Abstract

The present qualitative study aimed in-depth exploration of dyadic coping among couples dealing with chronic illness. There were 12 couples (six females and six males) with chronic illness and their healthy partners were interviewed. The in-depth interviews were conducted through interview guide based on Systematic Transactional Model (STM) (Bodenmann, 1995) and lived experiences of participants. The results were analyzed by using (Braun & Clarke, 2006) method of thematic analysis. The results revealed that female diagnosed partners showed less supportive dyadic coping to deal with physical and emotional burden of their chronic illnesses as compared to chronically ill male partners. However, the economic hardships is equally stressful for both members of the couples resulted in negative dyadic coping. The therapeutic assistance should be given to improve the dyadic coping among couples to deal with burden of chronic illness and live with better quality of life.

Key Words

Dyadic Coping, Burden of Illness, Cardiovascular Diseases, Diabetes,       Hypertension

Introduction

The onset of chronic illness introduces various challenges and difficulties in life. The individuals dealing with any of the chronic illness dealing with distress or discomfort not only by themselves, but also their closed ones. According to Berg and Upchurch (2007) the diagnosis of chronic illness introduces significant distress not only in patients but their partners as well. Revenson (2003) evaluated that ‘coping is not an individual process but it happens within a social and historical context’. The earlier theories ignored the coping as reciprocal process especially in the context of close relationships. Falconier and Kuhn (2019) suggested that role of partner’s support was overlooked in reducing other’s stress. They added that the researchers from last two decades shifted their observation of stressors as affecting both of the partners either directly e.g., financial problems or indirectly e.g., medical problem. 

The adaptation to chronic illness is a dyadic phenomenon for patients with chronic illness and their partners (Karademas, 2021). Berg and Upchurch (2007) explained about the dyadic perspective, when couples dealing with stressors in result of chronic illness, the stress management resources becomes activated to maintain the state of homeostasis within marital relationship. However, during this time of crisis patients use every possible source of coping either personal or interpersonal to deal with practical burden of illness and its effects (Karademas, 2021). 

Review of Literature

The way of dealing with chronic illness among couples can be analyzed at individual as well as a dyadic process that consider the mutual influence of each other, and their ways of dealing with stress in relation to each other (Bodenmann, 1997). 

According to Bodenmann (2005) dyadic coping (DC) refer as element or part of a group of two individuals. It also refers to the coping interaction between two individuals in an intimate, heterosexual relationship. The theory of dyadic coping was first introduced to assist partners to cope their daily troubles (i.e. trivial stressors), but later it is extended to assist partners who experienced chronic stress in their everyday life (Bodenmann, 2005). Specifically, the Systematic Transactional Model (STM) introduced by Bodenmann (1995) discussed stress and coping as a social process among romantic partners (Bodenmann, Randal & Falconier, 2016). This theory is applicable in the management of major stressors which are associated with events in life (Bodenmann, 2005; Revenson & DeLongis, 2011). The STM suggested that dyadic coping is an interpersonal and circular process for managing stressful events shared by both members of the couple. They discussed that it is a multidimensional model in which both partners using positive and negative approaches to cope with stressful situation (Bodenmann, 2005; Leuchtmann & Bodenmann, 2018). 

Bodenmann (1995, 2005) distinguished various forms of dyadic coping as supportive DC, delegated DC and common DC. The partner using supportive and delegated dyadic coping expressing his/her efforts to express solidarity towards stressed partner. Specifically in delegated DC one partner provide practical help by managing his/her duties. Some other theorists suggested that delegated and supportive DC can be problem-focused and emotion-focused as well, while in common DC both partners make efforts to overcome the dyadic stress (Donato et al., 2009).

However, theory of dyadic coping expanded the individualistic perspective of stress and coping to a system perspective of stress and coping. It is assumed that the stress appraisals and coping efforts of one partner will eventually affect the other partner as well as the relationship. Therefore, according to the theory of dyadic coping, partner’s initial attempt to deal with the stressors individually is likely to affect the relationship in one way or another (Revenson & DeLongis, 2011).

