Rehabilitation Psychology © 2016 American Psychological Association

2016, Vol. 61, No. 3, 297–307 0090-5550/16/$12.00 http://dx.doi.org/10.1037/rep0000089

Validation of the Social Provisions Scale in People With Multiple Sclerosis

Chung-Yi Chiu and Robert W. Motl Nicole Ditchman

University of Illinois at Urbana-Champaign Illinois Institute of Technology

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
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

confirmatory factor analysis (CFA), and construct validity was examined based on the strength of
This document is copyrighted by the American Psychological Association or one of its allied publishers.

bivariate correlations with scores on related measures. Results: Findings from the CFA indicated that a
first-order, 6-factor measurement model provided a good fit for the 24 items of the SPS (CFI ⫽ .94,
TLI ⫽ .93, RMSEA ⫽ 0.07) and that the 6 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 6 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.

Impact and Implications

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 6-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—that is,
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.

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

Introduction fatigue, pain, numbness, tingling, weakness, muscle stiffness or

spasms, tremors, bladder and bowel dysfunction, visual problems,
Multiple sclerosis (MS) is a chronic, unpredictable, and often cognitive dysfunction, emotional changes, depression, slurred
debilitating disease that involves an immune system attack against speech, difficulty walking, and problems with balance (Compston
oligodendrocytes in the central nervous system (Compston & & Coles, 2008; Giesser, 2011; NMSS, 2014). These symptoms can
Coles, 2008; National Multiple Sclerosis Society [NMSS], 2014). lead to gradual declines in social functioning and interpersonal
There are approximately 450,000 individuals living with MS in the interactions, and ultimately, diminished social support (Krokav-
United States, and most people are diagnosed between the ages of cova et al., 2008; McCabe, Ebacioni, Simmons, McDonald, &
20 and 50 years (Compston & Coles, 2008; Giesser, 2011; NMSS, Melton, 2015). For example, the severity of MS has been shown to
2014). People with MS experience many symptoms, including 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
This article was published Online First April 18, 2016. research indicating social support is vital for maintaining physical
Chung-Yi Chiu and Robert W. Motl, Department of Kinesiology and and mental health and promoting well-being and quality of life by
Community Health, University of Illinois at Urbana-Champaign; Nicole modulating stress and protecting against health problems (Benito-
Ditchman, Department of Psychology, Illinois Institute of Technology. León, Morales, Rivera-Navarro, & Mitchell, 2003; Buljevac et al.,
This research was supported from the United States Department of
2003; Cohen, Gottlieb, & Underwood, 2000; Mitchell, Benito-
Health and Human Services, National Institutes of Health, National Insti-
tute of Neurological Diseases and Stroke (Grant NS054050).
León, Gonzalez, & Rivera-Navarro, 2005; Nurullah, 2012).
Correspondence concerning this article should be addressed to Chung-Yi For people with MS, social support has been linked to improved
Chiu, PhD, Department of Kinesiology and Community Health, University coping with illness-related challenges, better physical and mental
of Illinois at Urbana-Champaign, Champaign, IL 61820. E-mail: chiucy@ health, modulated perceptions of stress, and increased quality of
illinois.edu life and well-being (Chronister, Chou, Frain, & Cardoso, 2008;

297
 298 CHIU, MOTL, AND DITCHMAN

Chronister, 2009; Haber, Cohen, Lucas, & Baltes, 2007; Matti et with this population. Moreover, this measure captures Weiss’s
al., 2010; Mitchell et al., 2005; Stuifbergen, Seraphine, & Roberts, conceptualization of dimensions of support that include both per-
2000; Suh, Weikert, Dlugonski, Sandroff, & Motl, 2012). In par- ceived availability of support as well as the individual’s perceived
ticular, stress is associated with MS recurrence and progression responsibility as a provider of support, making it especially useful
(Lovera & Reza, 2013), and social support plays a significant role for understanding the bidirectional nature of social support for
in buffering the impact of stress (Thoits, 1982). In addition, social people with MS. Thus, the purpose of this study was to test the
support increases self-esteem and self-efficacy, which are critical factorial validity of the SPS using confirmatory factor analysis
components for living a positive, healthy, and productive life with (CFA) and to examine its construct validity based on correlations
MS (Bandura, 1982; Cobb, 1976; Cutrona & Russell, 1987; Dlu- with related measures among people with MS.
gonski & Motl, 2012). Further, Thoits (1986) reported that the way
individuals mobilize and process social support reflects how they
Social Provisions Theory
cope with stressful life events, such as MS. Hence, screening is an
important first step in efforts to maintain or enhance social support According to Weiss’s (1974) social provisions theory, social
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

for people with MS who are at increased risk for diminished social support is defined in terms of its function, namely, social provi-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

