Coping with multiple sclerosis: reconciling significant aspects of health-related quality of life

Fo Pee Re iew Only Coping wi h Mul iple Scle osis: Reconciling signi ican aspec s o heal h- ela ed quali y o li e Jou nal: AIDS Ca e - Psychology, Heal h & Medicine - Vulne able Child en and You h S udies Manusc ip ID PHM-2021-09-1202.R1 Jou nal Selec ion: Psychology, Heal h & Medicine Keywo ds: Mul iple Scle osis, Coping S a egies, Social Suppo , Heal h Rela ed Quali y O Li e, isk and p o ec i e Fac o s URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences This is an Accep ed Manusc ip e sion o he ollowing a icle, accep ed o publica ion in Psychology, Heal h & Medicine: Gil- González, I., Ma ín-Rod íguez, A., Con ad, R., & Pé ez-San-G ego io, M. Á. (2023). Coping wi h mul iple scle osis: econciling signi ican aspec s o heal h- ela ed quali y o li e. Psychology, Heal h & Medicine, 28(5), 1167–1180. h ps:// doi.o g/10.1080/13548506.2022.2077395. I is deposi ed unde he e ms o he C ea i e Commons A ibu ion-NonComme cial- NoDe i a i es License (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/), which pe mi s non-comme cial e-use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed, and is no al e ed, ans o med, o buil upon in any way Fo Pee Re iew Only Coping wi h Mul iple Scle osis: Reconciling signi ican aspec s o heal h- ela ed quali y o li e Mul iple scle osis (MS) symp oms and unp edic abili y can damage pa ien well-being. This s udy is aimed o in es iga e he ela ion be ween sociodemog aphic and clinical cha ac e is ics and he use o coping s a egies as well as social suppo on heal h- ela ed quali y o li e (HRQOL). We e alua ed 314 MS ou pa ien s o Vi gen Maca ena Uni e si y Hospi al in Se illa/Spain (mean age 45 yea s, 67.8% women) wice o e an 18-mon hs ollow up pe iod by B ie COPE Ques ionnai e (COPE-28), Mul idimensional Scale o Pe cei ed Social Suppo (MSPSS) and 12-I em Sho Fo m Heal h Su ey (SF-12). Female gende was signi ican ly ela ed o eligion ( =0.175, p<0.001), sel -dis ac ion ( =0.160, p<0.001) and sel -blame ( =0.131, p<0.05). Age co ela ed posi i ely wi h eligion ( =0.240, p<0.001), and sel -blame ( =0.123, p<0.05). P og essi e MS as well as unc ional impai men (EDSS) showed a posi i e ela ion wi h denial ( =0.125, p<0.05; =0.150, p<0.001). Longe du a ion since diagnosis was ela ed o lowe pe cei ed suppo om amily ( =-0.123, p<0.05). EDSS (β = -0.452, p < 0.001) was he s onges nega i e p edic o o physical HRQOL ollowed by age (β = -0.123, p < 0.001), whe eas amily suppo was a p o ec i e ac o (β = 0.096, p < 0.001). Denial (β=- 0.132, p< 0.05), sel -blame (β=-0.156, p<0.05), emale gende (β=-0.115, p<0.05) and EDSS (β=-0.108, p<0.05) nega i ely impac ed on men al HRQOL 18 mon hs la e , whe eas posi i e e aming (β=0.142, p<0.05) was a p o ec i e ac o . Ou s udy could iden i y sociodemog aphic and clinical a iables associa ed wi h dys unc ional coping s a egies, such as sel -blame and denial, which speci ically p edic wo se men al HRQOL as opposed o posi i e e aming. Diminishing dys unc