| Objectives1.To describe the prevalence of mutuality in adults with chronic heart failure(CHF)and their spouse caregivers,as well as to analyze the actor-partner effect of mutuality and its influencing factors in a quantitative study;to further explore and supplement the barriers,facilitators and intervention needs of mutuality in patients with CHF and their spouse caregivers in a qualitative study.2.Based on these influencing factors of the mutuality in patients with CHF and their spouse caregivers,as well as dyadic nostalgia therapy,a dyadic intervention program of mutuality in patients with CHF and their spouse caregivers was developed.3.To evaluate the effects of dyadic intervention program on outcomes such as mutuality and quality of life in patients with CHF and their spouse caregivers.MethodsThe first part was a cross-sectional study.From June 2020 to December 2020,a convenience sample of 206 dyads(412)of patients with CHF and their spouse caregivers was recruited from 4 tertiary hospitals in Shandong and Henan provinces.General information,perceived stress,coping styles,benefit finding,and mutuality were assessed for patients and their spouse caregivers.Statistical analysis was conducted using SPSS 26.0 and Amos 23.0,which included descriptive statistics,paired-samples t test,Pearson’s correlation,multiple linear regression and actor-partner independence model analysis.The second part was a qualitative study.The purpose sampling method was used to recruit 12 dyads of patients with CHF and their spouse caregivers from September 2020 to December 2020,who participated in the first stage of the cross-sectional study.The data was collected through semi-structured interviews and sorted using NVivo 11.0.The themes were refined using theme analysis.The third part was to develop an intervention program.The dyadic intervention program of mutuality in patients with CHF and their spouse caregivers was preliminarily constructed,based on factors from the above two parts,along with dyadic nostalgia therapy.The experts’consultation approach and pre-experiment were used to revise and supplement the intervention program.Finally,the intervention program’s implementation draft was formed.A quasi-experimental research was adopted in the fourth section.Eighty-nine dyads of patients with CHF and their spouse caregivers who met the criteria were recruited from 3 tertiary hospitals in Shandong Province from February 2021 to February 2022.Participants were assigned to the intervention group(44 dyads)and the control group(45 dyads)based on the floor of the ward.The control group only got routine care,while the intervention group got the dyadic intervention of mutuality on the basis of routine care.Mutuality and quality of life of patients and spouse caregivers(primary outcome),patients’ self-care,caregiver contributions to self-care and positive aspects of caregiving(secondary outcome)were assessed at baseline(T1),immediately after intervention(T2),4 weeks after intervention(T3),and 12 weeks after intervention(T4).SPSS 26.0 was used for data description and statistical analysis,and Generalized Estimated Equation(GEE)was employed to evaluate the intervention program’s effectiveness.Results1.The first part:a cross-sectional study(1)The prevalence of mutuality in patients with CHF and their spouse caregiversThe mean score for patient mutuality was(2.64±0.70),and 43.7%of the patients had a mutuality score lower than average level.The mean score for spouse caregiver mutuality was(2.38±0.81),and 55.3%of the caregivers had a mutuality score below the average.The scores for mutuality,love and affection,shared values and reciprocity dimensions in patients with CHF were higher than those in spouse caregivers(all P<0.01).(2)Comparisons of the score for mutuality by patient and spouse caregiver characteristicsPoor caregiver mutuality was reported in patients who were>60 years old,not working/retired,NYHA functional classification Ⅲ/Ⅳ,and number of comorbidities>3.Caregivers who were aged 60 or old,not working/retired,below high school education and with chronic diseases also reported poor mutuality than those who were less than 60 years old,working,high school education or above,and without chronic diseases(P<0.01 or P<0.05).There was no difference in the score for patient mutuality by patient and caregiver characteristics(all P>0.05).(3)Correlation coefficients of scores for perceived stress,coping style,benefit finding,and mutuality in patients with CHF and their spouse caregiversThe score for patient mutuality was positively correlated with the score for caregiver mutuality(r=0.432,P<0.01).The score for patient mutuality was negatively correlated with the score for patient perceived stress(r=-0.248,P<0.01),positively correlated with scores for positive coping(r=0.188,P<0.01)and benefit finding(r=0.561,P<0.01),negatively correlated with the score for caregiver perceived stress(r=-0.137,P<0.05),and positively correlated with the score for caregiver benefit finding(r=0.370,P<0.01).The score for caregiver mutuality was negatively correlated with the score for caregiver perceived stress scores(r=-0.231,P<0.01),positively correlated with scores for positive coping(r=0.230,P<0.01)and benefit finding(r=0.480,P<0.01),positively correlated with scores for patient benefit finding(r=0.227,P<0.01).