Chronic illness may affect marital quality or marital status (Burman & Margolin, 1992). Some other studies suggested that quality of couples’ dyadic coping related to the levels of psychological wellbeing and quality of relationship for example psychological distress, marital quality and wellbeing (Bodemann, 2000; Bodenmann et.al, 2008). The existing literature suggested that chronic illness of one partner produces enduring stresses in his/her spouses. These may precipitate financial strain and changed in living arrangement (Revenson, 2003). The other studies of chronic illnesses suggested that couple dealing breast and prostate cancer exhibited negative coping associated with higher levels of distress and psychological burden among patients (Badr et al., 2010; Regan et al., 2014). Molgora et al. (2019) found in their study that women and their partners using higher level of emotion-focused, problem-focused and delegated dyadic coping report high level of couple adjustment. 

This study aimed to explore the dyadic coping among couples dealing with any one of the chronic illness (cardiovascular diseases, diabetes and hypertension). The burden of illness intended to view not only from the patient’s perspective but also with the partner’s perspective as well. This qualitative study intended the in-depth exploration of the phenomenon in Pakistani sample. Unfortunately, Pakistan is developing country and the chronic illnesses brings crucial challenges for the family dealing with burden of disease. Durstine et al. (2013) found that increased rate of chronic illness has generated a massive economic, social and emotional burden all over the world. According to the little knowledge of researcher, scarcity of literature related to dyadic coping among couples with chronic illnesses i.e. cardiovascular diseases, diabetes and hypertension in Pakistani sample. Thus, this qualitative study may be an important addition in existing literature in context of dyadic coping of couples among them one partner is dealing with burden of chronic illness.




Objectives of the Research

• Develop an indigenous interview guide about dyadic coping based upon Bodenmann’s Systematic-Transactional Model (STM) of dyadic coping.

• Conduct in-depth interviews from participants diagnosed with chronic illness i.e., diabetes, cardiovascular diseases and hypertension.

• Identify the themes related to burden of chronic illness among participants.

Research Method and Material

This is a qualitative study in which the data was collected through semi-structured interviews from couples among them one partner is diagnosed with any one of the chronic illness i.e. diabetes, cardiovascular and hypertension living with their healthy spouses. The participants of the study were 12 married couples (N=24) with age ranging from 22-70 selected through purposive sampling from city Gujrat, Pakistan.  There were six diagnosed males (diabetes=3, cardiovascular=2, hypertension=1) and six diagnosed females (diabetes=2, cardiovascular=1, hypertension=3) living with their healthy spouses.

The semi-structured interviews were conducted with the help of interview guide. The interview involved questioning directed by identified themes in systematic way to get more elaborative answers (Qu & Dumay, 2011). The semi-structured interviews were based on semi-structured interview guide which provided schematic presentation of questions which were being explored by interviewer (DiCicco?Bloom & Crabtree, 2006). The interview guide in the present study was followed by Systematic Transactional Model (STM) developed by (Bodenmann, 1995). Moreover, after initial interview sessions, there were some other questions included in interview guide based on the lived experiences of participants. The interview guide included questions for partner with chronic illness e.g., did your partner take the responsibility of daily chores to reduce your burden? Did your partner perform the duties and tasks usually performed by you? Is your illness economic burden for your partner?  In addition, the interview guide for healthy partner included the same questions with different perspective for example, is the chronic illness of your partner burden for yourself? Can you afford the financial expenses of your partner’s illness? Did you share the burden of daily household chores? 