ional coping and suppo ing cogni i e e aming may con ibu e o imp o e HRQOL in MS. key wo ds: Mul iple Scle osis; Coping S a egies; Social Suppo ; Heal h Rela ed Quali y o Li e; isk and p o ec i e Fac o s Page 1 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only In oduc ion Coping s a egies play an essen ial ole in adap a ion o mul iple scle osis (MS) and Ca ne o Con en i e al. (2021) poin ou a nega i e ela ionship be ween maladap i e coping and HRQOL. Ca e (1997) di ided coping s a egies in o h ee ca ego ies: p oblem- ocused, emo ion- ocused, and dys unc ional coping. Gene ally, ac i e coping, p oblem sol ing, planning, posi i e e aming, accep ance, emo ional and ins umen al social suppo we e ela ed o a highe HRQOL in MS. Whils , a oidance, beha iou al disengagemen , sel -dis ac ion, denial, emo ion- ocused, sel -c i icism and en ing we e associa ed wi h lowe HRQOL (Gil-Gonzalez e al., 2020). Pa icula ly, Bassi e al. (2021) ound a nega i e associa ion be ween a oidance coping and physical HRQOL. In addi ion, Ce ea e al. (2021) disco e ed a posi i e associa ion be ween men al HRQOL and p oblem sol ing and a nega i e wi h emo ional discha ge and passi e coping (Ce ea e al., 2021; K s ić e al., 2021). The scien i ic li e a u e e ealed ha MS pa ien s use less ac i e and mo e a oidance and emo ional coping han he gene al popula ion (Ke ama Ka e al., 2019). In dealing wi h MS, in apsychic and in e pe sonal mechanisms a e closely in e wined. A s udy by Homayuni e al. (2021) ound ha MS pa ien s desc ibed coping s a egies and social suppo as HRQOL acili a o s. In ac , social suppo has been ela ed o imp o emen s ega ding a igue (Mikula e al., 2020), pain (Alphonsus & D’A cy, 2021), dep ession and anxie y (Hanna & S obe , 2020; Mikula e al., 2020; Ra ajska e al., 2020), he eby also p o ec ing employmen (Iwanaga e al., 2018). Social suppo also in luences pa ien s’ a i udes on medica ion selec ion as hey conside signi ican o he s’ opinions (Visse e al, 2020). In summa y, he e is e idence ha Page 2 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only di ec ly and/o indi ec ly highe social suppo is ela ed o be e HRQOL (Bassi e al., 2021; Dȩbska e al., 2020; Gil-González e al., 2020; Ke e e al., 2021; Ra ajska e al., 2020), while lowe social suppo is ela ed o wo se HRQOL (Cos a e al., 2017; S obe , 2018). The p esen s udy aimed a in es iga ing (1) sociodemog aphic and clinical ac o s unde lying coping s a egies and social suppo in adul s wi h mul iple scle osis (MS), and (2) he ole o coping s a egies and social suppo as well as sociodemog aphic and clinical ac o s as p edic o s o quali y o li e in MS o e an 18 mon hs’ ollow-up pe iod. Me hod Pa icipan s and p ocedu es The sample was ec ui ed be ween June 2017 and May 2018 (T1), and Decembe 2018 and Decembe 2019 (T2) a Vi gen de la Maca ena Uni e si y Hospi al in Se illa/Spain. Inclusion c i e ia we e: (1) con i med MS diagnosis; (2) age o e 18, and (3) men al, physical and cogni i e capabili y o pa icipa e and sign in o med consen . The s udy was app o ed by