(4)Multiple linear regression analysis of mutuality in patients with CHF and their spouse caregiversPatient benefit finding(β=0.449,P<0.001)and caregiver benefit finding(β=0.210,P=0.001)was positively associated with patient mutuality,which could explain 34.7%of the variation in mutuality(adjusted R2=0.347).Perceived stress of caregivers(β=-0.186,P=0.004)was negatively associated with caregiver mutuality,and benefit finding of caregivers(β=0.391,P<0.001)was positively associated with caregiver mutuality,which could explain 27.9%of the variance in mutuality(adjusted R2=0.279).(5)The actor-partner effect of mutuality and its associated factors in patients with CHF and their spouse caregiversPerceived stress had an actor effect on the mutuality(patient:β=-0.12,P<0.05;caregiver:β=-0.22,P<0.001),but had no partner effect on mutuality(all P>0.05).Patient benefit finding had only an actor effect on mutuality(β=0.46,P<0.001),but had no partner effect on mutuality(P>0.05).Caregiver benefit finding had both an actor effect(β=0.44,P<0.001)and a partner effect(β=0.21,P<0.001).2.The second part:a qualitative researchThrough analysis of the interview content,four themes of mutuality in patients with CHF and their spouse caregivers were derived,including multiple challenges,barriers,facilitators,and intervention needs.The multiple challenges they faced were traumatic reactions,changes in family roles,and family financial burdens.Barriers included overprotection,lack of communication,and dyadic concealment.Facilitators included adjusting communication styles,benefit finding,and vision support(mutual perspective);spousal commitment and downward social comparison(patient perspective);rethinking about marital relationships and emotional reserves(spouse caregiver perspective).Intervention needs included disease knowledge,participation together,and communication.3.The third part:the development of dyadic intervention program of mutualityThe dyadic intervention program of mutuality in patients with CHF and their spouse caregivers was developed based on factors(perceived stress and benefit finding)identified in the cross-sectional study and barriers(overprotection,lack of communication and dyadic concealment),facilitators(adjusting communication style,vision support,downward social comparison,relationship commitment and rethinking,emotional reserves),and intervention needs(disease knowledge,participation together,and communication)in the qualitative study,along with dyadic nostalgia therapy.Two rounds of expert consultation were conducted among 10 experts,with an expert authority coefficient of 0.825.The dyadic intervention program of mutuality in patients with CHF and their spouse caregivers was preliminarily constructed.Then,three dyads of patients with CHF and their spouse caregivers were recruited for pre-experiment to further revise the dyadic intervention protocol.The dyadic intervention program of mutuality in patients with CHF and spouse caregivers consisted of six themes:getting into mutuality,remembering yesterday,becoming open to each other,sharing each other’s achievements,working together to overcome difficulties,and keeping love alive.The intervention was conducted one on one(patient-caregiver dyad),for 30-40 minutes once a week for 6 weeks.The first intervention session was performed during the patient’s hospitalization,and the subsequent 5 intervention sessions were performed online.4.The fourth part:the application and evaluation of dyadic intervention program of mutuality(1)Comparisons of data in the baseline between the intervention group and control groupA total of 89 dyads of patients with CHF and their spouse caregivers were included at baseline(T1).Regarding patients,there were no statistical differences in general information,scores for mutuality,quality of life,self-care maintenance,self-care management,and self-care confidence between the intervention group and the control group(all P>0.05).Regarding spouse caregivers,except for working status(χ2=4.209,P=0.04),there were no statistical differences in other variables.Immediately after the intervention(T2),80 patients and 76 spouse caregivers were evaluated.There were no significant differences in the variables such as general information,mutuality,and quality of life between the lost samples and the completed samples(all P>0.05).(2)The effect of dyadic intervention program of mutuality on mutuality in patients with CHF and their spouse caregiversPatients:the interaction effect of group and time was statistically significant(P=0.029),indicating the differences in the variation in the mutuality score over time between the intervention group and the control group at four time points.The pairwise comparison of estimated marginal means showed that mutuality score at T2(mean difference=0.543,Cohen’s d=0.75),T3(mean difference=0.369,Cohen’s d=0.44)and T4(mean difference=0.366,Cohen’s d=0.48)in the intervention group were higher than that at T1.Mutuality score at T3 was lower than that at T2(mean difference=-0.175,Cohen’s d=0.24).In the control group,mutuality score at T3(mean difference=-0.236,Cohen’s d=0.28)and T4(mean difference=-0.252,Cohen’s d=0.26)were lower than that at T2.Inter-group comparison showed that mutuality score at T2(mean difference=0.392,Cohen’s d=0.46),T3(mean difference=0.453,Cohen’s d=0.49)and T4(mean difference=0.467,Cohen’s d=0.51)in the intervention group were higher than that in the control group.Spouse caregivers:The interaction effect of group and time was statistically significant(P=0.009),indicating the differences in the variation in the mutuality score over time between the intervention group and the control group at four time points.The pairwise comparison of estimated marginal means showed that mutuality score at T2(mean difference=0.522,Cohen’s d=0.76),T3(mean difference=0.402,Cohen’s d=0.51),T4(mean difference=0.395,Cohen’s d=0.51)higher than that at T1 in the intervention group.Inter-group comparison showed that mutuality score at T2(mean difference=0.455,Cohen’s d=0.62)in the intervention group were higher than that in the control group.Comparison of the effect of intervention on mutuality in patients and spouse caregivers:The interaction effect of role,time and group was not statistically significant(P=0.522),indicating that the effect of the intervention program on mutuality in patients and spouse caregivers was consistent.