presented in Table 1.
Provided and Received Support. To assess the perceptions of provided and received support
by each partner in each dyad, we applied the original Hebrew version of the Daily Support
Inventory, validated in Israel (Bar-Kalifa & Rafaeli, 2013) at both Time 1 and Time 2.
This questionnaire examines practical and emotional support acts provided and received
by both partners, with items such as “I told them I care about them” or “I offered them
Partner
Patient
Partner
Patient
Partner
Patient
Partner
Partner
Partner
Partner
Partner
Partner
1. Relationship satisfaction
2. Relationship satisfaction
3. Provided support
4. Provided support
5. Received support
6. Received support
7. Burden: General score
7a. Time-dependent burden
7b. Developmental burden
7c. Physical burden
7d. Social burden
7e. Emotional burden
3.61
3.94
3.10
2.93
2.56
3.11
1.54
1.62
1.68
1.67
1.50
1.26
(1.17)
(1.20)
(.63)
(.72)
(.87)
(.70)
(.57)
(.76)
(.77)
(.84)
(.68)
(.57)
M (SD)
1.97* (123)
C. 6.88*** (126)
B.
A. 3.73*** (127)
t (df)
.925
.943
.938
.938
.969
.974
.921
.843
.840
.843
.719
.861
McDonald’s omega
3.61
3.81
2.85
2.81
2.63
2.78
1.48
1.62
1.56
1.62
1.43
1.20
(1.15)
(1.04)
(.80)
(.72)
(.93)
(.77)
(.52)
(.77)
(.79)
(.77)
(.61)
(.39)
M (SD)
D. 1.640
(87)
E. .433
(87)
F. 1.481
(87)
t (df)
.944
.937
.959
.949
.967
.964
.927
.857
.913
.831
.744
.764
McDonald’s omega
Time 2 (n = 88)
Note. t-tests A-C present the differences between patients and partners in relationship satisfaction, provided support, and received support, respectively, as measured
at Time 1. Similarly, t-tests D-F present the differences between patients and partners in relationship satisfaction, provided support, and received support, respectively,
as measured at Time 2.
*p < .05. ***p < .000.
Role
Variable
Time 1 (n = 131)
Table 1. Descriptive and comparative statistics for the main variables of the study.
Katz et al.
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information that will help them with their problems” for provided support, and “They
comforted me physically with a hug or a kiss” or “They thought with me about possible
solutions to my problems” for received support. Each partner answered the 15 items of
provided support as well as the 15 items of received support questionnaires. For each
questionnaire, participants rated each statement on a scale ranging from not at all (0) to
very much (4). Scores were calculated for each scale (provided and received support) by
averaging the relevant items. McDonald’s omegas for reliability are presented in Table 1.
Patients’ Illness Severity. In keeping with Neeland et al. (2012), patients’ illness severity
was assessed by a senior cardiologist based on two criteria measured at hospitalization:
echocardiogram (examines the structure and functioning of the heart) and angiogram
(examines obstructed artery status). Echocardiogram and angiogram scores were both
assessed on a scale ranging from 1 (mild) to 4 (most severe).
Demographic and Medical Characteristics. At Time 1, all participants completed a short
demographic questionnaire consisting of their age, relationship duration (in years),
number of children, level of education (1 = elementary to 6 = doctorate), subjective
socioeconomic status (SES; 1 = much above average to 5 = much below average), and
current employment status (1 = full-time job; 2 = part-time job; 3 = unemployed; 4 =
retired; 5 = on sick leave; 6 = other). In addition, partners were asked to define their health
status on a scale ranging from 1 = excellent to 7 = extremely bad.
Analysis
Descriptive statistics were used to describe the sociodemographic data of the sample, as
well as the study’s measures. We applied Pearson correlations to assess the correlations
among the study variables, and paired t-tests to compare the differences between patients
and partners in those variables. Due to the asymmetric distribution of the burden outcome
measures, log transformations were used for this variable and its dimensions.
To test the research hypotheses, a path analysis approach was applied, using the Mplus
V.8.3 statistical package (Muthén & Muthén, 2018). In each model, we assessed the
contribution of one of the independent variables as measured for each partner in the dyad to
caregivers’ burden as follows: one of the three independent variables (relationship satisfaction, provided support, or received support) as measured at both Time 1 and Time 2 X
general burden as measured at both Time 1 and Time 2. It is important to note that we were
unable to analyze the three independent variables in one comprehensive model due to the
high multicollinearity among them. To retain the dyadic effect, we added the correlation
between the two independent variables in each path model, thus controlling for the dyadic
interdependence between patients and partners in the independent variables. In exploratory
analyses, we also repeated the analysis separately for each of the burden dimensions.