he esponsible E hics Commi ee (0846-N-18). Ins umen s Clinical and sociodemog aphic in o ma ion we e collec ed om he medical da a base and a ques ionnai e. Coping s a egies The Spanish e sion o B ie COPE Ques ionnai e (COPE-28) was applied o s udy he pa ien s use o di e en ac ions in dealing wi h s ess ul si ua ions (Mo án e al., 2010). Page 3 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only COPE-28 has 28 i ems g ouped in o he ollowing 14 dimensions: (1) accep ance; (2) emo ional suppo ; (3) humo ; (4) posi i e e aming; (5) eligion; (6) ac i e coping; (7) ins umen al suppo ; (8) planning; (9) beha io al disengagemen ; (10) denial; (11) sel - dis ac ion; (l2) sel -blaming; (13) subs ance use; (14) en ing. I ems a e sco ed on a ou -poin Like scale ( om 0 o 3). Highe sco es indica e g ea e use (Ca e , 1997). C onbach’s alpha anged om 0.60 o 0.88 o he 14 subscales. Social Suppo Pa icipan s pe cep ion o social suppo was measu ed by he Mul idimensional Scale o Pe cei ed Social Suppo (MSPSS). The MSPSS comp ises 12-i ems sco ed on a 7- poin Like scale anging om 1 o 7. The o al sco e a ies om 12 o 84 (A echabala and Mi anda, 2002; Zinne , 1988). C onbach’s alpha in ou sample anged om 0.91 o 0.96 o he subscales. Heal h ela ed Quali y o li e The 12-I em Sho Fo m Heal h Su ey (SF-12) consis s o 12 i ems sco ed on a 3 o 5- poin Like scale. The SF-12 consis s o eigh domains: physical unc ioning, ole- physical, bodily pain, gene al heal h, i ali y, social unc ioning, ole-emo ional and men al heal h. Subscales sco es ange om 0 (wo s ) o 100 (bes ). These subscales a e combined o o m he Physical Componen Summa y Sco e (PCS) and he Men al Componen Summa y Sco e (MCS) (Vilgau e al., 2008; Wa e e al., 2002). In ou sample, dimensions C onbach’s alpha anged om 0.70 o 0.96 a T1 and om 0.64 o 0.96 a T2. C onbach’s alpha o he PCS and MCS was 0.92 and 0.88, espec i ely (Ma uish, 2012). Page 4 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only S a is ics Pea son and Spea man co ela ions a e p esen ed o coping s a egies/social suppo and clinical/demog aphic a iables. S epwise eg ession analyses iden i y quali y o li e p edic o s and de e mine hei ela i e con ibu ion. Two mul i a ia e models we e buil wi h MCS and PCS sco es a T2 as dependen a iables. Sociodemog aphic (gende , age, pa ne ship, educa ional le el and occupa ion), clinical a iables (EDSS, MS sub ype, mon hs since diagnosis and mon hs since he ou b eak), coping s a egies and social suppo a T1 we e conside ed as p edic o s. All es s we e compu ed using SPSS- 26. Signi icance le el was se o p< 0.05. E ec size coe icien we e calcula ed using G*Powe So wa e. Coe icien s we e in e p e ed acco ding o Cohen (1988) guidelines; o co ela ions: p ≥ 0.10 small, ≥ 0.30 medium, and ≥ 0.50 la ge e ec and in mul iple eg ession: 2 ≥ 0.02 small, ≥ 0.15 medium, and ≥ 0.35 la ge e ec . Resul s The inal sample comp ised 314 MS pa ien s (d opou a e 19.69%; see igu e 1). -Figu e 1- As can be seen in Table 1, he sample was composed o 213 (67.8%) emales and 101 (32.2%) males. Mean