Patients with heart failure and their spouses’ experiences of heart failure symptom: a dyadic qualitative study

Patients with heart failure and their spouses’ experiences of heart failure symptom: a dyadic qualitative study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Patients with heart failure and their spouses’ experiences of heart failure symptom: a dyadic qualitative study Min Zhou, Jingran Yang, Yimei Zhang, Yu Wang, Ruijie Yanglan, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7268167/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Heart failure symptoms severely diminish the quality of life of patients, and the importance of symptom management has been widely recognized. However, patients still face significant pressure in managing symptoms. Family members are considered to be an important resource for symptom management and the need for understanding the dyadic experiences in symptom management is highlighted. Methods Based on face-to-face and semi-structured interviews, a dyadic descriptive phenomenological research design was employed. Patients with heart failure who met the inclusion criteria and their spouses were invited to participate in interviews, and the data were analyzed using framework analysis. Results A total of 17 dyads participated in the study. Based on the framework analysis approach, four themes and nine subthemes were developed: (1) being haunted by symptoms (2) diverse ways of coping with symptoms (3)both decreased and strengthened family wellbeing. Conclusions This study explores the symptom experiences of heart failure patients and their spouses, highlighting that medical staff should offer practical resources and support to heart failure family, accurately identify the distinct attitudes within the family in coping with symptoms, and facilitate family communication to enhance family closeness, thereby improving family health. It also emphasizes that more research is needed to focus on the positive experiences of heart failure symptoms. Clinical trial number Not applicable heart failure symptom management spouses dyadic qualitative study 1. Background Heart Failure (HF) is a complex and life-threatening syndrome marked by high rates of morbidity, mortality, hospitalization, and economic burden, and it has emerged as a significant public health concern in the 21st century [ 1 ] . According to the survey, the number of adults with HF is over 64 million worldwide and increasing by 2 million per year. It is expected that the prevalence of HF will increase by 46% in the next 20 years [ 1 , 2 ] , and about 60% of HF patients die within 5 years of diagnosis, with a mortality rate of up to 50% [ 3 , 4 ] . Patients with HF experience a diminished quality of life due to symptoms including dyspnea, fatigue, and depression, as well as adverse health outcomes characterized by frequent exacerbations and readmissions [ 5 ] . Studies have shown that over 50% of HF patients are readmitted to the hospital within 6 months due to HF-related symptoms, which leads to a significant consumption of medical resources and generates high medical costs, especially in emergency departments and other medical institutions [ 6 ] . Furthermore, as they age, patients face a greater symptom burden, which seriously affects their daily activities and psychological state [ 7 ] . A study interviewed 287 HF patients from the time of their first hospitalization to six months after admission, and the results showed that more than half of the patients were willing to trade survival time for improved symptom control shortly after discharge [ 8 ] . In recent years, symptom management of HF has been increasingly recognized. However, due to the fact that patients with HF often cannot recognize their early symptoms very well, and they might be used to having symptoms, or unaware of the worsening of their symptoms, HF patients are always under great pressure in managing their symptoms [ 9 , 10 ] . Hence, it is necessary to explore HF patients’ experiences of HF symptoms for better symptom management based on patients’ perspectives. Family members are considered to be an important resource for HF patients, who can monitor and manage patients’ existing symptoms, and respond to new symptoms quickly [ 11 , 12 ] . Studies have shown that caregivers, especially spouses, can enhance patients' self-management and perception of symptoms, leading to improvements in quality of life [ 13 ] . Since HF is increasingly carried out at home by individuals and their informal caregivers (dyads), patients’ care has been shifted from clinician to dyadic focused care. The theory of dyadic illness management calls for the need for understanding the dyadic experiences in symptom management [ 14 ] . However, in HF, the literature that explores the experience of HF symptom in the form of dyads remains limited, and the majority of it is quantitative research [ 15 – 17 ] . Because symptoms are subjective and multidimensional, there are some limitations to using scales or questionnaires to assess symptom experience alone [ 18 ] . Dyadic qualitative approaches offer an optimal method for evaluating an individual's emotions, interactions, perceptions, and behaviors, providing couples with an opportunity to narrate their stories beyond the confines of quantitative measurements, thus deepening our comprehension of dyadic experience of symptoms [ 19 , 20 ] . Therefore, this study used dyadic qualitative research methods to explore the experiences of HF symptoms among HF patients and their spouses, as well as the process of managing HF symptoms, and provide direction for future research on dyadic care interventions related to HF symptom management for medical professionals. 