Other than the rare cases where missing values were detected (among five caregivers
and two patients who filled out the questionnaires by hand), we also had about a 30%
drop-out rate, for which we applied the full information maximum likelihood (FIML)
Katz et al.
11
framework, based on the random pattern of these missing values (Little’s Test of Missing
Completely at Random/MCAR: χ 2 = 124.96, df = 143, p = .859); that is, missing values
were correlated with existing data within the path model.
Sample size. To ensure sufficient power for the regression model (1-β > .80), we used the
G*Power calculator (Faul et al., 2009) and set α = .05, medium effect size ( f 2) = .15, and
five regression predictors (for the three controlled sociodemographic and medical variables and the two versions – patient/partner – of the independent variable). A minimum
sample of 92 observations generated the desired power of .80, while a sample size of
130 observations as in our sample generated over 94% power.
Results
Sample Characteristics
Partners ranged in age from 35 to 73 (M = 54.60, SD = 9.90), and had been married (or in a
long-term relationship) to the patient for an average of 29.6 years (SD = 13.50; range: 1–
55). They had an average of 3.12 children (SD = 1.70, range: 1–11). Almost half of the
sample (46.20%) defined their SES as high, a third of the sample (31.50%) defined it as
average, and a quarter (22.30%) defined it as lower than average. Most partners (89.70%)
had completed at least 12 years of formal education, and most of them (68.50%) had a
part- or full-time job at the time of the study. Most of the partners (81.70%) reported
having good to very good health.
Patients ranged in age from 35 to 90 (M = 57.7, SD = 10.3). Most patients (92.4%) had
completed at least 12 years of formal education, and most (65.6%) had a part- or full-time
job at the time of the study. All the patients underwent angioplasty, and almost all of them
(97%) had an echocardiogram. Both measures showed a low to moderate illness severity
(MAngio = 2.28, SD = 1.140) and (MEcho = 1.79, SD = .950).
Of all the demographic and clinical variables, relationship length, SES, and echocardiogram results (MEcho) were significantly associated with partners’ burden at Time 1,
and thus were controlled for in the primary analysis.
Preliminary Analysis
Table 1 presents the descriptive and comparative statistics of the study’s main variables. To
assess the differences between patients’ and partners’ relationship satisfaction, provided
support, and received support, as measured at Time 1 and Time 2, three paired t-tests were
performed for each study phase. At Time 1, patients reported higher levels of relationship
satisfaction compared to that reported by their partners. In addition, partners’ provided
support was higher than patients’ provided support, and patients’ received support was
higher than partners’ received support. No differences were found between patients and
partners in any of these variables at Time 2.
Tables 2 and 3 presents the correlations among the study’s main variables at both
measurement times and over time (across Time 1 and Time 2). Higher levels of burden
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Table 2. Intercorrelations among the study’s main variables at time 1 and partner’s burden as
measured at both measurement times (N = 131).
Measurement
time
Time 1
Time 2
Variable
1. Partners’
relationship
satisfaction
2. Patients’
relationship
satisfaction
3. Partners’
provided
support
4. Patients’
provided
support
5. Partners’
received
support
6. Patients’
received
support
7. Partners’
burden
8. Partners’
burden
1
2
3
4
5
6
7
.534**
.483**
.269**
.328**
.575**
.241**
.696**
.377**
.596**
.394**
.397**
.632**
.336**
.703**
.339**
.431**
.199*
.130
.088
.366**
.178*
.525**
.223*
.303**
.197
.454**
.201
.618**
Note. All correlations with Time 2 burden were based on 88 couples.
*p < .05. **p < .005.
were associated with lower levels of relationship satisfaction of both partners and patients,
both cross-sectionally at both measurement times, and over time. Burden was also
negatively associated with partners’ provided support at Time 2 and over time, and with
patients’ provided support, but only at Time 2. Finally, burden was negatively associated
with partners’ received support at all measurement times and over time. However, it was
negatively associated with patients’ received support only at Time 1.
Primary Analysis
The primary analysis included an assessment of three path analysis models. In each
model, the outcome variable was the overall burden score, measured at Time 1 and Time
2, and each of the three separate models focused on one of the predictors (either relationship satisfaction, provided support, or received support) as measured for both patients
and partners, at both measurement times. Table 4 presents the path analysis modeling
results. Standardized regression coefficients and correlations (shaded cells) are shown for
each predictor. Regression coefficients are either autoregressive – from each of the Time
Katz et al.