Before the conduction of interview, prior permission was taken from the participant and availability of the participants was ensured, because the duration of interview was almost 45 min to one hour for each participant. The interview was scheduled on mutually convenient date, and written informed consent was taken. The interviews were conducted in the native languages of the participants i.e. Urdu and Punjabi. This initiative helped the researcher to build up the rapport with participants and enable them to concentrate on interview session without eccentricity. The interviews were audio-recorded and transcribed in written notes. In the present study, Braun and Clarke’s (2006) specific techniques for thematic analysis were used to identify themes within and across cases and common themes were identified. The inductive approach of thematic analysis were followed and the themes identified in this approach are strongly linked with data (Patton, 1990). In inductive approach data have been collected through interview or focus group discussion and identified themes may have little relationship to the specific questions that were asked from the participants. In this approach, the themes are data driven that cannot fit in to the preexisting codes and researcher’s analytic perception (Braun & Clarke, 2006).




Ethical Consideration

The written consent form was obtained from each participant and the availability of the participants were ensured according to their provided schedules. The study was approved from Departmental Research and Review Committee (DRRC), Department of Psychology, Board of Faculty (BoF), Advanced Studies and Research Board (ASRB) University of Gujrat. The American Psychological Association (APA, 2009) ethical guideline was followed. The anonymity of the participants was also ensured with the help of pseudo names.

Thematic Analysis

This study involved the couples among them one partner is diagnosed with any one of the chronic illness (cardiovascular, diabetes and hypertension) dealing with the burden of illness. The data was analyzed by using inductive approach of thematic analysis. The chronic illness may affect the quality of dyadic relationship and resulted in physical, emotional and economic burden for both members of dyad. In this situation, both of them need collaboration for problem focused as well as emotional focused dyadic coping to deal with the chronic stress. The present data explored three key themes in the study; Dyadic coping for physical burden of chronic illness, dyadic coping for emotional burden of chronic illness and dyadic coping for economic burden of chronic illness.

First theme “Dyadic coping for physical burden of illness” includes variety of accounts in relation to the physical burden related to the health conditions. The narratives include positive as well as negative dyadic coping among the couples in terms of sharing the burden of daily duties and tasks. The burden of illness varied with regards to the nature of the chronic illness and the gender difference also recorded by the researcher. The respondent added her narratives that; 

“From the early days of marriage, my husband shared burden and after the diagnosis of my health problem he is providing extra ordinary help to me. He came back home, he comes to kitchen and doing little things for me to share my burden. If I am washing clothes, he helped to spread the clothes on wires and many other things. Moreover, if I said that there is pain in my legs, he start pressing my legs” (Ameena, p, 4-5, 117-125). 

The respondent appreciate the physical support from her healthy spouse. She added that her spouse using the problem solving coping skills towards her health problem and willingly collaborate with her to lessen her physical burden. The healthy partner endorsed the account of his wife and added that;

“I share the burden of my wife 100 %, the shopping, grocery, each and every necessary things of the home are my responsibility. She even never go to the street shop for buying the match box. Along with this I helped her out in the household chores as well and after the diagnosis of her health problem, I tried my level best to share extra burden of her” (Ameena’s husband, p, 15, 409-415).

In opposition of this, the other respondent added that;

“It looks very bad, if male members do household chores and they should not perform any household chores. These household tasks should be performed by female members. What the people in society and as well as in the family perceived about this? They will say that he is ‘rann mureed’ (wife’s servant). I really do not want to listen such statements about my husband. I am unable due to my illness, my daughters will do the household chores (Ghazala, p, 18-19, 497-501).

The sharing of physical burden of female partner is not accepted socially and culturally. It is expected that household chores are unrelated to the male members of the dyad, and solely the responsibility of female members. The male tasks are different from female tasks as the male members are the bread winner and work outside the house. However, the household chores are perceived as inside chores which are unrelated to the male members of the family. The narratives of some other respondents recorded the negative behavior of their spouses in terms of sharing the household responsibilities. The account showed that;

“The duties and responsibilities assigned related to household chores was not shared by anyone. Even if I am dying with pain in my body, I have to do my part. If say something, my mother-in-law started to quarrel with me and asked my husband to divorce her and get married again with a healthy women. She also said, we bring sickness sore at our home. Even though I was diagnosed with this chronic illness after 4 years of my marriage, but no one tried to understand. How can I do talk about others, when my own husband does not stands up for me” (Zahraa, p, 26, 717-726).

