Content uploaded by Marcin Rzeszutek
Author content
All content in this area was uploaded by Marcin Rzeszutek on Apr 02, 2018
Content may be subject to copyright.
Contents lists available at ScienceDirect
Journal of Psychosomatic Research
journal homepage: www.elsevier.com/locate/jpsychores
Paradoxical effect of social support among people living with HIV: A diary
study investigating the buffering hypothesis
Marcin Rzeszutek
a,⁎
, Ewa Gruszczyńska
b
a
Faculty of Psychology, University of Warsaw, Stawki 5/7, 00-183 Warsaw, Poland
b
Faculty of Psychology, University of Social Sciences and Humanities, Chodakowska 19/31, 03-815 Warsaw, Poland
ARTICLE INFO
Keywords:
HIV
Diary study
Social support
Stress
Affect
ABSTRACT
Objective: The aim of this study was to examine the buffering role of time-varying received and provided support
in the relationship between stress and end-of-day mood among people living with HIV. In addition, the mod-
erating role of intimate relationships in this buffering effect was verified.
Methods: The participants included 115 patients with a confirmed diagnosis of HIV infection. The data were
collected using an online diary method. For five consecutive days (from Monday to Friday), participants com-
pleted an online time-stamped questionnaire in the evening to assess their end-of day-mood, stress related to a
central hassle on any given day and social support that was received and provided.
Results: The results of the multilevel analysis showed that daily provided, but not received, support had the
following partial buffering effect: the association between negative affect and stress was weaker on days with
higher support provision. However, this effect was limited to those participants who were in an intimate re-
lationship; the opposite effect was observed in single participants.
Conclusion: These findings suggest that the buffering effect of daily support may be modified by other social
resources, such as being in an intimate relationship, and when they are not available, it can even become
detrimental.
Previous studies investigating the psychosocial aspects of living
with HIV have focused mainly on the negative consequences of living
with HIV. This perspective assumes that people living with HIV are
primarily preoccupied with substantial HIV-related distress associated
with being diagnosed with a potentially life-threatening virus, such as
the unpredictability of the progression of HIV and intense social stig-
matization [26,43,52]. However, due to great advances in antiretroviral
treatment (ART) and knowledge regarding HIV/AIDS, many patients
with HIV currently consider their HIV infection a chronic, manageable
health condition, and while their health status remains important, it is
not necessarily a predominant source of everyday distress [13]. Partner
and family related conflicts [42], employment problems [40] and even
daily hassles [35] occur frequently, but these sources of daily stressors
are understudied in this patient group. Thus, despite having the same
source of chronic stress, i.e., the HIV infection, the stress level of pa-
tients with HIV may also fluctuate daily, which may be related to sig-
nificant individual differences in psychological functioning over time
[41]. The use of new technologies, such as electronic diaries provided a
unique opportunity to monitor these individual differences within this
population [44].
Electronic daily diaries are increasingly used in health studies as
part of broader mobile health programmes (m-Health; [33]). The use of
an intensive longitudinal design that includes the completion of elec-
tronic diaries as a component of data collection, overcomes several
limitations of traditional longitudinal designs by capturing behaviors as
they occur in real time and in the person's natural environment. Thus,
this design has the potential to provide a unique picture of daily within-
person fluctuations [6]. In studies of people living with HIV, daily
diaries have been applied to monitor various, yet rather restricted areas
of functioning, such as adherence to treatment [28], sexual activity
[23] and coping with HIV-internalized stigma [49]. To date, only
Farmer et al. [16] have examined daily problems associated with social
relationships via diaries and concluded that this area of functioning
may be a source of one of the highest levels of daily distress among
people living with HIV. Therefore, in this study, daily received and
provided support and its relationship to end-of-day well-being were
examined among this patient group.
Numerous studies have illustrated the beneficial role of social sup-
port in various areas of functioning among patients with HIV, including
better health-related quality of life [25], higher CD4 count [45] and
https://doi.org/10.1016/j.jpsychores.2018.03.006
Received 16 November 2017; Received in revised form 13 March 2018; Accepted 13 March 2018
⁎
Corresponding author.
E-mail addresses: marcin.rzeszutek@psych.uw.edu.pl (M. Rzeszutek), egruszczynska@swps.edu.pl (E. Gruszczyńska).
Journal of Psychosomatic Research 109 (2018) 25–31
0022-3999/ © 2018 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
T
lower levels of HIV-related distress [21]. However, many studies in-
vestigating social support among patients with HIV are inherently
limited by various shortcomings, such as the lack of a distinction among
different social support dimensions and the failure to explore the me-
chanism by which social support exerts its beneficial impact on various
stressors in this patient group [48]. Several authors have provided
evidence consistent with the classical buffering hypothesis [12], which
posits that perceived social support may act as a moderator of the re-
lationship between HIV-related distress and its various negative out-
comes, particularly depressive symptoms [5]. However, the aforemen-
tioned studies only used traditional retrospective measures of social
support and between-person designs. Therefore, these studies did not
verify the within-person effect of social support among patients with
HIV.
Tofullyverifythebuffering hypothesis of perceived social support, this
latter construct should be enriched with the inclusion of both directions of
social exchange, i.e., both received and provided support, because these two
social support dimensions may be differentially related to well-being under
stress [39]. Most authors have focused only on received support and have
shown both its beneficial [31] and detrimental effects [30]. The role of
provided support has been understudied, but according to certain studies,
this support may promote well-being to a greater extent [58]. However, in
the long term, if provided support is not reciprocated, it may actually have
the opposite effect on the provider's well-being [60], which is consistent
with the equity theory [47].