13
Table 3. Intercorrelations among the study’s main variables and partner’s burden at time 2
(N = 88).
Variable
1.
2.
3.
4.
5.
6.
7.
Partners’ relationship satisfaction
Patients’ relationship satisfaction
Partners’ provided support
Patients’ provided support
Partners’ received support
Patients’ received support
Partners’ burden
1
.514**
.501**
.325**
.704**
.330**
.498**
2
.228*
.526**
.386**
.632**
.394**
3
.354**
.752**
.310**
.334**
4
.415**
.784**
.238*
5
.421**
.472**
6
.155
*p < .05. **p < .005.
1 variables to the same variable as measured at Time 2, or cross-lagged, from the Time
1 predicting variables to Time 2 burden. The fit indices were acceptable and presented in
the note toTable 4. Table 5 presents the exploratory modeling for the five dimensions of
burden separately and shows the effect of the three predictors as measured at Time 1 on
each of the dimensions of burden, as measured at Time 2, controlling for the same burden
dimension as measured at Time 1. As these dimensions were highly correlated, we could
not include them in the same path model; rather, we had to run five identical models in
which only the burden dimension at Time 1 and Time 2 was alternated in each of the five
analyses. The autoregressive correlations of each variable in the five models were similar
to the effects detected in the general model, and all alternate models met the required
goodness of fit indices.
Observing the contribution of the demographic characteristics across the models, we
detected that relationship duration was consistently associated with lower levels of
general burden, but no other background effect was found significant. An additional
general finding was that the autoregressive associations among all variables measured at
both measurement times were positive and high.
Relationship Satisfaction. Table 4 presents the findings for relationship satisfaction as the
independent variable across both measurement times. Partners’ and patients’ relationship
satisfaction was positively correlated when measured at each time point, yet this correlation was lower at Time 2. When assessed at both measurement times separately,
burden was negatively correlated with both partners’ and patients’ relationship satisfaction. In addition, the cross-lagged coefficients show that partners’ but not patients’
relationship satisfaction at Time 1 was negatively associated with burden at Time 2. This
negative association remained for all dimensions of burden except for the physical dimension, whereas the associations of Time 1 patients’ satisfaction with each of the dimensions of Time 2 burden were non-significant (Table 5).
Provided Support. Table 4 presents the findings for provided support as the independent
variable across both measurement times. Partners’ and patients’ provided support was
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Journal of Social and Personal Relationships 0(0)
Table 4. Path analysis results for the study variables and partners’ burden (N = 131).
Provided support
Associations and correlations
Control variables associations
Rel dur and burden
Echocard and burden
SES and burden
Time 1 correlations
T1 partners and T1 patients
T1 partners and burden
T1 patients and burden
Time 2 correlations
T2 partners and T2 patients
T2 partners and burden
T2 patients and burden
Autoregressive associations
T1 partners → T2 partners
T1 patients → T2 patients
T1 burden → T2 burden
Cross-lagged associations
T1 partners → T2 burden
T1 patients → T2 burden
B
SE
p
.19
.20
.11
.08
.09
.09
.25
.20
.16
Relationship
satisfaction
Received support
B
SE
p
B
SE
p
0.019
0.022
0.207
.20
.15
.12
.08
.08
.08
0.009
0.065
0.127
.19
.14
.07
.08
.08
.08
0.013
0.079
0.406
.09
.08
.09
0.004
0.023
0.065
.34
.41
.22
.08
.08
.09
0.000
0.000
0.012
.54
.43
.22
.06
.07
.09
0.000
0.000
0.012
.18
.22
.16
.11
.10
.11
0.094
0.033
0.128
.28
.29
.10
.10
.10
.11
0.006
0.003
0.347
.27
.29
.31
.10
.10
.10
0.008
0.004
0.002
.47
.62
.65
.08
.06
.06
0.000
0.000
0.000
.55
.61
.60
.08
.07
.08
0.000
0.000
0.000
.67
.77
.54
.06
.04
.08
0.000
0.000
0.000
.16
.05
.08
.08
0.041
0.479
.19
.03
.10
.08
0.040
0.735
.29
.06
.09
.09
0.002
0.536
Note. T1 = Time 1; T2 = Time 2; Rel Dur = relationship duration in years; Echocard = echocardiogram results
(higher scores indicate worse physical status); SES = socioeconomic Status (higher scores indicate better status).