The partner with chronic illness expressed that her spouse is uninvolved towards physical burden of her. Moreover, she is facing very difficult time of her life as her husband does not show solidarity towards her illness. He does not empathize her and showed reluctance to support her by taking on the responsibilities of her to lessen the workload.  The narratives of healthy spouses are contradictory to the account of their diseased partners. Some of the healthy partners discussed that they helped their spouses in household responsibilities and perform his or her duties as well. It creates extra burden to them, but husband and wife are just like two fingers of one hand, if one is in pain, other automatically feels that pain. The accounts of healthy spouses showed supportive coping towards the illness related physical burden of spouse. But these narratives does not support to the explanation of partner with chronic illness. The other respondent added that;

“I had the whole burden of household responsibilities, when my son got married, the burden was shared by my daughter-in-law. But, I cannot sit idle, and helped her a lot. Whenever, my condition becomes worse due to my health issue, then my daughter-in-law support me physically, master sahib never support me in household responsibilities. He said, these tasks are related to the females, as bad as my condition were, he never asked me to help me out. He said that household chores are against the glory of men. The male members do not looks good to do female related household tasks. There is no maid at home, so we have to do all the tasks. If I said that I am not feeling well, please make a cup of tea for me, he never made. He can do all the tasks out of home, but never help inside the home” (Habiba, p. 50-51, 1397-1410).

The lack of problem focused approach to lessen the physical burden of partner with chronic illness. The socio-cultural perception of collectivist culture exposed that duties of household tasks are only attached with the female member of the family and the male members feel their insult to do such work at home as it is not socially accepted phenomenon. The health problem of partner was not perceived as common problem of the dyad by the healthy spouse. The chronic illness was viewed as home mater, not their personal matter, and the he is not responsible to take care of his wife to lessen her burden and related stresses of chronic illness. The negative dyadic coping and detachment was observed by researcher in the explanation of male healthy spouses. They discussed that physical burden regarding household responsibilities is unrelated to the male members of the society. As their bodies were designed by Allah in such a way, that they can bear the environmental hardships. So the outside home tasks are assigned to males and household responsibilities are typically related to the females, as their bodies are designed for child bearing, rearing and running home related duties appropriately. They elaborated that socio-cultural norms are established, that household chores are typically associated with the female members of the society and male members are less participative, even in difficult health conditions of their spouses.

The second theme “dyadic coping for emotional burden of illness”. The analysis of data showed the emotional load of disease also shared among couples. The mixed results were found with respect to the positive and negative emotional discharge of the stress among both of the gender. The narratives of a respondent showed that;

“My wife understand my feelings, you know I have diabetes and sue to this illness person also become short tempered, the level of tolerance becomes lower. When something going against my mood and temperament, then I outburst, but my wife bear all these things patiently. As she knows me very well, and soon after that I realized and say sorry for my behavior. I think this the beauty of married life” (Nazim, p. 69, 1936-1941).

The account of both members of dyad compliment the narration of each other. Both the partner have good emotional coordination related to the consequences of illness related stress. There were other respondents acknowledged the efforts of their spouses to lessen the emotional burden of disease. The results showed the emotional solidarity of some of dyads with respect to the chronic illness. The healthy partner showed more emotion focused coping towards the stressful condition of his spouse. There were some other participants added their experiences and elaborated that the disease of their partners is not an emotional burden for them. The results showed that the relationship of husband wife is not based sympathy, it is based on love and affection and provide empathic support to each other. The narratives showed that husband and wife are the two wheels of vehicle, as said “he is from me and I am from him”. The ill partners showed consistency with the account of healthy partners and said we can only cope with this illness just because of their spouses. The participant added that;

“I am very straight forward person, if you ask me to give marks to her, I will award her 110 marks out of 100 marks. Specifically, I said by witnessing God that she supported me a lot and saying this with full confidence and hiding nothing. She emotionally, morally support me, care me very much. Allah Almighty must gave her reward. She is the best wife, as she faced very difficult situation courageously” (Amir, p. 99, 2776-2782).

