Restricted accessResearch articleFirst published online 2026
The relationship between two-way social support,psychological flexibility,intolerance of uncertainty,and patient activation in patients with chronic obstructive pulmonary disease: A chain mediation model
This research aimed to investigate whether psychological flexibility and intolerance of uncertainty serve as intermediaries connecting two-way social support to patient activation in patients with chronic obstructive pulmonary disease (COPD). A cross-sectional study was conducted with 442 Chinese COPD patients. Data analysis was performed using IBM SPSS v26.0 software and the PROCESS macro. The results showed that the COPD patient activation score was 60.62 ± 14.84. Correlation analysis showed that patient activation scores were positively correlated with two-way social support scores, but negatively correlated with psychological flexibility scores and intolerance of uncertainty scores. Mediation analyses confirmed that both psychological flexibility and intolerance of uncertainty significantly mediated the relationship between two-way social support and patient activation. Developing targeted interventions against these mediators is essential to activate patient health behaviors.
AlmutairiMAlmutairiAAAlodhialahAM (2025) Assessing the impact of community health coaching on self-management of chronic illness among older adults: A cross-sectional approach. Clinical Interventions in Aging20: 231–244.
2.
BacchettiPLeungJM (2002) Sample size calculations in clinical research. Anesthesiology97: 1028–1029.
3.
BlauPM (1964) Exchange and Power in Social Life. John Wiley & Sons.
4.
BondFWHayesSCBaerRA, et al. (2011) Preliminary psychometric properties of the acceptance and action questionnaire-II: A revised measure of psychological inflexibility and experiential avoidance. Behavior Therapy42: 676–688.
5.
Bos-TouwenISchuurmansMMonninkhofEM, et al. (2015) Patient and disease characteristics associated with activation for self-management in patients with diabetes, chronic obstructive pulmonary disease, chronic heart failure and chronic renal disease: A cross-sectional survey study. PLoS One10: e0126400.
6.
CalhounCDStoneKJCobbAR, et al. (2022) The role of social support in coping with psychological trauma: An integrated biopsychosocial model for posttraumatic stress recovery. Psychiatric Quarterly93: 949–970.
7.
CaoJJiYZhuZ (2013) Reliability and validity of the Chinese version of the acceptance and action questionnaire-second edition (AAQ-II) in college students. Chinese Mental Health Journal27: 873–877.
8.
CarletonRN (2016) Fear of the unknown: One fear to rule them all?Journal of Anxiety Disorders41: 5–21.
9.
CarletonRNNortonMAPJAsmundsonGJG (2007) Fearing the unknown: A short version of the intolerance of uncertainty scale. Journal of Anxiety Disorders21: 105–117.
10.
ChenCZhuYSunY, et al. (2025) The relationship between social support and interpersonal self-efficacy among higher vocational college students: Parallel mediation effects of anxiety and loneliness. BMC Psychology13: 102.
11.
Collaborators GCRD (2023) Global burden of chronic respiratory diseases and risk factors, 1990–2019: An update from the global burden of disease study 2019. eClinical Medicine59: 101936.
12.
CuiYZhaoQZhaoT, et al. (2022) Validation of the brief 2-way social support scale in community-living older people : Testing reliability and validity. Journal of Nursing Science37: 94–97.
13.
DaiSShiYZhangY, et al. (2023) Influencing factors of two-way social support for the old adults in China: A cross-sectional study. Geriatric Nursing54: 192–198.
14.
DaşcıESalihoğluKDaşcıE (2023) The relationship between tolerance for uncertainty and academic adjustment: The mediating role of students’ psychological flexibility during COVID-19. Frontiers in Psychology14: 1272205.
15.
DuGLyuH (2021) Future expectations and internet addiction among adolescents: The roles of intolerance of uncertainty and perceived social support. Frontiers in Psychiatry12: 727106.
16.
FanVSCoultasDB (2022) Peer support and chronic obstructive pulmonary disease self-management: A promising approach?Annals of the American Thoracic Society19: 1640–1641.
17.
Fernández-SánchezMCRuiz-LópezFJRos-LucasJA, et al. (2024) Persons with chronic obstructive pulmonary disease and high levels of activation improved their physical activity skills after an educational session. Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation11: 270–281.
18.
FongJH (2019) Disability incidence and functional decline among older adults with major chronic diseases. BMC Geriatrics19: 323.
19.
GrossJJ (2002) Emotion regulation: Affective, cognitive, and social consequences. Psychophysiology39: 281–291.
20.
HarbNFosterJMDoblerCC (2017) Patient-perceived treatment burden of chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease12: 1641–1652.
21.
