Health literacy and mutuality are core correlates of self-care among older Chinese HF patient-spouse dyads, with dimension-specific dyadic interaction patterns, while traditional social support showed no significant association with self-care outcomes.
Key Findings
Results
Both older heart failure patients and their spouses scored below the 70-point adequacy threshold across all three self-care subscales.
The three self-care subscales measured were maintenance, management, and confidence.
145 dyads of older HF patients and their spouses were recruited from a tertiary hospital in Zhejiang, China.
The 70-point threshold represents the established adequacy benchmark for self-care measurement instruments used in the study.
This finding applied to both patients and their spousal caregivers across all dimensions.
Results
The Actor-Partner Interdependence Model (APIM) revealed significant actor effects of health literacy and mutuality on self-care for both dyad members.
Actor effects indicate that an individual's own health literacy and mutuality levels were significantly associated with their own self-care behaviors.
This pattern was observed for both patients and spouses independently.
The APIM was applied separately for three self-care subscales: maintenance, management, and confidence.
Health literacy was measured using a disease-specific instrument, and mutuality was also measured with a validated scale.
Results
Spouse mutuality was positively associated with patient self-care maintenance as a significant partner effect.
B = 5.352, 95% CI: 0.631–9.828, p = 0.027.
This represents a partner effect, meaning the spouse's mutuality level influenced the patient's (not the spouse's own) self-care maintenance behavior.
Mutuality reflects the quality of the relationship between patient and spouse, including shared values, love, and reciprocity.
This was one of two significant partner effects identified across all self-care dimensions.
Results
Spouse health literacy was positively associated with patient self-care confidence as a significant partner effect.
B = 0.364, 95% CI: 0.193–0.533, p < 0.001.
This partner effect indicates that a spouse's disease-specific health literacy level was linked to the patient's confidence in self-care.
This was the second of two significant partner effects identified in the study.
No significant partner effect was detected in the self-care management dimension, which also showed suboptimal model fit and was interpreted as exploratory.
Results
No significant paths of traditional social support were retained in the final APIM models for any self-care dimension.
Traditional social support was measured using a validated instrument and included in the quantitative models.
This null finding applied across all three self-care subscales (maintenance, management, confidence) and for both actor and partner effects.
The qualitative phase provided a contextual hypothesis for this finding, suggesting factors such as economic burden and reliance on digital healthcare services may explain why traditional social support was not significantly associated with self-care.
Results
Qualitative analysis identified four thematic levels of factors influencing self-care: individual, dyadic, family/social, and cultural.
Ten dyads were purposively sampled from the quantitative sample for one-to-one semi-structured interviews.
Data were analyzed using Colaizzi's phenomenological method.
Contextual factors emerging from qualitative data included economic burden, reliance on digital healthcare services, and neglect of spousal caregivers.
Qualitative findings supplemented and helped contextualize the quantitative null finding regarding traditional social support.
Methods
An explanatory sequential mixed-methods design integrating quantitative and qualitative findings was employed, guided by the Theory of Dyadic Illness Management (TDIM).
The quantitative phase used multiple linear regression and APIM; the qualitative phase used Colaizzi's phenomenological method.
Integration of findings adhered to the TDIM framework.
The study recruited 145 dyads for the quantitative phase and 10 dyads for the qualitative phase.
The authors describe the study as providing 'exploratory evidence for context-specific extension of the TDIM framework.'
What This Means
This research suggests that older Chinese heart failure patients and their spouses both struggle with self-care — including maintaining healthy behaviors, managing symptoms, and feeling confident in their abilities — with both groups scoring below the level considered adequate. The study, which combined surveys of 145 patient-spouse pairs with in-depth interviews of 10 pairs, found that how well someone understands their illness (health literacy) and the quality of the relationship between patient and spouse (mutuality) were the most important factors linked to better self-care. Importantly, a spouse's own health literacy and sense of mutual connection also influenced the patient's self-care outcomes, suggesting that spouses are not just bystanders but active contributors to how well patients manage their condition.
The study also found that traditional forms of social support — such as help from friends, community, or formal services — were not significantly linked to self-care outcomes in this population. The interviews helped explain this unexpected result: factors like financial strain, difficulty using digital health tools, and a lack of attention to the needs of spousal caregivers may limit the effectiveness of conventional support systems in this context.
This research suggests that healthcare programs for heart failure in China should treat patients and spouses as a team rather than focusing only on the patient. Tailored strategies targeting health literacy and relationship quality within the couple, alongside efforts to make digital health services more accessible for older adults, may be more effective than general social support programs. The findings also highlight that spousal caregivers often go unrecognized and may need support of their own.
Wu X, Zhuang Y, Wang M, Jin J, Ke Y. (2026). Factors influencing self-care among older patients with heart failure and spouses in China: a mixed methods study.. Frontiers in public health. https://doi.org/10.3389/fpubh.2026.1902052