The table shows standardized coefficients and standard errors. Shaded cells stand for within-time correlation
coefficients.
Fit indices for provided support: CFI = .945; TLI = .932; RMSEA = .053; c2 = 28.81; df = 21; p = .12; SRMR = .073.
Fit indices for received support: CFI = .956; TLI = .946; RMSEA = .053; c2 = 28.60; df = 21; p = .12; SRMR = .080.
Fit indices for relationship satisfaction:
CFI = 1.00; TLI = 1.00; RMSEA = .000; c2 = 20.77; df = 21; p = .47; SRMR = .062.
positively correlated at both measurement times, yet this correlation was non-significant
at Time 2. When assessed at each measurement time separately, burden was significantly
and negatively correlated with partners’ and patients’ provided support except for patients’ provided support at Time 2. The expected cross-lagged association between
partners’ provided support at Time 1 and burden at Time 2 was found significant and
negative and remained for the developmental and social dimensions of burden (Table 5).
No significant cross-lagged association was detected for patients’ provided support as
measured at Time 1 on burden as measured at Time 2 (Table 5).
Received Support. Table 4 presents the findings for received support as the independent
variable across both measurement times. Partners’ and patients’ received support was
.06
.18
.55
.10
.14
.49
.12
.25
.51
B
.09
.09
.07
.10
.10
.08
.11
.10
.08
SE
.543
.057
.000
.282
.181
.000
.274
.014
.000
p
.05
.18
.60
.07
.23
.51
.09
.34
.49
B
.08
.08
.07
.08
.10
.09
.10
.09
.08
SE
Deva
.564
.031
.000
.361
.020
.000
.365
.000
.000
p
.10
.02
.59
.08
.12
.57
.004
.18
.52
B
.09
.09
.07
.09
.10
.08
.10
.10
.08
SE
Phya
.235
.850
.000
.386
.225
.000
.969
.056
.000
p
.08
.21
.65
.04
.24
.63
.03
.21
.62
B
.07
.07
.06
.07
.08
.06
.09
.09
.07
SE
Soca
.228
.003
.000
.586
.004
.000
.753
.020
.000
p
.08
.15
.48
.02
.31
.38
.01
.34
.34
B
.09
.10
.09
.09
.11
.11
.10
.12
.11
SE
Emoa
.358
.116
.000
.821
.004
.000
.887
.004
.002
p
Note. Pat = patient; Par = partner; Bur = burden; Pro Sup = provided support; Rec Sup = received Support; Rel Sat = relationship Satisfaction; Time Dep = timedependent burden; Dev = developmental burden; Phy = physical burden; Soc = social burden; Emo = emotional burden.
a
Time 2.
b
Time 1.
Pat Pro Sup
Par Pro Subb
Bur Pro Supb
Pat Rec Supb
Par Rec Supb
Bur Rec Supb
Pat Rel Satb
Par Rel Satb
Bur Rel Satb
b
Associations
Time Depa
Table 5. Path analysis results for the study variables and partners’ burden factors in time 2 (N = 131).
Katz et al.
15
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Journal of Social and Personal Relationships 0(0)
positively correlated at both time points. When assessed at each measurement time
separately, burden was significantly and negatively correlated with partners’ and patients’
received support except for patients’ received support at Time 2. The expected crosslagged association between partners’ received support at Time 1 and burden at Time 2 was
found significant and negative and remained for the developmental, social, and emotional
dimensions of burden (Table 5). No significant cross-lagged association was detected for
patients’ received support as measured at Time 1 on burden as measured at Time 2.
Discussion
Most studies focusing on caregivers’ burden have examined mainly individual-level
factors whereas fewer studies have examined the interpersonal, dyadic aspects of
caregiving (i.e., how both partner and patient relationship-related factors affect the
caregiving partner’s burden). The current study presents a bidirectional perspective of
caregiving and extends past work by focusing on the caregiving partners, and on interpersonal aspects of the relationship, including both partners’ and patients’ perceptions
of relationship satisfaction and provided and received support, as factors contributing to
caregiving partners’ burden. Moreover, to shed light on the progression of these dynamics
over time, we examined partners’ burden upon patients’ admission to a cardiac rehabilitation program, before any formal intervention took place, as well as upon the
completion of this program, 3 months later. Findings were generally replicated across the
two distinct timepoints, with only a few exceptions.