age was 45.31 yea s (±10.77), ange om 19 o 78 yea s. The p edominan MS ype was emi en 272 (86.6) and mean EDSS sco e was 3.17 (±1.92). -Table 1- Sociodemog aphic/clinical a iables and coping s a egies Female gende co ela ed wi h highe use o sel -dis ac ion ( =0.160, p<0.001), eligion Page 5 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only ( =0.175, p<0.001), and sel -blame ( =0.131, p<0.05). Age also co ela ed posi i ely wi h eligion ( =0.240, p<0.001), and sel -blame ( =0.123, p<0.05). Highe educa ional le el was ela ed o a highe use o planning ( =0.167, p<0.001), seeking emo ional suppo ( =0.119, p<0.05), and en ing ( =0.151, p<0.001). Being unemployed was ela ed o a lowe use o en ing ( =-0.121, p<0.05) and highe use o denial ( =0.133, p<0.05) as well as eligion ( =0.112, p<0.05). P og essi e MS sub ype showed a nega i e ela ion wi h en ing ( =-0.134, p<0.05) and a posi i e ela ion wi h denial ( =0.125, p<0.05). Mon hs since diagnosis posi i ely co ela ed wi h sel -blame ( =0.147, p<0.001), as well as mon hs since he ou b eak ( =0.143, p<0.05), which also co ela ed nega i ely wi h ac i e coping ( =-0.115, p<0.05). EDSS was ela ed o a highe use o beha io al disengagemen ( =0.112, p<0.05), denial ( =0.150, p<0.001), subs ance use ( =0.124, p<0.05), and humo ( =0.120, p<0.05). The e we e no signi ican co ela ions in ega d o pa ne ship s a us in he use o coping s a egies. E ec sizes coe icien s (p) o signi ican co ela ions anged om 0.33 o 0.48, medium e ec s (Table 2). - Table 2- Sociodemog aphic/clinical a iables and pe cei ed social suppo Age ( =-0.130, p<0.05) and p og essi e MS sub ype ( =-0.114, p<0.05) we e nega i ely ela ed wi h social suppo om iends (see Table 3). Being wi hou a pa ne showed a nega i e ela ion wi h social suppo om signi ican o he s ( =-0.128, p<0.05). Page 6 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only Highe educa ional le el ( =-0.119, p<0.05) and longe du a ion since diagnosis ( =-0.123, p<0.05) was ela ed o lowe pe cei ed suppo om amily. Wi h ega d o gende , occupa ion, mon hs since diagnosis ou b eak and EDSS no signi ican associa ions we e ound wi h social suppo . Fo signi ican esul s co ela ion e ec sizes (p) we e medium ( om 0.34 o 0.38). - Table 3- Physical and men al HRQOL p edic o s EDSS (β=-0.452, p<0.001) was he s onges nega i e p edic o o PCS ollowed by age (β=-0.123, p<0.001). Highe EDSS and olde age we e ela ed o lowe PCS 18 mon hs la e . On he con a y, he a iable amily suppo (β=0.096, p<0.001) led o an inc ease o PCS (Table 4). All a iables oge he accoun ed o 27.4% o PCS a iance, wi h a la ge e ec size ( 2=0.377). Denial (β=-0.132, p<0.05), sel -blame (β=-0.156, p<0.05), emale gende (β=- 0.115, p<0.05) and EDSS (β=-0.108, p<0.05) nega i ely impac ed on MCS 18 mon hs la e , whe eas posi i e e aming (β=0.142, p<0.05) was a p o ec i e ac o . All a iables in he model oge he explained 10.1% o MCS, wi h small e ec size ( 2=0.112). (See Table 4). -Table 4- Discussion HRQOL in MS depends on a wide spec um o ac o s, which ye ha e o be ully unde s