1. Current study
The beneficial role of received support in the well-being of patients
with HIV has been well-established but it has only been examined using
a between-person design (e.g., [1,38]). In contrast, to the best of the
authors' knowledge, the day to day process of support provision by
patients with HIV has not yet been examined in the literature. Thus, the
first novelty of this study is that we examined the buffering role of time-
varying received and provided support in the relationship between
stress and end-of-day mood among patients with HIV. In our first hy-
pothesis we investigated the within-person interaction to test whether
the daily relationship between stress and affect is moderated by the
daily received and provided social support.
Hypothesis 1. The daily received and provided support buffers the
negative effect of daily stress on end-of-day mood.
Hypothesis 1.1. Within the same person the negative relationship
between stress and end-of day mood is weaker on those days with
higher than typical received social support.
Hypothesis 1.2. Within the same person the negative relationship
between stress and end-of day mood is weaker on those days with
higher than typical provided social support.
There is some evidence in the literature that the main effect of social
support may modify the buffering effect of emotional social support
[18]. A close relationship serves as an important and stable source of
social support, mainly because it provides a framework for social ex-
change [34], especially on a daily basis and within the emotional do-
main [32]. The social context of HIV/AIDS makes the status of being in
an intimate relationship potentially even more important than it would
be for healthy individuals. Therefore, we decided to test whether the
within-person effect of support is modified by between-person differ-
ences in relationship status, which assumes three-way interaction: re-
lationship status × daily stress × daily social support on a daily mood.
In other words, we wanted to investigate whether being in a stable
intimate relationship may potentially boost the buffering effect of daily
support described in the first hypothesis.
Hypothesis 2. Being in a stable relationship moderates the within-
person buffering effect; that is, the buffering effect is stronger in
participants who are currently in a stable intimate relationship.
2. Method
2.1. Participants and procedure
One hundred and twenty participants with a confirmed diagnosis of
HIV infection were recruited during a control visit to an outpatient
clinic where they were receiving antiretroviral treatment. Two of these
people provided < 50% of the required diaries so they were excluded
from the study. In addition, three participants were excluded from the
analysis because they did not provide information regarding their re-
lationship status. Of the final sample (N = 115) 85% were men aged
40 ± 10.6 years, 76% of whom were employed, while 62% held a
university degree. Approximately 60% of the participants declared that
they were in an intimate relationship. The detailed socio-demographic
and health-related characteristics of the participants are presented in
Table 1.
The inclusion criteria were as follows: 1) medically confirmed di-
agnosis of HIV infection, 2) receiving ART, 2) a lack of illness-related
cognitive disorders, 3) no current diagnosis of substance dependence,
and 4) access to the Internet. The participation was voluntary, without
remuneration to participants.
The study protocol was approved by the local ethics commission.
The data were collected using an online diary method. This data col-
lection approach is considered a special case of a longitudinal design to
capture participants' experiences in a way that is not possible using
traditional longitudinal or cross-sectional designs [6]. For five con-
secutive days (Monday to Friday) the participants completed online
time-stamped questionnaires that were sent as hyperlinks via e-mail
each evening to assess their end-of-day mood, their stress as related to a
central hassle on that day, and their social support both received and
provided. Each day's evaluation required approximately 5 to 7 min. The
online diaries were accessible from Internet-connected PCs, smart-
phones and tablets. Daily access was restricted to a limited time, after
which the diary could not be accessed. In addition, the participants
were unable to review their previous answers. This procedure is the
gold standard in diary studies [37].
Table 1
The sample characteristics (N = 115).
Variable N (%)
Gender
Male 98 (85.2%)
Female 17 (14.8%)
Age in years (M ± SD) 40.0 ± 10.6
Being in an intimate relationship
Yes 69 (60.0%)
No 46 (40.0%)
Education
University degree 71 (61.7%)
Below university degree 44 (38.3%)
Employment
Yes 87 (75.7%)
No 28 (24.3%)
HIV/AIDS status
HIV+ only 95 (82.6%)
HIV/AIDS 20 (17.4%)
HIV infection duration in years (M ± SD) 7.77 ± 6.86
Antiretroviral treatment (ART) duration in years (M ± SD) 5.69 ± 4.94
CD4 Count 595.75 ± 243.54
M. Rzeszutek, E. Gruszczyńska Journal of Psychosomatic Research 109 (2018) 25–31
26
2.2. Measures
End-of-day mood was assessed using the following 12 items from
the PANAS-X, which was developed by Watson et al. [59] in a Polish
adaptation of Brzozowski [11]: 6 items assessed negative affect (e.g.,
tired, unhappy, and upset), and 6 items assessed positive affect (e.g.,
calm, excited, and satisfied). The participants evaluated how they felt at
the end of each day and provided their answers on a 5-point scale from
1 = very slightly or not at all to 5 = strongly. The multilevel reliability
(omega coefficient, [15]) is provided in Table 2. The values were sa-
tisfactory at both the within- and between-person levels.
The stress level due to central hassles was evaluated using the oper-
ationalization modification proposed by Dunkley et al. [14]. The partici-
pants chose their most central hassle in a given day and then answered
questions about event-related stress, controllability and importance. In this
study, the data focused only on experienced stress levels. For the question
“How stressful was the event or issue to you?”, the participants provided an
answer from 1 = not at all to 5 = very much.
Received and provided emotional social support were each mea-
sured using 3 items from the relevant subscales of the Berlin Social
Support Scales developed by Schulz and Schwarzer [55] in a Polish
adaptation of Łuszczyńska et al. [36]. They were rephrased accordingly
to adjust the items to daily measurement. The participants reported
their responses regarding their daily interpersonal relationships in
terms of the support provided and received on a 5-point scale (1 = not
at all to 5 = very much). The subscales had good reliability at both
measurement levels (see Table 2).
Relationship status was a dichotomous yes/no variable (coded 1/0)
according to the answer to the question “Are you currently in an in-
timate formal or informal relationship?”