support over time. sions. This theory considers the functions of social relationships
The construct of social support is complex and multidimen- across specific social roles (e.g., romantic partner, spouse, family
sional (Cobb, 1976; Lakey & Cohen, 2000). Although definitions members, friends, colleagues, etc.), especially when individuals
of social support are numerous and varied (e.g., Cobb, 1976; face critical life-changing events. Weiss (1974) proposed that
Heaney & Israel, 2002; Thompson, 1995; Wallston, Alagna, De- social ties provide social support and that specific social ties might
Vellis, & DeVellis, 1983), in general they highlight that social meet individuals’ different social support needs or might influence
support involves a process of perceiving the availability of differ- individuals to offer social support. Specifically, he analyzed social
ent types of support through interpersonal relationships among roles and their specific functions among adults who experienced a
social ties. The various definitions of social support have resulted major disruption in their lives, such as a change in health status,
in the development of a number of social support measures. death of a spouse, or retirement (Weiss, 1974). Based on his
However, there are only a few measures based on sound theories analysis of various social functions among interpersonal relation-
of social support (Chronister, Johnson, & Berven, 2006; Chronis- ships, he proposed six types of social provisions. Attachment refers
ter, 2009; Tawalbeh & Ahmad, 2013), and this adversely impacts to feelings of intimacy, peace, and security (similar to emotional
the quality of social support measurement (Chronister et al., 2006; support); social integration denotes sense of belonging to a group
Chronister, 2009; Gottlieb & Bergen, 2010). Moreover, most def- with whom one shares common interests and social activities;
initions and measures of social support focus solely on an indi- opportunity for nurturance represents the support receiver provid-
vidual’s perception of received or available support, and fail to ing care to others, such as children or senior family members;
recognize the bidirectional nature of support by not considering the reassurance of worth refers to having others validate one’s com-
extent to which the individual is also responsible for providing petence and value; reliable alliance has to do with perceived
support. access to assistance in times of need from others; and finally,
Use of a theory-driven social support measure is needed to guidance refers to having people available who can provide sug-
better assist in social support intervention development and eval- gestions, solutions, and advice when needed (Cobb, 1979). Ac-
uation (Chronister et al., 2006; Krokavcova et al., 2008). Yet, at cording to Weiss’s theory, each type of support provision is
this point, the rehabilitation field is lacking such a measure vali- embedded in a network of social connections, and multiple types
dated for use with people with MS. The Social Provisions Scale of social provisions may occur through a single connection. Weiss
(SPS), developed by Cutrona and Russell (1987) and based on further posited that people need all six types of social provisions,
Weiss’s (1974) social provisions theory, is one of the few theory- and if one type is deficient, people are at risk for experiencing
based social support measures available. The SPS has been used to social and/or emotional loneliness. This loneliness could subse-
a limited extent with people with disability and chronic illnesses. quently lead to poor concentration, distress, tension, disturbed
Scores on the SPS have been found to have a strong negative sleep, and disengagement, along with depression and generalized
correlation with loneliness among people with severe traumatic dissatisfaction (Weiss, 1974).
brain injury (McLean, Jarus, Hubley, & Jongbloed, 2014) as well Weiss’s social provisions theory has application to understand-
as significant correlations with psychosocial adjustment and symp- ing social support and well-being for people with MS. Research
tom severity among women with breast cancer (Mallinckrodt, suggests that people with MS rely on a number of individuals in
Armer, & Heppner, 2012). Two studies have used the SPS in their social network to provide different forms of support as
research with people with MS. Motl et al. (2007) found a relation- posited by this theory. Evidence supports that people who consti-
ship between scores on the SPS and exercise self-efficacy, func- tute the social networks of people with MS, such as professionals,
tional limitations, and quality of life among individuals with MS. family, friends, and partners, do indeed provide different forms of
Similarly, Jaracz et al. (2010) found that the SPS had a positive social support to serve a number of supportive functions (Costa,
relationship with the physical and mental health composite scores Sa, & Calheiros, 2012; Kouzoupis, Paparrigopoulos, Soldatos, &
on the MS Quality of Life measure (MSQOL-54; Vickrey, Hays, Papadimitriou, 2010). At the same time, the literature recognizes
Harooni, Myers, & Ellison, 1995). the benefits individuals derive as providers of social support
The SPS constitutes a potentially useful theory-based assess- (Plow, Finlayson, Gunzler, & Heinemann, 2015). For people with
ment tool for examining social support among people with MS, but MS, the ability to offer social provisions through performing social
further research is needed to provide support for the use of the SPS roles (e.g., parenting, working, volunteering) is associated with
 SOCIAL SUPPORT IN MULTIPLE SCLEROSIS 299

greater self-esteem, better quality of life, and higher levels of expressed interest in participating and 387 of them underwent
coping self-efficacy related to living well with MS (Plow et al., screening. Twenty-seven individuals did not satisfy the inclusion
2015). criteria, and 16 individuals declined participation. Informed con-
Much of the research applying and evaluating Weiss’s (1974) sent documents and verification letters were sent to the remaining
theory of social provisions uses the 24-item SPS developed by 344 individuals, and 300 consent forms were received. The re-
Cutrona and Russell (1987). The SPS has six subscales that align sponse rate was 87.2% at this point. Eight additional individuals
with Weiss’s six types of support provisions. In addition to eval- dropped out for unknown reasons, yielding a final sample of 292
uating perceived social support, the SPS takes into account social individuals with MS.
support that is offered by the individual. This scale’s emphasis on The majority of the participants (n ⫽ 245) were female. Most
the bidirectional nature of social support makes it idiosyncratic (n ⫽ 246) reported relapsing-remitting MS, followed by secondary
among the many other measures of social support. This feature is progressive MS (n ⫽ 34) and primary progressive MS (n ⫽ 12).
important because reciprocal support is necessary for living to- The mean age of the sample was 48.0 years (SD ⫽ 10.3, range ⫽
gether well, particularly in family relationships with an individual 20 – 69 years) and the average time since definitive diagnosis of
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