The respondent with chronic health issue acknowledged the selfless support of his spouse. Conversely, some of the participants exhibited the negative dyadic coping particularly with reference to the emotional burden of illness. The respondent mentioned in the storyline that;

“I personally go to the school on foot for pick and drop of children. I am highly burdened at home. I used to tell to my husband, but he never bothered in front of his mother and sister. No body at home tried to understand my emotions including m husband, that how much difficulty I am facing due to my illness. I am unable to perform household tasks due to my illness. The tasks would not be a big better, if my husband emotionally support me. Even though he left the home, when his mother and sisters start fighting with me” (Zahraa, p. 27, 728-735).

The respondent complaints the careless attitude of her healthy spouse and lack of sharing of emotional burden of her illness. The partner with chronic illness feels herself emotionally unaccompanied in the family by her husband and in-laws. In contrast with this, the healthy partner blamed his spouse of her bad behavior with him and his family. The account of healthy partner was inconsistent with the diseased partner, as he discussed about his efforts to compose his wife emotionally for her stressful emotional condition. The narrative of healthy spouse showed emotional detachment with the feelings of his spouse in relation of her illness and blamed her not to take care of her dietary habits. The other respondent also added that;

“My husband didn’t care us throughout the life, now the circumstances has been changed, and do not need him anymore, the relationship of husband wife based on emotions and feelings, if feelings are absent, even have negative feelings about each other, so what is the reason to have such relationship” (Rehana, p. 62, 1730-1733).

The results further revealed that some of the participants realized that, their illness is not an emotional burden for their spouses, as they confined their emotions to themselves. This showed negative dyadic coping to deal with emotional burden of illness. In the same line the following account revealed that;

“My disease does not create problems for my wife and family. Actually, I tried myself to keep my emotions and feeling to myself and never shared with anyone, so it does not create any emotional burden for my life partner. I carried my load by myself and never burdened anybody else in the family” (Arshad, p. 83, 2325-2330).

The healthy spouse ignored the above mentioned stance and added that, her spouse’s illness is not as severe as he expressed and the account is contradictory to the explanation of partner with chronic illness. This also showed lack of emotional commitment between the couple. The partner with chronic illness consider his health issue as severe and he is unable to perform his job, but the healthy partner minimize the seriousness of the illness. There was lack of collaborative approach of understanding of illness related emotions. The results also showed that irrespective of the gender differences, the male and female both partners diagnosed with diabetes become very short tempered and unable to control their anger. The accounts of their healthy spouses also compliment the same findings. The emotional burden is generally observed in both healthy and unhealthy female partners among the couples rather than males. There were few respondent added the lack of emotional bonding with his healthy spouse. The participant added his stance that;

“I become short tempered due to my health problem, and often show anger outburst, my wife is too younger than me and we do not have such emotional bonding. She is afraid of me that is why she did not shared her feelings so much with me. This is my second marriage and we two children. She just talk about the children and never asked me about my feelings and emotions. We are not so much frank with each other” (Yousaf, p. 124-125, 3496-3500).

The respondent showed his emotional detachment in between the couple and his healthy spouse. The healthy partners revealed that male partners are conventional husbands as they are culturally bound to express the emotional burden of their illnesses. The chronic illness is a stressful event for the family and lack of emotional discharge highlight the stresses in dyadic relationship. 