3. Data analysis
The data had a hierarchical structure with repeated measures for all
participants. This structure leads to a two-level model with daily
measures for the same person at Level 1 (within-person) and stable
individual differences in measured variables at Level 2 (between-
person). The raw data were transformed to differentiate these two
sources of variance. The daily repeated measures were centred around
individual means and were interpreted as day-by-day variations from
the typical levels of each person (Level 1). To identify the differences
among individuals, all measurement points were aggregated for each
variable and then centred around the mean of the whole sample (Level
2). Because the daily measures of the same individual are not in-
dependent, a first-order autoregressive covariance structure was as-
sumed [6]. Also, random intercept and slopes were included as models
with them fitted the data significantly better than models without them.
The hypotheses were verified using a stepwise approach. In Model 1
the Level-1 variables, including daily positive (or negative) affect, daily
stress, daily received (or provided) support, were entered, followed by
the Level-2 variables, including between-person positive (or negative)
affect, stress, provided (or received) support and being in relationship.
The Level-2 variables, except for relationship status, were added to
control for interpersonal differences in affect, stress and support. Time
was also included to control for possible systematic changes during the
study. To test hypothesis 1, the respective Level-1 interaction term was
included in Model 2 as follows: daily stress × daily support, which can
be interpreted as within-person buffering effect. Next, in Model 3 two
other interaction terms necessary to test hypothesis 2 were added. Fi-
nally, the cross-level three-way interaction term was examined in
Model 4, with being in a relationship as a potential moderator of the
aforementioned Level-1 interaction. The improvement of each model
over the previous model was assessed using the difference between the
likelihood ratios (−2LLdiff) and chi square distribution. Because the
random part of the models remained unchanged in all analyses, the
number of degrees of freedom for the difference comparison was based
on the number of added fixed parameters. The analyses were conducted
using IBM SPSS 24 statistical software [27].
4. Results
4.1. Preliminary analysis
An examination of the data did not show any systematic pattern of
missingness. Therefore they could be considered missing at random
and, based on the current recommendations, dealt with maximum
likelihood procedures [22].
The intraclass correlation coefficient (ICC) for daily measured
variables ranged from 0.29 to 0.56. Values of ICC above 0.20 are re-
garded as dependence which may cause biased results if a hierarchical
data structure is ignored in data analysis [6]. Only 29% of the varia-
bility in the answers regarding stress can be explained by between-
person variations, whereas these values are 56 and 52% for received
and provided support, respectively. Additionally, considering the 5-
point answering scale used for the support measurement, the obtained
aggregated mean values, which are reported in Table 2, can be con-
sidered high. However, the ICC suggests that up to 48% of the social
support variance can be explained by within-person variability, which
is important for the aim of the study, i.e., testing the buffering hy-
pothesis using a day-by-day approach.
The socio-demographic and health-related characteristics (i.e., gender,
age, education, employment status, CD4 count and diagnosis of AIDS) were
unrelated to the end-of-day mood; thus, these variables were excluded from
all further analyses. However, positive and negative affect were significantly
inversely related (−0.53, p < .001); thus, affect of opposite valence was
included in all analyses to control for this shared variance.
4.2. Hypothesis 1
To verify Hypothesis 1, Model 2 was tested against Model 1. As
shown in Tables 3 and 4, a significant increase in the model fit and
significant daily stress × daily support interaction were observed for
negative affect and provided support only. A simple slope analysis [46]
revealed that on the days on which the participants reported lower than
typical levels of provided support, the positive relationship between
daily stress and negative affect was stronger (γ= 0.29, SE = 0.05,
z = 5.58, p < .001) than that on the days on which the participants
reported higher than typical levels of provided support (γ= 0.15,
SE = 0.06, z = 2.66, p < .01). Thus, Hypothesis 1 can be considered
as partially supported.
4.3. Hypothesis 2
Similarly, Model 4 showed a significant fit improvement over Model
3 for negative affect only but for both daily received and provided
support (see Tables 3 and 4, respectively). As shown in Figs. 1 and 2,
the previously described interaction effects differ between participants
who are in an intimate relationship and those who are not. A partial
Table 2
Means, standard deviations, ICC and multilevel reliability of the studied variables.
Variable M SD ICC Omega
Level 1 Level 2
Negative affect 2.09 0.57 0.35 0.81 0.91
Positive affect 2.87 0.65 0.48 0.79 0.91
Received support 3.98 0.75 0.56 0.76 0.97
Provided support 4.04 0.68 0.52 0.74 0.95
Stress 2.83 0.73 0.29 ––
Note. Mean and standard deviations for aggregated scores, n =115 participants.
There are no omega values for stress as it was measured with one item only.
M. Rzeszutek, E. Gruszczyńska Journal of Psychosomatic Research 109 (2018) 25–31
27
buffering effect of received support (Fig. 1) was observed only in par-
ticipants in a relationship; the positive relationship between daily stress
and negative affect was stronger with lower daily support receipt
(γ= 0.32, SE = 0.06, z = 5.05, p < .001) than that with higher daily
support receipt (γ= 0.14, SE = 0.07, z = 2.09, p = .04). In contrast,
the single participants reported a significant relationship between daily
stress and negative affect only when higher than typical social support
is received (γ= 0.26, SE = 0.09, z = 3.05, p = .002). On days with a
lower support receipt, daily stress and negative affect were unrelated in
this group (γ= 0.08, SE = 0.09, z = 0.84, ns). The pattern was similar
for provided support (Fig. 2): the relationship between daily stress and
negative affect was stronger on days with a lower support provision
(γ= 0.34, SE = 0.06, z = 5.71, p < .001) than that on days with a
higher support provision (γ= 0.11, SE = 0.06, z = 1.75, ns) for parti-
cipants in a relationship. For participants who declared being single,
the opposite effect was noted. Namely, the relationship between daily
stress and negative affect was insignificant on days with lower support
provision (γ= 0.12, SE = 0.09, z = 1.25, ns) but was positive and
significant on days with higher support provision (γ= 0.30, SE = 0.10,
z = 2.89, p = .004).