with chronic illness (Ek, Ternestedt, Andershed, & Sahlberg- MS was 10.3 years (SD ⫽ 7.9, range ⫽ 1–35 years). The sample
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Blom, 2011). Moreover, the provision of support by people facing was mostly Caucasian (94%), married (68%), and employed
challenges is also essential for mutual-aid and self-help support (53%). More than half (57.7%) were college graduates and another
groups (Gottlieb & Bergen, 2010). Importantly, being able to offer 28.0% reported some college education. Approximately two thirds
social support stimulates individuals’ self-esteem and self-efficacy (67.7%) reported a median annual household income of greater
(Cutrona & Russell, 1987; Weiss, 1974). than $40,000.
Although there is support for the factorial and construct validity
of the SPS (e.g., Cutrona & Russell, 1987), this scale has not been
Instruments
thoroughly validated for use with people with MS. Specifically,
researchers have not yet examined the extent to which the six Social Provisions Scale (SPS). The SPS assesses the degree
latent variables correspond with an overall, higher-order latent to which an individual perceives his or her social relationships to
factor of social provisions for people with MS. Although some provide various dimensions of social support, including opportu-
research has supported the relationship between the SPS global nities for the individual to provide support (Cutrona & Russell,
scale and quality of life and health indicators for people with MS 1987). It is a self-report questionnaire requiring approximately five
(Motl, McAuley, & Snook, 2007; Vickrey et al., 1995), more minutes to complete. It includes 24 items rated on a four-point
research is needed to understand the relationship between the SPS Likert-type scale with anchors of strongly disagree (1) and
subscales and measures of physical and psychological well-being. strongly agree (4). The scale includes six subscales based on
For this study, we hypothesized that the six factor structure of the Weiss’s (1974) social provisions theory: reliable alliance, attach-
SPS would be supported and that the SPS overall and subscale ment, nurturance, social integration, reassurance of worth, and
scores would have moderate to strong correlations with measures guidance. Each subscale has four items: two positively worded
of life satisfaction, mental health, and self-efficacy, but small to items describing the presence of a type of support and two nega-
moderate correlations with physical health status, including fatigue tively worded items assessing the absence of a type of support. For
and pain, as measures of social support generally are found to have example, on the attachment subscale two items are “I have close
higher correlations with mental rather than physical health indica- relationships that provide me with a sense of emotional security
tors (Chronister et al., 2008). Findings have the potential to support and well-being” and “I feel that I do not have close personal
the use of the SPS with people with MS and provide a foundation relationships with other people.” Cutrona and Russell (1987) used
for more focused examination and tailored intervention efforts CFA to support the validity of the six factor structure of the SPS
involving social provisions among this population. among college students, teachers, and nurses. They also recorded
test–retest reliability coefficients ranging from .37 to .66 over a
Method 6-month period. The Cronbach’s alpha coefficients of the six
factors ranged from .67 to .76, and items loaded on the respective
Participants factors supporting the construct validity of the scale (Cutrona &
Russell, 1987). In addition, moderate to high correlations between
This study involved a secondary analysis of existing baseline the SPS and other measures of support provided evidence for the
data from a previously completed study investigating changes in construct validity of the scale (Cutrona & Russell, 1987). Subse-
quality of life over time among people with MS (Motl, McAuley, quent studies have further supported the internal consistency of the
Snook, & Gliottoni, 2009). Participants came from a convenience global scale and subscales of the SPS in a range of populations
sample recruited through the Greater Illinois, Gateway, and Indi- (e.g., Green, Furrer, & McAllister, 2007; McLean et al., 2014;
ana chapters of the National MS Society. Recruitment occurred Ribas & Lam, 2010; Vogel & Wei, 2005). Additionally, a number
through (a) research announcements mailed to past study partici- of studies documenting correlations between the SPS and mea-
pants, (b) advertisements placed in each chapter’s MS Connection sures of well-being and physical health provide further evidence of
quarterly publication, and (c) e-mail messages that were distrib- the construct validity of the scale (e.g., Cutrona & Russell, 1987;
uted to all registered members of the chapters. To be included in Dlugonski & Motl, 2012; Jaracz et al., 2010; Mallinckrodt et al.,
the study, individuals had to (a) have an established definitive 2012; Motl et al., 2007).
diagnosis of MS, (b) be relapse free for the past 30 days, and (c) Satisfaction With Life Scale (SWLS). The SWLS was de-
be ambulatory with minimal to no assistance. Initially, 511 people signed to measure an individual’s perceived global life satisfaction
 300 CHIU, MOTL, AND DITCHMAN

across different life domains based on his or her values and captures subjective sensory and affective dimensions of pain (e.g.,
standards (Diener, Emmons, Larsen, & Griffin, 1985; Pavot, Die- throbbing, sharp; Melzack, 1987). It is rated on a four-point
ner, Colvin, & Sandvik, 1991). The SWLS has five items (e.g., “In Likert-type scale (0 ⫽ none to 3 ⫽ severe). The scores from the
most ways my life is close to my ideal.”) rated on a 7-point items are summed to form a pain rating index. The SF-MPQ is
Likert-type scale from one (strongly disagree) to seven (strongly internally consistent, appears to be reliable across time, and has
agree). The SWLS has good internal consistency, test–retest reli- evidence of score validity (Melzack, 1987). The Cronbach’s alpha
ability, and evidence of score validity (Diener et al., 1985; Pavot for the SF-MPQ was .88 in the present study.
et al., 1991). The Cronbach’s alpha coefficient for the SWLS was Patient Determined Disease Steps (PDDS). The PDDS is a
.89 in the present study. self-report measure based on response to a single item on a 9-point
Short Form 12 (SF-12). The SF-12 was used to measure ordinal scale describing level of perceived disability (e.g., 0 ⫽
perceived health-related quality of life (Ware, Kosinski, & Keller, normal, 8 ⫽ bedridden; Hadjimichael, Kerns, Rizzo, Cutter, &
1996). The scale consists of 12 items, and depending on the item, Vollmer, 2007). Scores from the PDDS have been found to be
response options range from a dichotomous “yes” or “no” re- linearly and strongly correlated with physician-administered Ex-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

sponse, to three-, and five-point rating scales (e.g., 1 ⫽ excellent panded Disability Status Scale (EDSS) scores, providing evidence
This document is copyrighted by the American Psychological Association or one of its allied publishers.