The third theme of the study is “dyadic coping for economic burden of illness”. The economic burden of illness in the family may also have opposing effects on the relationships especially in couples. These effects may compromise the process of dyadic coping to face the illness related stress. The results of the study exhibited various explanations in terms of social class, income level, and nature of chronic illness and gender differences in relation to illness. The results showed that these non-medical problems are affecting the quality of dyadic relationship. The study showed that mostly couples facing economic hardships specifically for the treatment of illness. There were few respondents among the sample who added that the illness of their partners is not economic burden for the family. They added that the chronic illness of their spouses is not a burden for themselves. The study revealed that some healthy partners take extra care of their ill spouse and spend a lot of money for the treatment. They are able to provide better treatment due to their better financial condition. The account of partners with illness were consistent with the explanation of healthy spouses. For example, ill partner added that;

“I have moral, emotional and even financial support of my wife with me, she is government employ in health department. I am sitting idle from last one year, she didn’t allow me to do any job due to my health issue, and financially we have no issue. She is managing everything very well” (Amir, p. 101, 2840-2843).

However, the couples facing economic difficulties are unable to manage the expenses of the treatment. Therefore, the economic problems serves as dyadic stressor among couples in which one member is living with chronic illness. Due to poor socioeconomic status the illness is perceived as burden among healthy partners and affect the dyadic relationship. The narratives of the female partner diagnosed with diabetes added her stance that;

“What do you know, how much problems I am facing in my life. Due to my poor health, I need proper medicine, but I don’t get medicine for a long time, just because of having no money. Everyone suggest me that you need insulin, but how can I manage to have insulin. We are living in extended family, we will remain hungry inside the room, but cannot express with in front of relatives just for so called honor” (Zahraa, p. 29, 785-789).

The economic destitution creates the conflicting situation in the family, so that the illness is perceived as burden especially by the healthy partner of the dyad. This introduces relationship problems and lack of dyadic efforts to cope with stressful health condition of ill partner. The other respondent’s account also consistent with the previous explanation, she added that;

“He didn’t give money to spend for household necessities, contrarily he demand different things to eat. If I denied to make food for him, due to my health condition, he start fighting with me and even beat me. Then he go out, bring chicken roast for himself and start eating in front of children. He used to do just job for himself, never give penny to us. This is the reason, my health going to poor day by day. I used to work in three or four houses at time. Because of this anxiety and burden I became ill in very young age” (Rehana, p. 59, 1652-1659).

The couples having scarcer financial resources reported interpersonal problems greater stress in their relationship. The study also revealed that chronically ill female partners performing dual responsibilities by taking care of husband, children and family of in laws as well. Though, the chronically ill male members experience less burden by depending of their partners for their needs. The results also showed the complaining attitude of healthy female partners about the careless attitude of the partner towards the financial responsibilities and showing detached behavior concerning of economic burden of the family. The majority of the couples among participants showed inconsistency of accounts of chronically ill male and female partners with the narratives of healthy male and female partners. 

Discussion

This was a qualitative study of dyadic coping among couples dealing with burden of chronic illness. The sample of the study were married couples among them one partner is living with one of the chronic illness i.e. diabetes, cardiovascular and hypertension. The first theme was ‘dyadic coping for physical burden of chronic illness’ revealed mixed results. The majority of the female participants with chronic illness facing hard time, as they have lack of physical support from their healthy partners for daily household tasks. Oliver and Cronan (2005) suggested that if chronically ill partner is less active in his/her social responsibilities and household, it may impede the couple’s life. Moreover, the healthy female partners also facing double burden by managing their own household responsibilities, children, along with sharing the physical burden of their partners. The empirical evidences are consistent with the study as women carry more burden and more affected psychosocially with chronic illness of their spouse as compared to men with chronically ill partner (Coyne & Fiske, 1992; Hagedoorn et al., 2000; Lyons et al., 1995). The study also found the positive dyadic coping among few participants who are involved in sharing of physical burden of their chronically ill spouse. However, Kimmel and Patel (2003), suggested that the female members overcharge themselves in order not to burden for the other family members which might resulted in higher level of distress as compared to men. The experience of stress can have detrimental effects on the relationship of romantic partners (Lau, 2019). The present study also revealed defined socially expected roles of being male and female. The finding explored that males are responsible for outside work and females are responsible for inside household chores and take care of children and other family members. Richter et al. (2014) found that husbands have authority in household due to their economic responsibility and wives are responsible for child-rearing.