5. Discussion
The results of this study were consistent with the first hypothesis but
only to a certain extent. The relationship between daily stress and ne-
gative affect was moderated by daily provided, but not received, social
support. Additionally, compared to days with a lower support provi-
sion, a partial, but not total, buffering effect was observed on days with
a higher support provision, and the relationship between stress and
negative affect was weaker but still significantly different from zero.
Table 3
Results of multilevel analyses for received support, stress and being in relationship on the end-of-day-mood (fixed effects).
Parameters Negative affect Positive affect
Model 1 Model 2 Model3 Model 4 Model 1 Model 2 Model3 Model 4
Est (SE) Est (SE) Est (SE) Est (SE) Est (SE) Est (SE) Est (SE) Est (SE)
Intercept 2.04 (0.08)
⁎⁎⁎
2.04 (0.08)
⁎⁎⁎
2.04 (0.08)
⁎⁎⁎
2.04 (0.08)
⁎⁎⁎
2.72 (0.08)
⁎⁎⁎
2.72 (0.08)
⁎⁎⁎
2.72 (0.09)
⁎⁎⁎
2.72 (0.09)
⁎⁎⁎
Time 0.006 (0.02) 0.006 (0.02) 0.005 (0.02) 0.007 (0.02) 0.04 (0.02)
⁎
0.04 (0.02)
⁎
0.03 (0.02)
⁎
0.03 (0.02)
⁎
Daily opposite affect −0.53 (0.04)
⁎⁎⁎
−0.53 (0.04)
⁎⁎⁎
−0.52 (0.04)
⁎⁎⁎
−0.52 (0.04)
⁎⁎⁎
−0.52 (0.04)
⁎⁎⁎
−0.52 (0.04)
⁎⁎⁎
−0.52 (0.04)
⁎⁎⁎
−0.52 (0.04)
⁎⁎⁎
Daily stress (S) 0.23 (0.04)
⁎⁎⁎
0.22 (0.04)
⁎⁎⁎
0.22 (0.08)
⁎⁎
0.22 (0.08)
⁎⁎
−0.06 (0.04) −0.06 (0.04) 0.004 (0.06) 0.003 (0.07)
Daily received support (RSup) −0.0008 (0.01) 0.0008 (0.01) 0.006 (0.02) 0.006 (0.02) 0.03 (0.01)
⁎
0.03 (0.01)
⁎
0.03 (0.02) 0.03 (0.02)
Being in relationship (R) 0.06 (0.09) 0.06 (0.09) 0.06 (0.09) 0.05 (0.09) 0.15 (0.10) 0.15 (0.10) 0.15 (0.10) 0.15 (0.10)
S × RSup −0.02 (0.02) −0.02 (0.02) 0.02 (0.03) 0.006 (0.01) 0.005 (0.01) −0.001 (0.03)
RSup × R −0.01 (0.03) −0.007 (0.03) −0.01 (0.02) −0.01 (0.02)
S×R −0.002 (0.09) −0.007 (0.08) −0.09 (0.07) −0.09 (0.08)
S × RSup × R −0.07 (0.03)
⁎
0.008 (0.03)
−2 Restricted Log
Likelihood (−2LL)
981.42 979.32 979.18 975.35 988.49 988.32 986.80 986.74
−2LL diff(df) 2.1 (1) 0.14 (2) 3.83 (1)
⁎
0.17 (1) 1.52 (2) 0.06 (1)
Note. 115 participants and 575 measurement points. Est (SE) –estimate and standard error. Each model was adjusted for between-person effects of stress, provided support and opposite
affect but for simplicity's sake their estimates were removed from the table.
⁎
p < .05.
⁎⁎
p < .01.
⁎⁎⁎
p < .001.
Table 4
Results of multilevel analyses for provided support, stress and being in relationship on the end-of-day-mood (fixed effects).
Parameters Negative affect Positive affect
Model 1 Model 2 Model3 Model 4 Model 1 Model 2 Model3 Model 4
Est (SE) Est (SE) Est (SE) Est (SE) Est (SE) Est (SE) Est (SE) Est (SE)
Intercept 2.04 (0.08)
⁎⁎⁎
2.04 (0.08)
⁎⁎⁎
2.04 (0.08)
⁎⁎⁎
2.05 (0.08)
⁎⁎⁎
2.73 (0.08)
⁎⁎⁎
2.73 (0.09)
⁎⁎⁎
2.74 (0.09)
⁎⁎⁎
2.74 (0.09)
⁎⁎⁎
Time 0.009 (0.02) 0.008 (0.02) 0.007 (0.02) 0.008 (0.02) 0.03 (0.02) 0.03 (0.02) 0.03 (0.02) 0.03 (0.02)
Daily opposite affect −0.55 (0.04)
⁎⁎⁎
−0.55 (0.04)
⁎⁎⁎
−0.55 (0.04)
⁎⁎⁎
−0.54 (0.04)
⁎⁎⁎
−0.53 (0.04)
⁎⁎⁎
−0.53 (0.04)
⁎⁎⁎
−0.53 (0.04)
⁎⁎⁎
−0.53 (0.04)
⁎⁎⁎
Daily stress (S) 0.22 (0.04)
⁎⁎⁎
0.21 (0.04)
⁎⁎⁎
0.21 (0.07)
⁎⁎
0.25 (0.07)
⁎⁎
−0.04 (0.04) −0.04 (0.04) 0.04 (0.07) 0.04 (0.07)
Daily provided support (PSup) −0.002 (0.01) −0.002 (0.01) 0.01 (0.02) 0.01 (0.02) 0.04 (0.02)
⁎
0.04 (0.01)
⁎
0.05 (0.02)
⁎
0.05 (0.02)
⁎
Being in relationship (R) 0.05 (0.09) 0.04 (0.09) 0.04 (0.09) 0.02 (0.09) 0.18 (0.11) 0.18 (0.11) 0.17 (0.11) 0.17 (0.11)
S × PSup −0.03 (0.02)
⁎
−0.03 (0.02)
⁎
0.03 (0.03) −0.007 (0.02) −0.005 (0.02) 0.005 (0.03)
PSup × R −0.02 (0.03) −0.02 (0.03) −0.03 (0.03) −0.03 (0.03)
S×R −0.004 (0.09) −0.05 (0.09) −0.12 (0.08) −0.12 (0.09)
S × PSup × R −0.09 (0.04)
⁎⁎
−0.01 (0.04)
−2 Restricted Log
Likelihood (−2LL)
978.43 974.30 973.47 967.81 990.57 990.39 987.59 987.44
−2LL diff(df) 4.13 (1)
⁎
0.83 (2) 6.66 (1)
⁎
0.18 (1) 2.80 (2) 0.15 (1)
Note. 115 participants and 575 measurement points. Est (SE) –coefficient and standard error. Each model was adjusted for main effects of between-person effects of stress, provided
support and opposite affect but for simplicity's sake their estimates were removed from the table.