As hypothesized, we found that caregiving partners who were more satisfied with their
relationship, as measured upon patients’ admission to the CPRP, felt less burdened at both
admission and at follow-up, 3 months later. The same pattern was found when we focused
on the different aspects of burden as measured at follow-up. Partners’ relationship
satisfaction was associated with lower levels of burden with regard to all dimensions,
except for the physical dimension. These findings align with findings from previous
research showing that greater relationship satisfaction can buffer the detrimental effects of
caregiving (Bouchard et al., 2019; Pailler et al., 2016). It is also not surprising that the
specific experience of physical burden is less affected by the benevolent impact of relationship satisfaction. Patients’ relationship satisfaction, on the other hand, was associated with partners’ burden, but only when measured cross-sectionally and not over time.
Thus, we cannot draw a definitive conclusion regarding the contribution of patients’
relationship satisfaction to their caregiving partners’ burden.
To better understand the role of more nuanced interpersonal factors which may
contribute to partners’ burden in times of illness, we also assessed social support-related
variables. First, we observed whether provided support (i.e., by the caregiving partners)
made any contribution to caregiving partners own burden upon patients’ admission, as
well as 3 months later. Interestingly, and contrary to our hypothesis, partners who reported
providing more support felt less burdened at both Time 1 and Time 2, as well as over time.
Partners who provided more support evidenced lower burden with regard to specific
aspects, namely developmental and social burden.
Katz et al.
17
One possible explanation for these associations may be tied to caregiving values.
Values are “chosen qualities of being and doing” that act as a guiding light for what’s
important in one’s life (Hayes, 2019, p. 25). Moreover, value-guided actions are linked to
feelings of meaning and richer lives (Hayes et al., 2016). The values caregivers hold about
their obligations to their partners may shape their appraisals of the situation. For example,
higher caregiver anxiety might decrease a caregiver’s contribution to a patient’s self-care,
but this association may be attenuated if the caregiver values the caregiving role (Vellone
et al., 2021). Being a caregiver for one’s partner may align with an individual’s values of
being a caring partner. Thus, it may be that when partners provide more support, they
experience greater congruence between their own values and their role as caregivers,
leading them to feel less burdened even when the caregiving situation continues its
demands over time.
In a similar vein, our hypothesis that patients’ received support (i.e., the patient’s
subjective perception of receiving support from the caregiving partner) would be associated with higher levels of partners’ burden was not confirmed, as patients’ received
support was related to lower burden (and only when measured at Time 1 but not at Time
2 or over time). Thus, it seems that patients’ acknowledgment of the support they
receive from their caregiving partners has the potential to act as a buffer against the
accumulation of caregiving burden. Yet patients may not have clearly or consistently
communicated their recognition and appreciation of the caregivers’ support; thus, the
effect of their perceived received support on their caregiving partners’ burden seems to
fade over time.
Finally, it was detected that patient provided support was associated with less burden,
at least when measured at Time 1. Also here, we cannot draw a definitive conclusion
regarding the contribution of patients’ provided support to their caregiving partners’
burden over time. However, partner received support was associated with reduced burden
at all time points and over time, for the developmental, social, and emotional dimensions
of burden (but not the more concrete physical and time-dependent dimensions).
These findings align with those of previous studies on the beneficial effect of social
support on caregiver burden (Pailler et al., 2016; Shokrgozar et al., 2022). Moreover, they
align with other work showing that partners who felt they had to make sacrifices for the
sake of the relationship were more satisfied with the relationship when they felt supported
by the other partner (W. F. Lin et al., 2017). Our findings suggest that caregiving partners
should be regarded as care receivers just as much as they are regarded as caregivers.
Although they are not the ones who are ill, the illness still takes over their lives and their
identity no less and sometimes even to a greater extent than it does for the patients
themselves (Revenson et al., 2016). The dichotomous differentiation between care receivers and caregivers may be misleading as both partners in the dyad need support and
encouragement when coping with illness.
The strengths of the current study are the relatively large sample size, the participation of both couple members, and the examination and general replication of associations across two distinct timepoints. Nevertheless, several limitations must be
acknowledged. First, the generalizability of the current findings is limited because, due
to the gender difference in the occurrence of cardiac events, all patients were men, and
18
Journal of Social and Personal Relationships 0(0)
therefore patient status and gender cannot be disentangled. As mentioned earlier,
women who experience this type of cardiac event tend to be older, more likely to be
widowed, and are taken care of by other members of the family (Tsao et al., 2022).
Additional work will need to focus on situations in which women are the patients.