to 5 ⫽ poor). Items include: “In general, would you say your for the scale’s validity (Hadjimichael et al., 2007).
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?”.
Procedure
Ratings on the 12 items are summed to calculate a Physical
Component Summary Scale (PCS) and a Mental Component Sum- After initial contact and screening, an informed consent docu-
mary Scale (MCS) that range from 0 to 100. Scores are standard- ment and a form-letter for verifying the participant’s diagnosis of
ized from the general population (M ⫽ 50, SD ⫽ 10). Test–retest MS were sent to all participants through the U.S. Postal Service
reliability estimates based on a 2-week interval were .89 and .76 (USPS), along with prestamped and preaddressed envelopes for
for the PCS and the MCS, respectively (Ware et al., 1996). return postal service. The researchers called to ensure the partici-
Cronbach’s alpha coefficients for the PCS and MCS were .80 and pants received the documents, understood the directions, and
.78, respectively. signed the informed consent. Once the informed consent and MS
Hospital Anxiety and Depression Scale (HADS). The verification were returned, the battery of questionnaires was sent to
HADS is a subjective measure of anxiety and depressive moods all participants through the USPS, along with a prestamped and
(Zigmond & Snaith, 1983). The HADS contains two subscales preaddressed envelope for return postal service. The researchers
measuring self-reported anxiety (e.g., “Worrying thoughts go called to make sure the participants received the package and
through my mind.”) and depression (e.g., “I have lost interest in understood the directions. Participants then returned the study
my appearance.”). Each subscale has seven items. This scale has materials through the USPS. All questionnaires were checked for
been used in previous studies examining quality of life for people completeness. In the event of missing data, participants were
with MS (Janssens et al., 2003), and there is evidence of its score contacted by a member of the research team to collect the data over
reliability and validity (Zigmond & Snaith, 1983). For the present the phone. All participants received $20 after returning the ques-
study, the Cronbach’s alpha for the anxiety and depression com- tionnaire battery.
ponents of the HADS were .83 and .82, respectively.
Multiple Sclerosis Self-Efficacy Scale (MSSE). The MSSE
Data Analysis
was developed to assess perceived self-efficacy among people
with MS. The measure has two subjective subscales related to The data were analyzed with Mplus 7.0 (Muthén & Muthén,
function and control; each subscale has nine items rated on a scale 2012) and the Statistical Package for the Social Sciences (SPSS,
of 10 (very uncertain) to 100 (very certain; Schwartz, Coulthard- version 22.0). The measurement structure of the SPS was analyzed
Morris, Zeng, & Retzlaff, 1996). The function subscale assesses an using CFA with the robust maximum likelihood (MLR) estimator
individual’s confidence with functional abilities (e.g., “walk 100 in Mplus. The MLR estimator estimates standard errors and a
feet on flat ground”), whereas the control subscale measures con- chi-square test statistic that are robust to non-normality (Muthén &
fidence with managing symptoms and coping with the demands of Muthén, 2012). Two models for the SPS were tested using CFA:
illness (e.g., “how certain are you that you can control your (a) six, correlated first-order factors with four items per factor, and
fatigue?”). In the present study, the Cronbach’s alpha for the (b) one, second-order factor for describing the correlations among
function and control subscales were .79 and .95, respectively. the six first-order factors from the previous model. Model-data fit
Fatigue Severity Scale (FSS). The FSS was used to measure was assessed using the chi-square goodness-of-fit test, chi-square/
perceived fatigue (Krupp, LaRocca, Muir-Nash, & Steinberg, degree-of-freedom ratio, the comparative fit index (CFI), and the
1989) rated on a seven-point Likert-type scale (1 ⫽ disagree to root mean square error of approximation (RMSEA) following
7 ⫽ agree). The FSS has nine items that are combined to form an guidelines presented by Weston, Gore, Chan, and Catalano (2008).
overall measure of a person’s severity of fatigue symptoms (e.g., A nonsignificant chi-square, a relative chi-square (␹2/df) in the
“Fatigue interferes with my work, family, or social life”). There is range of 1 to 3, and values greater than 0.90 for the CFI are
support for the internal consistency, test–retest reliability, and considered an acceptable model fit, with a value of 0.95 or higher
score validity of this scale (Krupp et al., 1989). The Cronbach’s considered an excellent fit. For RMSEA, a value of less than 0.05
alpha for the FSS was .93 in the present study. indicates a close fit and values of up to 0.08 indicate reasonable
Short-Form McGill Pain Questionnaire (SF-MPQ). The errors of approximation in the population (Weston et al., 2008).
SF-MPQ scale is comprised of a 15-item adjective checklist that The critical ratio, which operates as a z-statistic in testing the
 SOCIAL SUPPORT IN MULTIPLE SCLEROSIS 301

significance of parameter estimates, was examined to determine Cronbach’s alpha coefficients ranged from .66 to .81 for the six
whether any SPS items could be deleted and modification indices subscales (see Table 1). The Cronbach’s alpha coefficient of the
were examined to determine whether additional model parameters overall SPS was .89. There were no large modification indices
could be estimated to provide a better model fit. Descriptive suggesting model parameters that should be freely estimated.
statistics were computed for all study variables using SPSS. Cron- Given that the CFA analyses supported the original six-factor
bach’s coefficient alphas were computed to evaluate the internal model, we calculated a global SPS score and the six subscale
consistency reliability of the SPS and its subscales using SPSS. scores for our subsequent analyses. The bivariate correlations
Pearson product–moment correlations were computed using SPSS between the SPS global score and six subscale scores are provided
to determine the relationships among SPS global scores and sub- in Table 2. The correlations among the subscales ranged from .30
scale scores with SWLS, HADS-Depression, HADS-Anxiety, to .63. The correlation coefficients between the global SPS and
MSSE, MCS, PCS, FSS, SF-MPQ, and PDDS. each subscale ranged from .63 to .78. The means, standard devi-
ations, and ranges of scores are reported in Table 3.
Results
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Construct Validity of the SPS

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SPS Reliability and Factorial Validity

Table 4 provides the correlations between the construct validity
The first-order model with six correlated factors adequately scales and the SPS scale. As hypothesized, the SPS total score had
described the pattern of variances and covariances for the 24 items moderate to strong correlations with psychosocial outcomes,
of the SPS (␹2 ⫽ 610.04, p ⬍ .001, df ⫽ 230, CFI ⫽ .94. TLI ⫽ whereas the correlations with physical health outcomes, although
.93, RMSEA ⫽ 0.07). The factor loadings ranged from .45 to .94. statistically significant, were low to moderate in magnitude. This
The second-order model indicated that the variances and covari- general pattern of higher correlations with psychosocial outcomes
ances among the six first-order factors were explained by a single, held for the subscales of the SPS as well. All SPS subscales, with
second-order factor of the overall social provisions construct (␹2 ⫽ the exception of the social integration subscale, were most strongly
676.81, p ⬍ .001, df ⫽ 246, CFI ⫽ .93. TLI ⫽ .92, RMSEA ⫽ correlated with the SWLS and HADS-depression scale, suggesting
0.08). The factor loadings for the second-order factor ranged that higher scores on most social provisions dimensions were most
between .65 and .90. Table 1 summarizes the standardized factorial strongly associated with greater overall satisfaction with life and
loadings and internal consistency coefficients of the SPS. The with lower symptoms of depression. For the social integration