⁎
p < .05.
⁎⁎
p < .01.
⁎⁎⁎
p < .001.
M. Rzeszutek, E. Gruszczyńska Journal of Psychosomatic Research 109 (2018) 25–31
28
Finally, notably, stress experienced due to a central hassle was related
only to negative affect at the end of the day, which may explain the lack
of the aforementioned buffering effect of positive affect.
The non-significant role of received support is consistent with other
studies showing the phenomenon of the mixed blessing of receiving
support [20]. This type of support is occasionally unrelated to well-
being and can even have a detrimental effect on the support's recipient,
as it may create feelings of guilt, dependency or inefficiency, especially
if people receive more support than they are in need of, making support
receipt an indicator of high stress [7], which was also found in daily
diary studies [54]. In contrast, the beneficial effect of providing support
on the provider's well-being is particularly visible on a daily basis [39].
Daily support provision may be particularly important for chronically
ill patients because it constitutes a relieving experience that distracts
their attention from illness-related distress, allowing them to show their
independence and boost their self-efficacy and self-esteem [29]. Thus,
this finding is consistent with the general esteem enhancement theory
of social support [3]. Similarly, in this study, the participants appeared
to benefit more in terms of their end-of-day negative affect from the
self-perception of being support providers rather than support re-
cipients.
This finding, however, cannot be interpreted without a direct re-
ference to the surprising results of testing Hypothesis 2, which con-
tradicted our expectations; the buffering effect was limited to partici-
pants in a relationship, while for those who were single, a detrimental
effect was noted. In particular, for participants in a relationship, on
days with a higher than typical level of provided or received support, a
weaker association between daily stress and negative affect was noted
compared to that observed on days with a lower than typical level of
support. In contrast, a paradoxical effect was noted in the single par-
ticipants, i.e., a higher support provision or receipt was a condition
under which higher daily stress corresponded with higher negative
affect. On days with a lower level of received or provided support, this
relationship was not significant. Thus, the relationship status did
moderate the relationship between daily stress and daily support on
negative affect but unexpectedly “divided”the relationship into buf-
fering and detrimental effect. This finding is a major contribution of this
study since it provides empirical evidence that being in relationship is a
resource that may change negative affect-stress-support associations on
a daily basis.
According to the equity theory of social support, the balance be-
tween providing and receiving support is crucial for well-being [19].
Being in a relationship constitutes a type of obligation to be mutually
supportive, particularly during stressful days, which may facilitate the
effective regulation of this balance on a daily basis [32]. This obligation
is even more strongly pronounced in the relational regulation theory
[34], which assumes that the beneficial effect of social support on
emotional well-being is due to repeated moment-by-moment ordinary
daily interactions and activities rather than specific sources of distress
and coping with the distress. Thus, support provision was shown to
exert a beneficial effect on the provider's well-being among emotionally
engaged providers but may be unrelated to or even deteriorates well-
being among emotionally unengaged participants [10]. In contrast,
there is evidence in the literature suggesting that single people, com-
pared to coupled individuals, report higher levels of loneliness and
distress, and thus, the exchange of emotional social support in the face
of daily stress may require a single person to make additional invest-
ments of psychological resources [53]. The cost of this investment may
overbalance the benefits, which results in a higher negative affect de-
spite receiving or providing support.
However, the question of how strongly this effect is related to the
sample specificity, i.e., patients with HIV, remains unanswered.
Although family and friends provide support to this patient group, the
most important source of support stems from relationship partners
Fig. 1. Interaction effect of daily stress and daily received support on negative affect depending on relationship status: Results of simple slopes analysis.
Fig. 2. Interaction effect of daily stress and daily provided support on negative affect depending on relationship status: Results of simple slopes analysis.
M. Rzeszutek, E. Gruszczyńska Journal of Psychosomatic Research 109 (2018) 25–31
29
[24,51]. Providing love and intimacy is crucial for maintaining close
relationships among patients with HIV [50,57] and helps cope with the
uncertainty related to disease progression [9]. Additionally, compared
to those in a relationship, single patients with HIV receive less support
due to the social interpretation of the infection and the dilemma of
disclosure [56], which can also be related to risky behaviors and poor
affective well-being [4]. Thus, these study results are consistent with
the reasoning presented earlier and suggest that the effect may not be
specific to patients with HIV but may be particularly strong among this
population. Therefore, further studies are required in this group and
other groups of people potentially vulnerable to social stigmatization.