The second theme ‘dyadic coping for emotional burden of chronic illness’ showed positive as well as negative dyadic coping to deal with emotional burden of partner’s chronic illness. Therefore, Revenson et al. (2005) suggested that men and women cope with illness in very different manner as the women experience more burden than men whether they are caregiver or with chronic illness. The results revealed the adjustment problems coping for sharing of emotional burden which is inconsistent with the existing literature. Studies showed couples coping with prostate cancer and breast cancer exhibited negative coping and common negative coping of partners associated with higher psychological burden and higher level of distress of patients, however positive coping associated with lower distress (Badr et al., 2010; Regan et al., 2014). In addition, healthy partners face societal expectations to take care of their ill spouses. The partners having chronic illness means the other partner should serve as caregiver for the rest of the diseased partner’s life which is a considerable emotional and practical burden for partners (Revenson, 2005). The use of emotion words between romantic partners is positively associated with relationship satisfaction (Slatcher & Pennebaker, 2006). Moreover the study estimated that female kidney transplant recipient facing higher psychological burden, when the coping efforts of partners were estimated (Tkachenko et. al., 2019).

The third theme of the study is ‘dyadic coping for economic burden of illness’. The majority of the couples in the study revealed that the treatment of chronic illness creates extra burden for the family due to lack of financial resources. The empirical evidences proposed the finding related dyadic coping among couples who are facing the non-medical stressors such as economic problems, raising children with disabilities immigration related issues, emotional behavioral problems and caring the elderly family members (Falconier & Kuhn, 2019). Revenson et al. (2005) suggested that financial resourceful couples taking some of the burden of their ill partners, but the situation is different among the families with less economic resources. The studies also suggested that couples with lower socio-economic status are more emotionally vulnerable to be affected with undesirable stressful events and health shocks (Mcleod & Kessler, 1990). The present study revealed the scarcer financial resources leads towards interpersonal problems, dissatisfaction, and negative dyadic coping among couples especially in case of female partner with illness. Likewise, the study is consistent with these findings and found that economic destitution is linked with higher level of conflict (HallidayHardie & Lucas, 2010) high pessimism and lower life satisfaction (Haid & Seiffge-Krenke, 2012). There is another study suggested that economic pressure reduce the use of supportive dyadic coping among couples overtime (Johnson et al., 2016).

Conclusion

The study overall suggested three themes of dyadic coping among couples dealing with burden of chronic illness. The physical burden of illness is related to the sharing of household responsibilities in case of female diagnosed partner and outside responsibilities in case of male diagnosed partner. The study found that in majority of cases the chronically ill female partners facing stressful situation by bearing double burden in both cases whether healthy or ill. In contrast to this, chronically ill male partners showed positive dyadic coping, because their healthy female partners sharing extra responsibilities of them, for example, pick and drop of children from schools, grocery, and visit to physician for consultation. The dyadic coping for emotional burden of chronic illness showed negative results in terms of lack of understanding in case of female ill partners and lack of emotional expression in case of male ill partners. The female partners feels themselves as emotionally unaccompanied, blamed the male partners as emotionally detached and lack of collaborative approach of their healthy male partners. There were few couples in which both members showed positive emotional bonding and have empathetic understanding towards illness. The economic burden of chronic illness resulted in negative dyadic coping and conflicting among most of the participants. The majority of the population in Pakistani society belongs to middle and lower middle and lower classes. The low income families are unable to bear the expenses of treatment of illness which compromised the quality of dyadic coping. These non-medical stressors buffered the relationship problem and leads towards less dyadic efforts to cope with stressful health condition. These negative dyadic coping strategies replaced with the positive dyadic coping styles by providing the therapeutic assistance to the couples, and teach them how to deal with the stressful situation in presence of primary stressors such as chronic illness and low socioeconomic status. 

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