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

1st order factor 2nd order factor

SPS item loading loading

Factor 1—Reliable alliance (Cronbach’s ␣ ⫽ .77) .84

6. If I needed financial assistance, there are people who would help me out. .76
12. There is at least one other person I would feel comfortable calling of I had a financial emergency .83
18. If I get in trouble, there is no one to help me. .88
24. I need assistance, there is no one I can count on. .75
Factor 2—Attachment (Cronbach’s ␣ ⫽ .81) .79
2. I lack a feeling of intimacy with another person. .77
10. I do not feel emotional closeness with even one other person .86
16. I have a special relationship with at least one other person. .86
22. There is someone to whom I feel very close. .88
Factor 3—Nurturance (Cronbach’s ␣ ⫽ .69) .82
5. Other people frequently turn to me for help. .63
11. I often provide assistance to others. .60
17. I rarely have the opportunity to help family members in need. .65
23. Family and friends never turn to me for help. .79
Factor 4—Social integration (Cronbach’s ␣ ⫽ .66) .65
4. I feel uncomfortable in group situations. .60
9. I usually disagree with the group consensus. .55
15. I participate in at least one group on a regular basis. .66
21. I feel part of at least one group. .94
Factor 5—Reassurance worth (Cronbach’s ␣ ⫽ .67) .90
1. I do not think other people respect my skills and abilities. .59
8. There are people who believe in my ability. .63
14. Other people know there are some jobs that are best handled by me. .61
20. No one values my skills and abilities. .83
Factor 6—Guidance (Cronbach’s ␣ ⫽ .69) .90
3. There are people who really know what I should do when I’m confused. .45
7. There is someone I can talk to who will provide solutions to my problems .76
13. I lack authoritive individuals who can provide me with advice .72
19. I do not know anyone who gives really good advice when I have problems. .74
 302 CHIU, MOTL, AND DITCHMAN

Table 2 However, this six-factor structure has not been consistently sup-
Bivariate Correlations Between the SPS Total Scores and SPS ported in the research. Mancini and Blieszner (1992) studied the
Subscale Scores factorial validity of the SPS among seniors aged 65 years and
older, finding only four factors: intimacy, social integration, reas-
Scale 1 2 3 4 5 6 7 surance of worth, and opportunity for nurturance (the original SPS
1. SPS total — factors of attachment, guidance, and reliable alliance were col-
2. Reliable alliance .77 — lapsed into one factor labeled intimacy). Participants in the present
3. Guidance .78 .63 — study were 20 to 69 years old, whereas participants were all over
4. Attachment .76 .41 .51 — 65 years old in Mancini and Blieszner’s study. As people age, the
5. Nurturance .69 .43 .36 .44 —
6. Social integration .63 .30 .36 .41 .36 — variety, quantity, quality, needs, and functions associated with
7. Reassurance of worth .78 .57 .54 .49 .52 .36 — individuals’ social networks likely change over time. Future stud-
ies to validate the SPS with people with MS over 65 years old is
Note. All correlations are significant (p ⬍ .001).
needed to examine whether the six-factor structure is maintained.
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

subscale, the highest correlations were with the HADS-depression Reliability of the SPS
and HADS-anxiety scales. There were only three correlations
between SPS subscales and validation scales that were not statis- The internal consistency findings of the overall SPS and its
tically significant, and these were related to physical health out- subscales were generally similar to previous internal consistency
comes. Specifically, the social integration subscale was not corre- coefficients reported in the literature (Cutrona & Russell, 1987;
lated with the SF-12 physical component score or with the PDDS, Green et al., 2007; McLean et al., 2014; Ribas & Lam, 2010;
and the reliable alliance subscale was not correlated with the Vogel & Wei, 2005), suggesting that the individual items com-
PDDS. prising 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 researchers were unable to deter-
Discussion mine whether social provisions vary over time. Motl et al. (2004),
This study was the first to examine the utility of the SPS in a however, determined through a longitudinal study with adolescent
sample of people with MS. Our findings provide support for the females that the SPS had good cross-validity, stationarity, and
psychometric strength of the SPS. We sought to investigate the stability over time. In terms of reliability over time for individuals
construct validity of the SPS and its subscales by comparing them with MS, when the disease progresses or disability increases, the
with measures of physical and psychosocial health commonly used dynamics of social provisions may change. Therefore, it would
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,
Table 3
thereby supporting that the SPS is consistent with Weiss’s social
Descriptive Statistics for the Study Measures (N ⫽ 292)
provisions theory. The correlation coefficients among the six sub-
scale scores were not as high as those reported by Cutrona and Measure Mean Standard deviation Range of scores
Russell (1987), and the moderate correlation coefficients among
the six subscale scores suggested that each social provisions factor SF-12 PCS 41.82 9.12 22.59–62.72
SF-12 MCS 41.19 9.14 19.38–60.81
represents related yet distinct types of social provisions. Further- SWLS 21.81 7.96 5.00–35.00
more, consistent with prior research (Chronister et al., 2006, 2008; PDDS 2.34 1.75 .00–6.00
Chronister, 2009; Cutrona & Russell, 1987; Haber et al., 2007), HADS_A 5.85 3.76 .00–18.00
our findings showed the SPS global score and subscale scores had HADS_D 6.05 4.17 .00–18.00
moderate to strong correlations with mental and psychosocial FSS 4.97 1.44 1.00–7.00
MPQ 10.73 7.77 .00–33.00
health indicators, and small to moderate correlations with mea- MSSE_Function 80.79 10.24 31.00–90.00
sures of physical health. Additionally, the present study raises MSSE_Control 66.08 19.29 13.00–90.00
important considerations for clinical practice and future research. SPS Global score 77.40 10.76 42.00–96.00
SPS subscale scores
Reliable alliance 13.32 2.59 4.00–16.00
Factorial Validity of the SPS Attachment 13.59 2.75 4.00–16.00
Nurturance 12.53 2.13 5.00–16.00
Results of the first and second-order factor analysis validated Social integration 12.44 2.39 5.00–16.00
that the SPS represents Weiss’s theoretical framework. This is Reassurance of worth 13.45 2.19 6.00–16.00
consistent with Cutrona and Russell’s (1987) prior findings. The Guidance 12.06 2.55 4.00–16.00
model fit index values in their study indicated that the six-factor Note. SF-12 PCS ⫽ SF12-Physical Component Summary Scale; SF-12
oblique model fit the data well. The authors assumed the possibil- MCS ⫽ SF12-Mental Component Summary Scale; SLWS ⫽ Satisfaction
ity of a second-order overall social provisions factor based on high With Life Scale; PDDS ⫽ Patient Determined Disease Steps Scale; HADS-
correlation coefficients between six factors and then conducted a A ⫽ Anxiety subscale of Hospital Anxiety and Depression Scale; HADS-
D ⫽ Depression subscale of Hospital Anxiety and Depression Scale;
six-factor, second-order CFA. This second-order model fit the data FSS ⫽ Fatigue Severity Scale; MPQ ⫽ Short-form of McGill Pain Ques-
well, and they concluded that the SPS assesses six distinct types of tionnaire; MSSE ⫽ Multiple Sclerosis Self-Efficacy Scale; SPS ⫽ Social
social provisions and one overall construct of social provisions. Provisions Scale.
 SOCIAL SUPPORT IN MULTIPLE SCLEROSIS 303