6. Strengths and limitations
This study has several strengths because it is among the first studies
to assess the daily functioning of HIV patients using the same design as
that used to investigate patients with other chronic diseases, reflecting
the current proceedings in the medical control of HIV infection.
Additionally, the good multilevel reliability of the tools is strength of
the study. Nevertheless, this study is not free from limitations. First,
although an intensive longitudinal design was applied, this study is
correlational in nature; thus, no cause-and-effect explanations are
possible. In addition, no other studies involving HIV patients that could
be directly compared with this specific study design have been per-
formed. Thus, the possibility that the findings of this study are sample
or time-specific cannot be entirely excluded. Finally, this study is based
on the participants' self-perception; thus, a dyadic approach should be
implemented in future studies involving HIV patients to test social ex-
change more in-depth.
7. Conclusion
Despite the aforementioned limitations, this study adds knowledge
regarding the so-called paradoxical effect of social support and expands
upon the growing body of empirical literature illustrating the different
effects of support provision and receipt. More specifically, this study
suggests that social support exerts a daily buffering effect that may be
limited to groups with higher social resources, but social support can be
detrimental for other groups. Additionally, this study may be an im-
portant contribution to the HIV/AIDS literature and underscores the
need for more studies investigating the functioning of HIV patients in
everyday life and the significance of being in an intimate relationship
for their daily affective well-being.
Conflict of interest
The corresponding author declares that he has no conflict of in-
terest. The second author declares that she has no conflict of interest.
Acknowledgments
This work was supported by the University of Warsaw, Faculty of
Psychology under Grant BST181409/2017.
References
[1] S. Abramowitz, L.J. Koenig, S. Chandwani, L. Orban, R. Stein, R. LaGrange,
W. Barnes, Characterizing social support: global and specific social support ex-
periences of HIV-infected youth, AIDS Patient Care STDs 23 (2009) 323–330.
[3] C. Batson, A. Powell, Altruism and prosocial behavior, Handbook of Psychology,
John Wiley & Sons, Inc., 20032003.
[4] J. Bauermeister, Sexual partner typologies among single young men who have sex
with men, AIDS Behav. 19 (2015) 1116–1128, http://dx.doi.org/10.1007/s10461-
014-0932-7.
[5] T. Bekele, S. Rourke, R. Tucker, S. Greene, M. Sobota, J. Koornstra, L. Monette,
S. Rueda, J. Bacon, J. Watson, S. Hwang, J. Dunn, D. Guenter, Direct and indirect
effects of perceived social support on health-related quality of life in persons living
with HIV/AIDS, AIDS Care 25 (2013) 337–346, http://dx.doi.org/10.1080/
09540121.2012.701716.
[6] N. Bolger, J. Laurenceau, Intensive Longitudinal Methods: An Introduction to Diary
and Experience Sampling Research, Guilford Press, New York, NY, US, 2013.
[7] N. Bolger, M. Foster, A.D. Vinokur, R. Ng, Close relationships and adjustment to a
life crisis: the case of breast cancer, J. Pers. Soc. Psychol. 70 (1996) 283–294,
http://dx.doi.org/10.1037/0022-3514.70.2.283.
[9] D. Brashers, J. Neidig, D. Goldsmith, Social support and the management of un-
certainty for people living with HIV or AIDS, Health Commun. 16 (2004) 305–331,
http://dx.doi.org/10.1207/S15327027HC1603_3.
[10] S. Brown, R. Nesse, A. Vinokur, D. Smith, Providing social support may be more
beneficial than receiving it: results from a prospective study of mortality, Psychol.
Sci. 14 (2003) 320–327, http://dx.doi.org/10.1111/1467-9280.14461.
[11] P. Brzozowski, Skala UczućPozytywnych i Negatywnych (SUPIN). Podręcznik.
[Positive and Negative Affect Schedule: Manual], Psychological Test Laboratory of
the Polish Psychological Association, Warsaw, 2010.
[12] S. Cohen, T. Wills, Stress, social support and the buffering hypothesis, Psychol. Bull.
98 (1985) 310–357, http://dx.doi.org/10.1037/0033-2909.98.2.310.
[13] S. Deeks, S. Lewin, D. Havlir, The end of AIDS: HIV infection as a chronic disease,
Lancet 382 (2013) 1525–1533, http://dx.doi.org/10.1016/S0140-6736(13)61809-
7(Published online October 21, 2013).
[14] D.M. Dunkley, D.C. Zuroff, K.R. Blankstein, Self-critical perfectionism and daily
affect: dispositional and situational influences on stress and coping, J. Pers. Soc.
Psychol. 84 (2003) 234–252, http://dx.doi.org/10.1037/0022-3514.84.1.234.
[15] T. Dunn, T. Baguley, V. Brunsden, From alpha to omega: a practical solution to the
pervasive problem of internal consistency estimation, Br. J. Psychol. 105 (2014)
399–412, http://dx.doi.org/10.1111/bjop.12046.
[16] S. Farmer, D. Mindry, W. Comulada, D. Swendeman, Mobile phone ecological
momentary assessment of daily stressors among people living with HIV: elucidating
factors underlying health-related challenges in daily routines, J. Assoc. Nurses AIDS
Care 28 (2017) 737–751, http://dx.doi.org/10.1016/j.jana.2017.04.001.
[18] B. Feeney, N. Collins, A new look at social support: a theoretical perspective on
thriving through relationships, Personal. Soc. Psychol. Rev. 19 (2015) 113–147,
http://dx.doi.org/10.1177/1088868314544222.
[19] M. Gleason, M. Iida, N. Bolger, P. Shrout, Daily supportive equity in close re-
lationships, Personal. Soc. Psychol. Bull. 29 (2003) 1036–1045, http://dx.doi.org/
10.1177/0146167203253473.