ood. The p esen s udy explo ed associa ions and p edic i e alue o sociodemog aphic and clinical ea u es alongside coping s a egies and social suppo o HRQOL in MS o e an 18 mon hs ollow-up pe iod. Page 7 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only Sociodemog aphic/clinical a iables and coping s a egies Female gende posi i ely co ela ed wi h eligion as an emo ion- ocused coping- s a egy. The endency o emales o use emo ion- ocused coping s a egies in MS is suppo ed by p e ious esea ches (Holland e al., 2019; Zengin e al., 2017). Pa icula ly, Zengin e al. (2017) ound emales o use eligion mo e equen ly as a coping s a egy han men. Clinically e en mo e impo an we ound signi ican ela ionships wi h he wo dys unc ional s a egies sel -blame and sel -dis ac ion. Olde age was also ela ed o a highe use o eligion and sel -blame. Ke ama Ka e al. (2019) discussed ha olde people wi h MS end o use eligion as a coping s a egy. The gende and age- ela ed endency o sel -blame is signi ican in iew o he iden i ica ion o possible isk ac o s o maladap i e coping ea ly in he diagnos ic p ocess. Highe le el o educa ion was ela ed o a highe use o planning, a p oblem- ocused s a egy, and seeking emo ional suppo , an emo ion- ocused s a egy. I can be a gued ha highe educa ed MS pa ien s can use hei knowledge o choose mo e e ec i e and adap i e s a egies, and make a g ea e use o social suppo (Ke ama Ka e al. 2019). On he con a y, highe educa ional le el was ela ed o a highe use o en ing, classi ied as a dys unc ional s a egy (Ca e 1997; Ledesma e al., 2018; Meye 2001). Unemploymen was posi i ely ela ed o a highe use o eligion, an emo ion- ocused coping s a egy (Ca e 1997; Meye 2001) and denial, as well as lowe use o en ing. Ou esul con i ms p e ious indings indica ing ha unemployed MS pa ien s end o a mo e emo ion-o ien ed coping s yle (Ke ama Ka e al., 2019), a oidance and maladap i e s a egies (Holland e al., 2019; Ke ama Ka e al., 2019). The lowe use o en ing con adic s i . Page 8 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only Re e ences Alphonsus, K. B., & D’A cy, C. (2021). 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Disabili y and Heal h Jou nal, 12(4), 608-614. h ps://doi.o g/10.1016/j.dhjo.2019.06.003 Zahn, R., Ly he, K. E., Ge hin, J. A., G een, S., Deakin, J. F., Young, A. H., & Moll, J. (2015). The ole o sel -blame and wo hlessness in he psychopa hology o majo dep essi e diso de . Jou nal o A ec i e Diso de s, 186, 337-341. h ps://doi.o g/10.1016/j.jad.2015.08.001 Zengin, O., E bay, E., Yıldı ım, B., & Al ındağ, Ö. (2017). Quali y o li e, coping, and social suppo in pa ien s wi h mul iple scle osis: A pilo s udy. [Mul ipl skle oz has ala ında yaşam kali esi, baş e me e sosyal des ek: Pilo çalışma]. Tu k No oloji De gisi, 23(4), 211-218. h ps://doi.o g/10.4274/ nd.37074 Zime , G. D., Dahlem, N. W., Zime , S. G., & Fa ley, G. K. (1988). The mul idimensional scale o pe cei ed social suppo . Jou nal o Pe sonali y Assessmen , 52(1), 30-41. h ps://doi.o g/10.1207/s15327752jpa5201_2 Page 18 