Table 4
Bivariate Correlations Between the Social Provisions Scale Global Score and Subscales With Other Measures

SPS Reliable Social Reassurance

Measure total alliance Guidance Attachment Nurturance integration of worth

Psychosocial measures
SWLS .64ⴱⴱⴱ .42ⴱⴱⴱ .48ⴱⴱⴱ .53ⴱⴱⴱ .46ⴱⴱⴱ .39ⴱⴱⴱ .51ⴱⴱⴱ
HADS_D ⫺.62ⴱⴱⴱ ⫺.38ⴱⴱⴱ ⫺.49ⴱⴱⴱ ⫺.51ⴱⴱⴱ ⫺.41ⴱⴱⴱ ⫺.47ⴱⴱⴱ ⫺.43ⴱⴱⴱ
HADS_A ⫺.45ⴱⴱⴱ ⫺.33ⴱⴱⴱ ⫺.34ⴱⴱⴱ ⫺.29ⴱⴱⴱ ⫺.32ⴱⴱⴱ ⫺.42ⴱⴱⴱ ⫺.29ⴱⴱⴱ
MSSE_Control .44ⴱⴱⴱ .30ⴱⴱⴱ .33ⴱⴱⴱ .33ⴱⴱⴱ .33ⴱⴱⴱ .33ⴱⴱⴱ .28ⴱⴱⴱ
SF12_MCS .40ⴱⴱⴱ .29ⴱⴱⴱ .34ⴱⴱⴱ .27ⴱⴱⴱ .23ⴱⴱⴱ .36ⴱⴱⴱ .26ⴱⴱⴱ
MSSE_Function .34ⴱⴱⴱ .24ⴱⴱⴱ .18ⴱⴱ .24ⴱⴱⴱ .31ⴱⴱⴱ .25ⴱⴱⴱ .30ⴱⴱⴱ
Physical health–related measures
FSS ⫺.32ⴱⴱⴱ ⫺.19ⴱⴱⴱ ⫺.23ⴱⴱⴱ ⫺.27ⴱⴱⴱ ⫺.23ⴱⴱⴱ ⫺.25ⴱⴱⴱ ⫺.21ⴱⴱⴱ
MPQ ⫺.28ⴱⴱⴱ ⫺.26ⴱⴱⴱ ⫺.23ⴱⴱⴱ ⫺.13ⴱ ⫺.13ⴱ ⫺.23ⴱⴱⴱ ⫺.23ⴱⴱⴱ
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

SF12_PCS .24ⴱⴱⴱ .15ⴱ .14ⴱ .21ⴱⴱⴱ .19ⴱⴱⴱ .11 .24ⴱⴱⴱ

This document is copyrighted by the American Psychological Association or one of its allied publishers.

PDDS ⫺.19ⴱⴱⴱ ⫺.07 ⫺.14ⴱ ⫺.16ⴱⴱ ⫺.17ⴱⴱ ⫺.10 ⫺.21ⴱⴱⴱ

Note. SLWS ⫽ Satisfaction With Life Scale; HADS_D ⫽ Depression subscale of Hospital Anxiety and Depression Scale; HADS_A ⫽ Anxiety subscale
of Hospital Anxiety and Depression Scale; MSSE ⫽ Multiple Sclerosis Self-Efficacy Scale; MCS ⫽ SF12-Mental Component Summary Scale; FSS ⫽
Fatigue Severity Scale; MPQ ⫽ Short-form of McGill Pain Questionnaire; PCS ⫽ SF12-Physical Component Summary Scale; PDDS ⫽ Patient Determined
Disease Steps Scale; SPS ⫽ Social Provisions Scale.
ⴱ
p ⬍ .05. ⴱⴱ p ⬍ .005. ⴱⴱⴱ p ⬍ .001.