Second, this study involved caregivers of patients who experienced a first-time cardiac
event, with no other accompanying chronic illnesses. This population is unique in that
the patients’ caregiving needs tend to be less demanding than among those who must
cope with more severe chronic illnesses, including other cardiac conditions. The current
caregiver burden measurement was developed for other types of chronic illnesses, and
as such, may be less sensitive to the unique needs of caregivers of patients coping with
ACS. Developing more appropriate measurement tools would improve the understanding of caregivers in this context. Third, in the 3-month period between Time 1 and
Time 2, patients participated in a cardiac rehabilitation and prevention program. This
program includes bi-weekly, monitored physical exercise, regular medical check-ups,
and support for diet changes and smoking cessation. Changes in partners’ burden might
have been affected by their husbands’ participation in the program. However, given that
this was not an intervention study using a randomized controlled trial design, such a
conclusion cannot be inferred. Future such studies could shed light on the effect of the
program on partners. Finally, the data are correlational, and therefore causal links cannot
be determined.
The findings of the current study may be of value for both researchers and clinicians
who work with couples coping with chronic illness, utilizing both personal- and
couple-based interventions. The findings point to the important contribution of interventions geared toward helping both members of a dyad feel more connected to
each other, especially when coping with a major health crisis in the family. More
specifically, we found that when the caregiving partners felt more supported by their
partners (the patients), they also felt less burdened with regard to three burden dimensions. This finding highlights the value of clinicians helping both members of the
dyad move away from the patient-caregiver dichotomy and toward a more reciprocal
dynamic in which both members are on the giving and receiving ends. Our findings
suggest that the associations among interpersonal variables and caregivers’ burden
can be detected as early as upon admission to the CPRP when the caregiver usually
accompanies the patient, and therefore practitioners are advised to capitalize on this
timing to begin dyadic interventions. Such interventions may facilitate the partner’s
adaptation to the caregiving role and reduce the attendant caregiving burden; at the
same time, such interventions may assist the patient in contributing to the caregiving
partner’s well-being. Empowering patients to see themselves not just as victims of
their illness but also as an important, contributing member of the dyad, and helping
partners receive support from the patients, may help to promote coping and well-being
for both partners.
Katz et al.
19
Author note
Data for this research is not available publicly because participants did not provide the required
consent. However, deidentified data used in the present paper will be provided upon reasonable
request.
Authors’ contributions
EK: Oversaw the study conceptualization, design, analysis, and writing. He conducted the data
collection, the statistical analysis and wrote the first draft. EBK: Has assisted in study conceptualization, design, and data analysis. PP: Has assisted in study conceptualization and writing. HW:
Oversaw the study data collection. RK: Has supervised data collection in the medical center. HH:
Has assisted with medical data analysis. NV: Designed the study, and supervised all its stages
including data collection, analysis and writing of the manuscript. All authors contributed to
manuscript revision, read and approved the submitted version.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: This study was supported by a grant from the Israel Science Foundation
(ISF 881/16).
Ethical approval
All procedures performed in studies involving human participants were in accordance with the
ethical standards of the institutional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards. Ethical approval number
3251–16-SMC, The Helsinki committee, SHEBA Tel Hashomer Medical Center.
Consent to participate
Informed consent was obtained from all individual participants included in the study.
Availability of data and material
Due to the nature of this research, the ethical committee did not agree for the data to be shared
publicly, so supporting data is not available.
Code availability
The Helsinki committee, SHEBA Tel Hashomer Medical Center has not approved code sharing for
this study.
Pre-registration
This research was pre-registered with OSF. The aspects of the research that were pre-registered were
the hypotheses and study design. The registration was submitted to: OSF.io. https://osf.io/krd3v/?
view_only=89a05608110540db931765d37d4234b3
20
Journal of Social and Personal Relationships 0(0)
Open research statement
As part of IARR’s encouragement of open research practices, the authors have provided the
following information: This research was pre-registered with OSF. The aspects of the research that
were pre-registered were the hypotheses and study design. The registration was submitted to:
OSF.io. https://osf.io/krd3v/?view_only=bc2c0270a3e546169723f92602fb174b. The data used in
the research cannot be publicly shared because participants did not provide the required consent.
However, deidentified data is available upon a reasonable request to the corresponding author via
email at erankatz@gmail.com.
ORCID iDs
Eran Katz  https://orcid.org/0000-0002-4189-9839
Paula Pietromonaco  https://orcid.org/0000-0003-1569-0246
Supplemental Material
Supplemental material for this article is available online.
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