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only Table 1. Clinical and sociodemog aphic cha ac e is ics T1 Sample N=391 T2 Sample N=314 Gende n (%) Male 123 (31.5) 101 (32.2) Female 268 (68.5) 213 (67.8) Age (M±SD) 45.66±11.13 45.31±10.77 Pa ne ship n (%) No pa ne 108 (27.6) 85 (27.1) Pa ne 283 (72.4) 229 (72.9) Occupa ion n (%) Employed/In educa ion 135 (34.5) 116 (36.9) Unemployed 256 (65.5) 198 (63.1) Educa ional le el n (%) P ima y educa ion 65 (16.6) 44 (14) Seconda y educa ion 128 (32.7) 102 (32.5) Uni e si y o highe 198 (50.6) 168 (53.5) EDSS (M±SD) 3.38±2.06 3.17±1.92 MS sub ype n (%) Remi en 326 (83.4) 272 (86.6) P og essi e 65 (16.6) 42 (13.4) Mon hs since diagnosis (M±SD) 145.31±89.49 145.68±89.56 Mon hs since ou b eak (M±SD) 184.90±108.47 186.11±111.18 Page 19 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only Table 2. Co ela ions be ween sociodemog aphic and clinical a iables and coping s a egies Ac i e Coping Planning Ins umen al Suppo Emo ional Suppo Sel - dis ac ion Ven ing Beha io al disengagemen Posi i e Re aming Denial Accep ance Religion Subs ance use Humo Sel - blame Gende 0.081 0.020 0.045 0.083 0.160** 0.036 0.047 0.040 0.056 0.021 0.175** 0.044 -0.039 0.131* p 0.28 0.14 0.21 0.28 0.40 0.18 0.22 0.20 0.24 0.14 0.42 0.21 0.20 0.36 Age 0.050 0.025 -0.079 -0.047 0.059 -0.102 0.007 -0.006 0.045 0.073 0.240** 0.030 -0.020 0.123* p 0.22 0.16 0.28 0.22 0.24 0.32 0.26 0.07 0.21 0.27 0.48 0.17 0.14 0.35 Pa ne ship 0.038 -0.061 0.032 -0.055 0.093 0.029 -0.072 0.077 -0.033 0.072 0.078 0.090 0.022 0.071 p 0.19 0.25 0.18 0.23 0.30 0.17 0.26 0.28 0.18 0.27 0.28 0.30 0.15 0.26 Educa ional le el 0.021 0.167** 0.090 0.119* 0.009 0.151** -0.092 -0.028 -0.024 -0.109 -0.004 -0.088 -0.061 -0.022 p 0.14 0.41 0.30 0.35 0.09 0.39 0.99 0.17 0.15 0.33 0.06 0.29 0.25 0.15 Occupa ion -0.008 -0.031 -0.024 0.002 0.060 -0.121* 0.077 -0.007 0.133* 0.032 0.112* 0.016 -0.055 0.037 p 0.28 0.18 0.15 00.04 0.24 0.35 0.28 0.08 0.36 0.18 0.33 0.13 0.23 0.19 MS Sub ype 0.034 0.036 -0.011 0.017 0.075 -0.134* 0.068 -0.101 0.125* 0.039 0.073 0.095 -0.028 -0.013 p 0.184 0.19 0.10 0.13 0.27 0.37 0.26 0.32 0.36 0.20 0.27 0.30 0.17 0.11 Mon hs since diagnosis -0.095 -0.029 -0.063 -0.073 0.062 -0.071 -0.038 -0.012 -0.092 0.044 0.093 -0.015 -0.020 0.147** p 0.30 0.17 0.25 0.27 0.24 0.27 0.19 0.11 0.30 0.21 0.30 0.12 0.14 0.38 Mon hs since ou b eak -0.115* -0.069 -0.050 -0.005 0.034 -0.101 0.036 -0.038 -0.044 0.028 0.084 -0.033 -0.041 0.143* p 0.34 0.26 0.22 0.07 0.18 0.31 0.19 0.19 0.20 0.16 0.28 0.18 0.20 0.38 EDSS -0.043 0.001 -0.065 -0.017 0.091 -0.045 0.112* -0.003 0.150** 0.030 0.027 0.124* 0.120* 0.059 p 0.20 0.03 0.25 0.13 0.30 0.21 0.33 0.05 0.39 0.17 0.16 0.35 0.34 0.24 EDSS, Expanded Disabili y S a us Scale *p< 0.05, **p<0.001, p, e ec size: ≥ 0.10 small, ≥ 0.30 medium, ≥ 0.50 la ge Page 20 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only Table 3. Co ela ions be ween sociodemog aphic and clinical a iables and pe cei ed social suppo EDSS, Expanded Disabili y S a us Scale *p< 0.05, **p<0.001, p, e ec size: ≥0.10 small, ≥0.30 medium, ≥0.50 la ge Family F iends Signi ican O he s To al Sco e Gende -0.029 -0.044 -0.064 -0.062 p 0.17 0.20 0.25 0.25 Age -0.042 -0.130* -0.078 -0.106 p 0.20 0.36 0.27 0.32 Pa ne ship -0.098 0.033 -0.128* -0.105 p 0.31 0.18 0.36 0.32 Educa ional le el -0.119* -0.072 -0.102 -0.074 p 0.34 00.26 0.31 0.27 Occupa ion 0.065 -0.070 0.102 -0.040 p 0.25 0.26 0.31 0.20 MS Sub ype 0.052 -0.114* 0.090 -0.068 p 0.22 0.38 0.30 0.26 Mon hs since diagnosis -0.123* -0.077 -0.039 -0.101 p 0.35 0.27 0.19 0.31 Mon hs since ou b eak -0.074 -0.055 0.008 -0.053 p 0.27 0.23 0.08 0.23 EDSS -0.081 -0.103 0.010 -0.077 p 0.28 0.32 0.01 0.27 Page 21 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only Table 4. Physical and men al HRQL Mul iple linea eg ession models *p<0.05, **p<0.001, §MSPSS Family Suppo Sco e Dependen a iable physical HRQOL (PCS) F R2 R2adj B SE.B β 1-β 2 Model 1 104.556 (1,312) 0.251** 0.249** 54.737** 1.057 1 0.335 EDSS -2.912** 0.285 -0.501 Model 2 56.012 (2,311) 0.265** 0.260** 59.839** 2.357 1 0.360 EDSS -2.668** 0.300 -0.459 Age -0.130* 0.054 -0.125 Model 3 39.010 (3,310) 0.274** 0.267** 55.446** 3.224 1 0.377 EDSS -2.626** 0.299 -0.452 Age -0.128* 0.053 -0.123 Family§ 0.696* 0.350 0.096 Dependen a iable men al HRQOL (MCS) F R2 R2adj B SE.B β 1-β 2 Model 1 11.736 (1,312) 0.036* 0.033* 48.548** 0.752 0.92 0.037 Denial -3.477** 1.015 -0.190 Model 2 9.557 (2,311) 0.058* 0.052* 50.401** 1.017 Denial -3.111* 1.014 -0.170 0.98 0.061 Sel -blame -1.737* 0.650 -0.148 Model 3 8.54 (3,310) 0.076* 0.067* 48.017** 1.391 0.99 0.082 Denial -2.770* 1.015 -0.152 Sel -blame -2.082* 0.659 -0.178 Posi i e Re aming 1.699* 0.683 0.140 Model 4 8.538 (4,309) 0.089* 0.078* 52.506** 2.537 0.99 0.097 Denial -2.702* 1.010 -0.148 Sel -blame -1.872* 0.663 -0.160 Posi i e Re aming 1.716* 0.680 0.141 Gende -2.849* 1.350 -0.116 Model 5 6.910 (5,308) 0.101* 0.086* 54.341** 2.691 1 0.112 Denial -2.416* 1.016 -0.132 Sel -blame -1.825* 0.660 -0.156 Posi i e Re aming 1.722* 0.676 0.142 Gende -2.829* 1.344 -0.115 EDSS -0.645 0.326 -0.108 Page 22 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only Figu e 1. S udy low-cha . Page 23 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences Fo Pee Re iew Only Table 1. Clinical and sociodemog aphic cha ac e is ics T1 Sample N=391 T2 Sample N=314 Gende n (%) Male 123 (31.5) 101 (32.2) Female 268 (68.5) 213 (67.8) Age (M±SD) 45.66±11.13 45.31±10.77 Pa ne ship n (%) No pa ne 108 (27.6) 85 (27.1) Pa ne 283 (72.4) 229 (72.9) Occupa ion n (%) Employed/In educa ion 135 (34.5) 116 (36.9) Unemployed 256 (65.5) 198 (63.1) Educa ional le el n (%) P ima y educa ion 65 (16.6) 44 (14) Seconda y educa ion 128 (32.7) 102 (32.5) Uni e si y o highe 198 (50.6) 168 (53.5) EDSS (M±SD) 3.38±2.06 3.17±1.92 MS sub ype n (%) Remi en 326 (83.4) 272 (86.6) P og essi e 65 (16.6) 42 (13.4) Mon hs since diagnosis (M±SD) 145.31±89.49 145.68±89.56 Mon hs since ou b eak (M±SD) 184.90±108.47 186.11±111.18 Page 24 o 29 URL: h ps://mc.manusc ip cen al.com/ac-phm- cy Email: [email p o ec ed] Heal h Sciences