HaukeGLohr-BergerCShafirT (2024) Emotional activation in a cognitive behavioral setting: Extending the tradition with embodiment. Frontiers in Psychology15: 1409373.
22.
HibbardJHMahoneyERStockardJ, et al. (2005) Development and testing of a short form of the patient activation measure. Health Services Research40: 1918–1930.
23.
HongYZouYWuJ (2018) Reliability and validity of the Chinese version of patient activation measure. Chinese Journal of Modern Nursing24: 3009–3015.
24.
JiangXSunJSongR, et al. (2024) Acceptance and commitment therapy reduces psychological distress in patients with cancer: A systematic review and meta-analysis of randomized controlled trials. Frontiers in Psychology14: 1253266.
25.
KashdanTBRottenbergJ (2010) Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review30: 865–878.
26.
KimBKimJ (2019) Influence of uncertainty, depression, and social support on self-care compliance in hemodialysis patients. Therapeutics and Clinical Risk Management15: 1243–1251.
27.
KorpershoekYBos-TouwenIDde Man-van GinkelJM, et al. (2016) Determinants of activation for self-management in patients with COPD. International Journal of Chronic Obstructive Pulmonary Disease11: 1757–1766.
28.
LeonidouCPanayiotouGBatiA, et al. (2016) Coping with psychosomatic symptoms: The buffering role of psychological flexibility and impact on quality of life. Journal of Health Psychology24: 175–187.
29.
LiPLiYHeC, et al. (2025) The mediating role of patient activation on the relationship between social support and health-promoting behavior in patients with thyroid cancer: A cross-sectional study. Journal of Multidisciplinary Healthcare18: 2131–2140.
30.
LiuHZhaoZShiH, et al. (2025a) The current status of social isolation and the caregiver compassion fatigue in elderly COPD patients. Clinical Interventions in Aging20: 739–750.
31.
MachadoABarussoMDe BrandtJ, et al. (2023) Impact of acute exacerbations of COPD on patients’ health status beyond pulmonary function: A scoping review. Pulmonology29: 518–534.
32.
MorrissJGohKHirschCR, et al. (2023) Intolerance of uncertainty heightens negative emotional states and dampens positive emotional states. Frontiers in Psychiatry14: 1147970.
33.
NewlandPLorenzROliverBJ (2021) Patient activation in adults with chronic conditions: A systematic review. Journal of Health Psychology26: 103–114.
34.
ObstPShakespeare-FinchJKroschDJ, et al. (2019) Reliability and validity of the brief 2-way social support scale: An investigation of social support in promoting older adult well-being. Sage Open Medicine7: 2050312119836020.
35.
OkayamaSMinihanSAndrewsJL, et al. (2024) Intolerance of uncertainty and psychological flexibility as predictors of mental health from adolescence to old age. Social Psychiatry and Psychiatric Epidemiology59: 2361–2368.
36.
PakenhamKILandiGGrandiS, et al. (2024) The mediating role of psychological flexibility in the relationship between resilience and distress and quality of life in people with multiple sclerosis. Journal of Health Psychology29: 65–80.
37.
PetersJBAntonsJCKoolenEH, et al. (2022) Patient activation is a treatable trait in patients with chronic airway diseases: An observational study. Frontiers in Psychology13: 947402.
38.
RegeerHvan EmpelenPBiloHJG, et al. (2022) Change is possible: How increased patient activation is associated with favorable changes in well-being, self-management and health outcomes among people with type 2 diabetes mellitus: A prospective longitudinal study. Patient Education and Counseling105: 821–827.
39.
Schock-GiordanoAM (2013) Ethnic families and mental health. Sage Open3: 1–7.
40.
SelinheimoSVuokkoALappalainenP, et al. (2025) The association between quality of life and psychological flexibility, depressive, anxiety or insomnia symptoms in patients with persistent indoor environment-related symptoms or chronic fatigue. BMC Psychology13: 229.
41.
Shakespeare-FinchJObstPL (2011) The development of the 2-way social support scale: A measure of giving and receiving emotional and instrumental support. Journal of Personality Assessment93: 483–490.
42.
ShenZZhangLShiS, et al. (2024) The relationship between uncertainty and fear of disease progression among newly diagnosed cancer patients: The mediating role of intolerance of uncertainty. BMC Psychiatry24: 756.
43.
ShiXWangYJiaQ, et al. (2025b) The relationship between intolerance of uncertainty and treatment adherence: The moderating effect of self-compassion on the chain mediation model. Patient Preference and Adherence19: 699–714.
44.
SmithBMTwohyAJSmithGS (2020) Psychological inflexibility and intolerance of uncertainty moderate the relationship between social isolation and mental health outcomes during COVID-19. Journal of Contextual Behavioral Science18: 162–174.