likely be valuable in clinical practice to periodically assess the sion at some point (Sadovnick, Eisen, Ebers, & Paty, 1991; Siegert
status of social provisions for individuals with MS. & Abernethy, 2005).
Notably, severity of disability was independent of reliable alli-
Construct Validity of the SPS ance. This indicates that reliable alliance from a core social tie
(e.g., close family members, trustworthy friends) represents a basic
Similar to findings reported in existing studies (Chronister, social need, regardless of the level of disability severity. In addi-
2009; Cutrona & Russell, 1987; Dlugonski & Motl, 2012; Jaracz et tion, the uncertainty of MS and unpredictability of flare-ups may
al., 2010; Mallinckrodt et al., 2012; Motl et al., 2007), our results lead individuals with MS to seek out support to manage the
indicate that the global SPS and its subscales have moderate to condition despite disability severity. When individuals with MS
high correlations with mental and psychosocial health indicators
relapse, they may need tangible or material support from the
and small to moderate correlations with physical health measures.
reliable alliance provision to get their immediate needs met.
Of the psychosocial measures used in the study, the SPS and its
Our findings show that attachment and social integration were
subscales were correlated most strongly with life satisfaction and
strongly associated with life satisfaction, depression, and anxiety.
depression. The results also suggest stronger associations between
Attachment and social integration provide individuals with com-
the global SPS scores and life satisfaction and depression than
fort, security, happiness, and group identity oftentimes through
previously documented in the literature (Chronister, 2009; Cutrona
social ties with their spouses/partners, family members, and
& Russell, 1987; Dlugonski & Motl, 2012; Jaracz et al., 2010;
friends (Weiss, 1974). Consistent with the existing literature
Mallinckrodt et al., 2012; Motl et al., 2007), suggesting that for
people with MS, the global social provisions construct may be (Chronister et al., 2006, 2008; Chronister, 2009; Cobb, 1979), we
particularly important for promoting life satisfaction and mitigat- found that perceiving stronger attachment is correlated with higher
ing depression symptoms. life satisfaction and lower levels of depression. Attachment, a form
The reliable alliance and guidance subscales were strongly cor- of emotional support, is fundamental to individuals’ mental health
related positively with life satisfaction and negatively with depres- (Chronister et al., 2006, 2008; Chronister, 2009; Cobb, 1979). As
sion and moderately negatively correlated with fatigue and pain. individuals with MS age and their level of disability increases, they
According to Weiss (1974), guidance is regarded as informational/ express more needs related to family and desire opportunities for
instrumental support, whereas reliable alliance is similar to tangi- relationship counseling to maintain or improve their relationships
ble/material support. Some studies have found that informational/ with spouses/partners or other close ties (McCabe et al., 2015).
instrumental support helps manage physical health for people with Studies have shown that spouses/partners and family members
chronic illnesses because such support usually comes directly from report stress and frustration when they help individuals with MS
health professionals (Gottlieb & Bergen, 2010; Luszczynska, cope with the condition, and that they feel anger and/or grief when
Sarkar, & Knoll, 2007; Nurullah, 2012). Similarly, our findings they observe the progression of MS affecting their loved ones
suggest that receiving informational or instrumental guidance ap- (Devins, Seland, Klein, Edworthy, & Saary, 1993). When individ-
pears to help people with MS cope with fatigue and chronic pain uals with MS perceive a deteriorated relationship with their family
more effectively. Importantly, our findings show that perceiving members, they are more likely to become depressed and angry and
more guidance is associated with lower levels of depression. This experience perceived loss of control (McCabe & McKern, 2002).
is particularly important for persons with MS because approxi- Conversely, healthy attachments with their spouses/partners (e.g.,
mately half of those living with MS will experience major depres- establishing friendly and comfortable relationships) help individ-
 304 CHIU, MOTL, AND DITCHMAN

uals with MS cope with the disease and maintain functioning gration, worth, assistance, and nurturance. Brandt and Weinert
(Ghafari, Khoshknab, Norouzi, & Mohamadi, 2014). (1981) studied 149 spouses of individuals with MS, and because
Social integration had the strongest negative correlations with the nurturance subscale had only small correlations with the other
depression and anxiety and was not associated with disability and four subscales of the PRQ, authors concluded that nurturance
physical health. These findings suggest that belonging, social seemed to be an independent dimension. By contrast, the partici-
identity, and peer-support play an important role in the mental pants in the present study were individuals with MS as opposed to
health of persons with MS, regardless of the severity level of family members.
disability. This aligns with the literature reporting that people with The opportunity of nurturance subscale had moderate to high
MS attending MS support groups report learning how to cope with correlations with the other five subscales of the SPS, indicating
MS from peers in similar situations (Jean, Paul, & Beatty, 1999). that there was some level of overlap among the six subscales in
Interestingly, compared with seniors with MS, young adults with this sample. Further, this suggests that when individuals with MS
MS have been found to more often seek out peer support groups to are able to provide support to their loved ones, they not only
address a greater variety of needs (e.g., job, MS treatment), meet- perceive more self-value but also indicate perceptions of receiving
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

ing times, and modes of communication (e.g., Skype, phone, social more support provisions. Although social support is typically
This document is copyrighted by the American Psychological Association or one of its allied publishers.