[20] M. Gleason, M. Iida, P. Shrout, N. Bolger, Receiving support as a mixed blessing:
evidence for dual effects of support on psychological outcomes, J. Pers. Soc.
Psychol. 94 (2008) 824–838, http://dx.doi.org/10.1037/0022-3514.94.5.824.
[21] J. Gonzalez, F. Penedo, M. Antoni, R. Dura, S. Pherson-Baker, G. Ironson, Social
support, positive states of mind, and HIV treatment adherence in men and women
living with HIV/AIDS, Health Psychol. 23 (2004) 413, http://dx.doi.org/10.1037/
0278-6133.23.4.413.
[22] J. Graham, Missing data analysis: making it work in the real world, Annu. Rev.
Psychol. 60 (2009) 549–576, http://dx.doi.org/10.1146/annurev.psych.58.
110405.085530.
[23] C. Grov, J. Rendina, A. Ventuneac, J. Parsons, Sexual behavior varies between
same-race and different-race partnerships: a daily diary study of highly sexually
active Black, Latino, and White Gay and Bisexual Men, Arch. Sex. Behav. 45 (2016)
1453–1462, http://dx.doi.org/10.1007/s10508-015-0677-z.
[24] S. Haas, Social support as relationship maintenance in gay male couples coping with
HIV or AIDS, J. Soc. Pers. Relat. 19 (2002) 87–111, http://dx.doi.org/10.1177/
0265407502191005.
[25] N. Hansen, A. Vaughan, C. Cavanaugh, C. Connell, Health-related quality of life in
bereaved HIV-positive adults: relationships between HIV symptoms, grief, social
support, and axis II indication, Health Psychol. 28 (2009) 249–257, http://dx.doi.
org/10.1037/a0013168.
[26] G.M. Herek, Thinking about AIDS and stigma: a psychologist's perspective, J. Law
Med. Ethics 30 (2002) 594–607, http://dx.doi.org/10.1111/j.1748-720X.2002.
tb00428.x.
[27] IBM Corp., IBM SPSS Statistics for Windows. Version 24, IBM Corp., Armonk, NY,
2016 (Released).
[28] S. Kalichman, M. Kalichman, C. Cherry, Brief behavioral self-regulation counseling
for HIV treatment adherence delivered by cell phone: an initial test of concept trial,
AIDS Patient Care STDs 25 (2011) 303–310, http://dx.doi.org/10.1089/apc.2010.
0367.
[29] A. Kleiboer, R. Kuijer, J. Hox, K. Schreurs, Receiving and providing support in
couples dealing with multiple sclerosis: a diary study using an equity perspective,
Pers. Relat. 13 (2006) 485–501, http://dx.doi.org/10.1037/fam0000333.
[30] N. Knoll, U. Schulz, R. Schwarzer, H. Rosemeier, Support provider's appraisal de-
tection bias and the efficacy of received support in medical students preparing for
an exam, Br. J. Soc. Psychol. 45 (2006) 599–615, http://dx.doi.org/10.1348/
014466605X59978.
[31] A. Kroemeke, E. Gruszczynska, Well-being and institutional care in older adults:
cross-sectional and time effects of provided and received support, PLoS One 11 (8)
(2016) e0161328, , http://dx.doi.org/10.1371/journal.pone.0161328.
[32] R. Kuijer, B. Buunk, J. Ybema, Are equity concerns important in the intimate re-
lationship when one partner of a couple has cancer? Soc. Psychol. Q. 64 (2001)
267–282, http://dx.doi.org/10.2307/3090116.
[33] S. Kumar, W. Nilsen, A. Abernethy, A. Atienza, Mobile health technology evalua-
tion: the mHealth evidence workshop, Am. J. Prev. Med. 45 (2013) 228–236,
http://dx.doi.org/10.1016/j.amepre.2013.03.017.
[34] B. Lakey, E. Orehek, Relational regulation theory: a new approach to explain the
link between perceived social support and mental health, Psychol. Rev. 118 (2011)
482–495, http://dx.doi.org/10.1037/a0023477.
[35] J. Lewis, S. Abramowitz, L. Koenig, S. Chandwani, L. Orban, Negative life events
M. Rzeszutek, E. Gruszczyńska Journal of Psychosomatic Research 109 (2018) 25–31
30
and depression in adolescents with HIV: a stress and coping analysis, AIDS Care 27
(2015) 1265–1274, http://dx.doi.org/10.1080/09540121.2015.1050984.
[36] A. Łuszczyńska, M. Kowalska, M. Mazurkiewicz, R. Schwarzer, Berlińskie Skale
Wsparcia Społecznego (BSSS). Wyniki wstępnych badan nad rzetelnościąi
trafnością. [Berlin Social Support Scales (BSSS). Preliminary results on the relia-
bility and validity], Stud. Psychol. 44 (2006) 17–27.
[37] L. Masumi, P. Shrout, N. Bolger, Using diary methods in psychological research, in:
H. Cooper (Ed.), APA Handbook of Research Methods in Psychology, Foundations,
Planning, and Psychometrics, vol. 1, 2012.
[38] S. Mavandadi, F. Zanjani, T. Have, D. Oslin, Psychological wellbeing among in-
dividuals aging with HIV: the value of social relationships, J. Acquir. Immune Defic.
Syndr. 51 (2009) 91–98, http://dx.doi.org/10.1097/QAI.0b013e318199069b.
[39] S. Morelli, I. Lee, M. Arnn, J. Zaki, Emotional and instrumental support provision
interact to predict well-being, Emotion 15 (2015) 484–493, http://dx.doi.org/10.
1037/emo0000084.
[40] M. Mugavero, J. Raper, S. Reif, K. Whetten, J. Leserman, N. Thielman, B. Pence,
Overload: The impact of incident stressful events on antiretroviral medication ad-
herence and virologic failure in a longitudinal, multi-site HIV cohort study,
Psychosom. Med. 71 (2009) 920–926, http://dx.doi.org/10.1097/PSY.