(3)The effect of dyadic intervention program of mutuality on quality of life in patients with CHF and their spouse caregiversPatients:For emotional dimension,the interaction effect of group and time was statistically significant(P=0.003),indicating the differences in the variation in the emotional dimension score over time between the intervention group and the control group at four time points.The pairwise comparisons of estimated marginal means showed that in the intervention group emotional dimension score at T2(mean difference=11.49,Cohen’s d=0.53),T3(mean difference=13.05,Cohen’s d=0.58),and T4(mean difference=12.48,Cohen’s d=0.52)were greater than that at T1.Inter-group comparison showed that emotional dimension score at T2(mean difference=10.09,Cohen’s d=0.50),T3(mean difference=12,97,Cohen’s d=0.72)and T4(mean difference=10.46,Cohen’s d=0.48)were greater than that in the control group.However,in term of physical dimension,the interaction effect of group and time was not statistically significant(P>0.05).Spouse caregivers:The interaction effect of group and time was statistically significant(P=0.036),indicating the differences in the variation in the score for quality of life over time between the intervention group and the control group at four time points.Pairwise comparisons of estimated marginal means showed that in the intervention group score for quality of life at T2(mean difference=4.19,Cohen’s d=0.43),T3(mean difference=5.40,Cohen’s d=0.52)and T4(mean difference=5.90,Cohen’s d=0.54)were higher than that at T1.(4)The effect of dyadic intervention program of mutuality on self-care in patients/contributions to self-care in spouse caregiversRegarding self-care maintenance,management and confidence in patients,there was no statistical significant in the interaction effect of group and time(all P>0.05).For contributions to self-care maintenance,management and confidence in contributing to self-care in caregivers,the interaction effect of group and time was not statistically significant(all P>0.05).(5)The effect of dyadic intervention program of mutuality on positive aspects of caregivingFor positive aspects of caregiving,the interaction effect of group and time was statistically significant(P=0.005),indicating the differences in the variation in the score for positive aspects of caregiving over time between the intervention group and the control group at four time points.Pairwise comparisons of estimated marginal means showed that in the intervention group the score for positive aspects of caregiving at T2(mean difference=4.51,Cohen’s d=0.70),T3(mean difference=3.60,Cohen’s d=0.54),T4(mean difference=5.10,Cohen’s d=0.80)was higher than that at T1.Inter-group comparison showed that the score for positive aspects of caregiving at T2(mean difference=3.71,Cohen’s d=0.55),T4(mean difference=3.91,Cohen’s d=0.45)were higher than that in the control group.Conclusions1.The mutuality in patients with CHF and their spouse caregivers interact each other.About half of the patients and their spouse caregivers have lower level of mutuality than the average,which needs to be further improved.2.The influencing factors of the patients’ mutuality include their own perceived stress,benefit finding and caregiver benefit finding.The factors of influencing caregivers’mutuality are their own perceived stress and benefit finding.The qualitative research find that mutuality barriers include overprotection,lack of communication,and dyadic concealment;mutuality facilitators include adjusting communication styles,benefit finding and vision support,downward social comparison,relationship commitment and rethinking,emotional reserves;and intervention needs(disease knowledge,participation together,and communication).The findings suggested that healthcare providers should view patients and their spouse caregivers as a whole,pay attention to dyadic disease knowledge needs,alleviate their perceived stress,enhance their benefit finding,build dyadic constructive communication,establish proper cognitive processing strategies and activate their emotional reserves to improve the mutuality in patients with CHF and their spouse caregivers.3.The dyadic intervention program of mutuality in patients with CHF and their spouse caregivers consists of six themes:getting into mutuality,remembering yesterday,becoming open to each other,sharing each other’s achievements,working together to overcome difficulties,and keeping love alive.The dyadic intervention program of mutuality in patients with CHF and their spouse caregivers has significant effects on improving dyadic mutuality,quality of life(emotional dimension)of patients,quality of life of caregivers,and positive aspect of caregiving.4.The dyadic intervention program of mutuality that integrates patients and their spouse caregivers as a whole can provide an effective way to improve psychological health and quality of life in patients with CHF and their spouse caregivers. |
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