media; Krokavcova et al., 2008). Additionally, Krokavcova and considered as an individual’s perceived availability or receipt of
colleagues (2008) noted that individuals with MS had fewer support, these findings highlight the importance of conceptualizing
friends and less contact from social networks. Yet, belonging to a social support as bidirectional. In other words, the positive benefits
peer cohort is considered an important component for helping associated with opportunities to provide support to others should
persons with MS adjust to living with a disability (Rudick, Miller, not be overlooked by clinicians and intervention strategies to
Clough, Gragg, & Farmer, 1992). improve well-being for people with MS.
The reassurance of worth subscale was strongly related to life
satisfaction and depression, and was moderately related to self- Limitations
efficacy for MS management. It is noteworthy that reassurance of
The following limitations of this study should be considered.
worth had small to moderate effect sizes with fatigue, chronic pain,
First, the sample may not be generalizable to all people with MS.
severity of disability, and general physical health. This suggests
The participants in this study primarily consisted of Caucasian
that individuals’ confidence in executing daily role functions may
women with relapsing-remitting MS. Although this is generally
be correlated with their perception of self-worth or self-esteem.
consistent with the national demographics of MS (NMSS, 2014),
Weiss (1974) stated that reassurance of worth can be beneficial for
we recommend that future research engage a more diverse sample
individuals experiencing either low or high levels of stress, be-
which would allow for a broader generalization of the findings
cause it increases individuals’ self-efficacy and self-esteem, and
among less representative groups of individuals with MS (e.g.,
can moderate the process of causal attributions. Self-esteem, de-
men, minority populations). A prior study found different factors
fined as an individual’s perceived worth, is developed in part from
of the SPS in seniors aged 65 years and above (Mancini &
opportunities to perform daily roles and social functions (e.g.,
Blieszner, 1992), whereas the majority of the participants in our
being a worker, partner, friend, family member, parent, etc.;
stud were younger than ages 65 years. We recommend that future
Rosenberg, 1989).
research recruit seniors with MS to assess the extent to which the
However, MS can present challenges to performing social func-
six factor structure holds. Further, the recruited participants in the
tions and consequently may reduce self-esteem. Low self-esteem
present study were all able to walk. Including only participants
has been correlated with depression, unhappiness, and poor quality
with walking ability may limit the range of disability severity.
of life among people with MS (Dlugonski & Motl, 2012; Kirana,
Overall, the majority of participants were middle class. It is pos-
Rosen, & Hatzichristou, 2009). Importantly, perceived self-worth
sible that lower social economic status and education levels may
moderates the impact of diseases, like MS, and facilitates positive
influence opportunities to receive and/or offer social provisions.
coping (Lazarus, 1966). Persons with MS reporting higher self-
Research focusing on validation of this scale in heterogeneous
esteem have been shown to employ more problem-focused coping,
groups of individuals with MS will provide further support for the
which is associated with positive adjustment to disability and
measurement structure and applications. Second, all measures in
well-being (Lazarus & Folkman, 1984; O’Brien, 1993). Hence, it
the study were based on self-report collected at the same time;
is important for health-related professionals to inquire whether
results might therefore be subject to response bias and overesti-
individuals with MS have difficulties performing their life roles
mation of validity coefficients. Further, assumptions regarding
and responsibilities to reassure or improve their perception of
causality cannot be made given the cross-sectional nature of the
self-worth. Health-related professionals may also need to provide
study. Additionally, we recommend the use of longitudinal CFA to
education to family members and coworkers about reasonable
examine pattern invariance, metric invariance, and intercept in-
expectations and potential accommodations to assist individuals
variance of the SPS over time, especially across human develop-
with MS to fulfill their role functions or work duties.
mental stages. Finally, participants in this study were self-selected
Being able to provide nurturance, or being able to help others, is
rather than being randomly selected, which is another source of
one of the ways to build self-worth. The opportunity for nurturance
potential bias that should be considered.
subscale had moderate to high correlations with life satisfaction
and depression and small to moderate correlations with fatigue.
Conclusions & Future Directions
This opportunity for nurturance factor was also adopted in the
Personal Resources Questionnaire (PRQ; Brandt & Weinert, The SPS is a useful instrument based on Weiss’s theory that
1981), which has five subscales—namely, intimacy, social inte- assesses six types of social provisions, incorporating both provi-
 SOCIAL SUPPORT IN MULTIPLE SCLEROSIS 305

sions that are perceived to be supportive and provisions provided adjustment to chronic illness and disability (pp. 149 –174). New York,
by the support receiver. In this study, results supported the facto- NY: Spring Publishing Company.
rial and construct validity of the SPS in a sample of individuals Chronister, J., Chou, C. C., Frain, M., & Cardoso, E. (2008). The relation-
with MS. Findings of the current study demonstrate the potential ship between social support and rehabilitation related outcomes: A
meta-analysis. Journal of Rehabilitation, 74, 16 –32.
utility of the SPS in clinical practice as a screening tool to assess
Chronister, J. A., Johnson, E. K., & Berven, N. L. (2006). Measuring social
social support for people with MS. Findings also highlight the
support in rehabilitation. Disability and Rehabilitation, 28, 75– 84.
importance of recognizing the functional specificity of interper- http://dx.doi.org/10.1080/09638280500163695
sonal relationships embedded in social ties. If an individual expe- Cobb, S. (1976). Presidential Address-1976. Social support as a moderator
riences a deficiency in one type of social provision, he or she may of life stress. Psychosomatic Medicine, 38, 300 –314. http://dx.doi.org/
not be able to compensate with other kinds of social provisions 10.1097/00006842-197609000-00003
based on Weiss’s theory (1974). Moreover, clinicians should rec- Cobb, S. (1979). Social support and health through the life course. In
ognize that building and maintaining various social ties may be M. W. Riley (Ed.), Aging from birth to death: Interdisciplinary perspec-
more helpful than securing limited types of social ties. Therefore, tives (pp. 93–106). Boulder, CO: Westview Press.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

it is important to screen for the social provisions status of individ- Cohen, S., Gottlieb, B. H., & Underwood, L. G. (2000). Social relation-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

uals with disabilities, like MS, by using a scale with sound psy- ships and health. In S. Cohen, L. Underwood, & B. H. Gottlieb (Eds.),
Social support measurement and intervention: A guide for health and
chometric characteristics. Our results support the SPS as a valid
social scientists (pp. 3–26). New York, NY: Oxford University Press.
reflection of Weiss’s six dimensions of social provisions and
http://dx.doi.org/10.1093/med:psych/9780195126709.003.0001
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closely. Additionally, our results indicate that social provisions tionships and adaptation to stress. In W. H. Jones & D. Perlman (Eds.),
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Devins, G. M., Seland, T. P., Klein, G., Edworthy, S. M., & Saary, M. J.
distinct social provision types mediate associations among biopsy-
(1993). Stability and determinants of psychological well-being in mul-
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MS with regard to age, severity of disability, gender, and minority satisfaction with life scale. Journal of Personality Assessment, 49, 71–
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with MS would be beneficial and allow for more comprehensive Dlugonski, D., & Motl, R. W. (2012). Possible antecedents and conse-
research and screening strategies through the inclusion of more quences of self-esteem in persons with multiple sclerosis: Preliminary
measures in a single study or clinic when time, participant, or evidence from a cross-sectional analysis. Rehabilitation Psychology, 57,
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Shifting life rhythms: Couples’ stories about living together when one
examine the predicative validity, pattern invariance, metric invari-
spouse has advanced chronic obstructive pulmonary disease. Journal of
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Ghafari, S., Khoshknab, M. F., Norouzi, K., & Mohamadi, E. (2014).
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