0b013e3181bfe8d2.
[41] B. Mustanski, The influence of state and trait affect on HIV risk behaviors: a daily
diary study of MSM, Health Psychol. 26 (2007) 618–626, http://dx.doi.org/10.
1037/0278-6133.26.5.618.
[42] U. Ndlovu, A. Ion, A. Carvalhal, “My children and my home”: the most recent and
challenging stressors of HIV-positive women, Arch. Women's Ment. Health 13
(2010) 215–222, http://dx.doi.org/10.1007/s00737-010-0148-4.
[43] G. Neigh, S. Rhodes, A. Valdez, T. Jovanovic, PTSD co-morbid with HIV: separate
but equal, or two parts of a whole? Neurobiol. Dis. 9 (2015) 116–123, http://dx.doi.
org/10.1016/j.nbd.2015.11.012.
[44] J. Pellowski, S. Kalichman, Recent advances (2011−2012) in technology-delivered
interventions for people living with HIV, Curr. HIV/AIDS Rep. 9 (2012) 326–334,
http://dx.doi.org/10.1007/s11904-012-0133-9.
[45] L. Persson, P.O. Ostergren, B.S. Hanson, A. Lindgren, A. Naucler, Social network,
social support and the rate of decline of CD4 lymphocytes in asymptomatic HIV-
positive homosexual men, Scand. J. Public Health 30 (2002) 184–190, http://dx.
doi.org/10.1080/14034940210133870.
[46] K. Preacher, P. Curran, D. Bauer, Computational tools for probing interactions in
multiple linear regression, multilevel modeling, and latent curve analysis, J. Educ.
Behav. Stat. 31 (2006) 437–448, http://dx.doi.org/10.3102/10769986031004437.
[47] R. Pritchard, Equity theory: a review and critique, Org. Behav. Hum. Perform. 4
(1969) 176–211, http://dx.doi.org/10.1016/0030-5073(69)90005-1.
[48] S. Qiao, X. Li, B. Stanton, Social support and HIV-related risk behaviors: a
systematic review of the global literature, AIDS Behav. 18 (2014) 419–441, http://
dx.doi.org/10.1007/s10461-013-0561-6.
[49] H. Rendina, M. Brett, J. Parsons, The critical role of internalized HIV-related stigma
in the daily negative affective experiences of HIV-positive gay and bisexual men, J.
Affect. Disord. 227 (2018) 289–297, http://dx.doi.org/10.1016/j.jad.2017.11.005.
[50] T. Rhodes, L. Cusick, Love and intimacy in relationship risk management: HIV
positive people and their sexual partners, Sociol. Health Illn. 22 (2000) 1–26,
http://dx.doi.org/10.1111/1467-9566.00189.
[51] M. Rzeszutek, W. Oniszczenko, Association between social support and tempera-
ment and the intensity of PTSD symptoms in a sample of HIV-positives, Pol.
Psychol. Bull. 44 (2013) 431–438, http://dx.doi.org/10.2478/ppb-2013-0046.
[52] M. Rzeszutek, W. Oniszczenko, E. Firląg-Burkacka, Gender differences in post-
traumatic stress symptoms and the level of posttraumatic growth among a Polish
sample of HIV-positive individuals, AIDS Care 28 (2016) 1411–1415, http://dx.doi.
org/10.1080/09540121.2016.1182615.
[53] D. Schachner, P. Shaver, O. Gillath, Attachment style and long-term singlehood,
Pers. Relat. 15 (2008) 479–491, http://dx.doi.org/10.1111/j.1475-6811.2008.
00211.x.
[54] U. Scholz, M. Kliegel, A. Łuszczyńska, N. Knoll, Associations between received so-
cial support and positive and negative affect: evidence for age differences from a
daily-diary study, Eur. J. Ageing 27 (2012) 361–371, http://dx.doi.org/10.1007/
s10433-012-0236-6.
[55] U. Schulz, R. Schwarzer, Soziale Unterstützung bei der Krankheitsbewältigung. Die
Berliner Social Support Skalen (BSSS), Diagnostica 49 (2003) 73–82.
[56] C. Smith, R. Cook, P. Rohleder, A qualitative investigation into the HIV disclosure
process within an intimate partnership: “The moment I realized that our relation-
ship was developing into something serious, I just had to tell him”, Br. J. Health
Psychol. 22 (2016) 110–127, http://dx.doi.org/10.1111/bjhp.12220.
[57] P. Theodore, R. Durán, M. Antoni, I. Fernandez, Intimacy and sexual behavior
among HIV-positive men-who-have-sex-with-men in primary relationships, AIDS
Behav. 8 (2004) 321–331, http://dx.doi.org/10.1023/B:AIBE.0000044079.
37158.a9.
[58] L. Warner, B. Schuz, S. Wurm, J. Ziegelmann, C. Tesch-Romer, Giving and ta-
king—differential effects of providing, receiving and anticipating emotional support
on quality of life in adults with multiple illnesses, J. Health Psychol. 15 (2010)
660–670, http://dx.doi.org/10.1177/1359105310368186.
[59] D. Watson, L. Clark, A. Tellegen, Development and validation of brief measures of
positive and negative affect. The PANAS Scales, J. Personal. Soc. Psychol. 54 (1988)
1063–1070 doi: 022-35l4/88/00.75.
[60] N. Bolger, A. Zuckerman, R. Kessler, Invisible Support and Adjustment to Stress, J.
Pers. Soc. Psychol. 79 (2000) 953–961, http://dx.doi.org/10.1037//0022-3514.79.
6.953.
M. Rzeszutek, E. Gruszczyńska Journal of Psychosomatic Research 109 (2018) 25–31
31