45.
StoeckelMCEsserRWGamerM, et al. (2016) Brain responses during the anticipation of dyspnea. Neural Plasticity2016: 6434987.
46.
SunJYinXLiC, et al. (2022) Stigma and peer-led interventions: A systematic review and meta-analysis. Frontiers in Psychiatry13: 915617.
47.
Szabo-ReedANDonnellyJE (2021) Cognitive training: Associations and implications for weight management and translational research. Translational journal of the American College of Sports Medicine6: e000151.
48.
SzinayDPerskiOJonesA, et al. (2021) Perceptions of factors influencing engagement with health and well-being apps in the United Kingdom: Qualitative interview study. JMIR mHealth and uHealth9: e29098.
49.
TangTDouBZhaHX, et al. (2022) Factors related to activation in Chinese patients with chronic obstructive pulmonary disease: A cross-sectional survey study. Journal of Nursing Research30: e209.
50.
ThinakaranKAhernABeckettRS, et al. (2025) Association between patient activation, self-management behaviours and clinical outcomes in adults with type 2 diabetes: A systematic review with narrative synthesis. BMJ Open15: e095456.
51.
WangCZhengYWangX, et al. (2025a) Psychological flexibility and diabetes self-management: The mediating roles of depressive symptoms and self-efficacy. Western Journal of Nursing Research47: 698–707.
52.
WangJLyLBarsonE, et al. (2025b) Perceived barriers and facilitators to managing psychological distress in COPD: The perspectives of patients and carers - a qualitative study using the theoretical domains framework (TDF). NPJ Primary Care Respiratory Medicine35: 27.
53.
WangRZhengFCaoG, et al. (2023) The relationship between social support and depression among HIV-positive men who have sex with men in China: The chain mediating role of psychological flexibility and hope. Frontiers in Public Health11: 1271915.
54.
WangWWangLFanR, et al. (2025c) Relationship among depressive symptoms, dyspnea-related fear and sarcopenia in patients with chronic obstructive pulmonary disease: The mediating effect of physical activity. Chronic Respiratory Disease22: 14799731251335028.
55.
WangXGuoJLiuH, et al. (2022) Impact of social participation types on depression in the elderly in China: An analysis based on counterfactual causal inference. Frontiers in Public Health10: 792765.
56.
WangZSongYOuL, et al. (2024) Factors affecting patient activation among patients with systemic lupus erythematosus. Scientific Reports14: 1632.
57.
WetzsteinMMShantaLLChlanLL (2020) Patient activation among community-dwelling persons living with chronic obstructive pulmonary disease. Nursing Research69: 347–357.
58.
WilsonEJStapinskiLDueberDM, et al. (2020) Psychometric properties of the intolerance of uncertainty scale-12 in generalized anxiety disorder: Assessment of factor structure, measurement properties and clinical utility. Journal of Anxiety Disorders76: 102309.
59.
YanXXuLShiB, et al. (2020) Epidemiology and risk factors of chronic obstructive pulmonary disease in Suzhou: A population-based cross-sectional study. Journal of Thoracic Disease12: 5347–5356.
60.
YaoFZhengMWangX, et al. (2021) Patient activation level and its associated factors in adults with chronic pain: A cross-sectional survey. Medicine100: e25929.
61.
ZhangRLiXLuoH, et al. (2025) Effect of self-efficacy, disease perception, social support, anxiety, and depression on self-management in young patients with stroke. Journal of Neuroscience Nursing57: 68–73.
62.
ZhangYSongJGaoY, et al. (2017) Reliability and validity of the intolerance of uncertainty scale-short form in university students. Chinese Journal of Clinical Psychology25: 285–288.
63.
ZhouLLiFLiuC, et al. (2025) Analysis of factors influencing self-management positivity in colorectal cancer chemotherapy patients based on the ABC -X model: A cross-sectional study. Nursing and Health Sciences27: e70147.
64.
ZhuoLWuQLeH, et al. (2021) COVID-19-related intolerance of uncertainty and mental health among back-to-school students in Wuhan: The moderation effect of social support. International Journal of Environmental Research and Public Health18: 981.
65.
ZhuYSongYWangY, et al. (2022) Relationships among social support, self-efficacy, and patient activation in community-dwelling older adults living with coronary heart disease: A cross-sectional study. Geriatric Nursing48: 139–144.
66.
ZhuYSongYWangY, et al. (2023) Relationships among patient activation, social support and online health information seeking of community-dwelling older adults living with coronary heart disease. Journal of Advanced Nursing79: 161–169.