2. Methods 2.1 Design This study was conducted using a descriptive phenomenology qualitative design based on semi-structured and in-depth interviews. It provides a direct and comprehensive understanding of dyadic symptoms experienced in HF. The study is reported following the recommendation of the Consolidated Criteria for Reporting Qualitative Research (COREQ) [ 21 ] . 2.2 Participants and setting Patients with CHF and their spouses who were hospitalized in the cardiovascular medicine department of a tertiary hospital located in Kunming, Yunnan Province, were recruited for interviews. Participants were selected using purposive sampling. The first author was responsible for recruiting participants face-to-face. The inclusion criteria of participants were as follows: a. Patients with HF: (i) aged ≥ 18 years; (ii) met the diagnostic criteria for HF of the 2022 AHA/ACC/HFSA Guidelines for the Management of Heart Failure [ 22 ] ; (iii) had cardiac function classes I-III; (iv) married, spouse is the primary caregiver; (ⅴ) willing to participate in this study and had normal comprehension and verbal ability. b. spouses of patients with HF: (i) aged ≥ 18 years; (ii) Patient's spouse with primary caregiving responsibilities; (iii) willing to participate in this study and had normal comprehension and verbal ability. Notably, only patient-spouse pairs in which both the patient and spouse met the inclusion criteria were included in the study. The size of the sample of participants was determined by data saturation, meaning that when no new themes emerged. 2.3 Data collection Semi-structured, face-to-face interviews were conducted with participants between September 2024 and November 2024. The initial interview guide was prepared after reviewing literature and discussing among the research team, and was adjusted based on feedback from participants during the interview process. A pilot study was conducted with two pairs of participants (patient-spouse) before the formal interview. The interview guide cited from supplementary file. Separate interviews were conducted to avoid potential power imbalances between patients and their spouses, which could affect their ability to express their own individual views more freely [ 23 ] . Interviews were conducted by the first author who had undergone systematic qualitative research training. Another researcher was responsible for taking field notes (including participants' emotions, body language, and environmental information). We chose the most appropriate time and location for the interview based on the participants' preferences and physical condition. The interview with patients were conducted at their bedside due to their poor condition, and we used bed curtains to create a more comfortable and undisturbed environment. Spouse chose the time of interview and its’ location at meeting room of the department, which offered a quiet environment. Participants were encouraged to talk widely and freely about their experiences and perspectives. During the interview, an objective record was maintained using recording and note-taking methods. Before the end of each interview, the interviewer would provide a brief summary of the interview, allowing the participant to clarify and share additional information. The duration of the interviews varied from 10 to 30 minutes. 2.4 Data Analysis Within 24 hours, two researchers carried out verbatim transcriptions of the audio recordings and cross-checked their accuracy. We used the framework method developed by Nicole et al [ 24 ] . for data analysis in this research, which includes the following eight stages: Transcription, familiarization with the interview, coding, charting codes into table of themes, dyadic analysis, developing a working analytical framework, applying analytical framework, interpreting data. This framework analysis method goes beyond individual experiences and can more clearly identify similarities and differences within and between dyads. The specific stages for data analysis are outlined in Table 1 . Microsoft Word and Excel were used for managing data analysis for this study. Table 1 Stages of Dyadic Analysis Stage Description 1. Transcription All audio recordings were transcribed verbatim by two researchers. 2. Familiarization with the interview The researchers listened to the recordings repeatedly and reviewed the interview recordings and contextual or reflective notes. 3. Coding After reading the transcript, we coded patients with heart failure and spouses separately. Codes were either relevant to both members of the dyad or just one. 4. Charting codes into table of themes A table of general themes were created based on the questions asked and the codes from the participants’ transcripts, including the description of symptoms of heart failure, management and coping strategies for symptoms, and the impact of symptoms. The codes of transcripts from patients and their spouses were placed under each theme with detailed quotes. Codes that did not reflect general themes were placed under the theme “Other” until such point that a theme was derived, or clarity sought to its appropriate coding. 5. Dyadic analysis The dyadic codes were created, containing a summary of individual codes based on the patients and their spouses. This involved exploring the extent of agreement between members of the dyad. 6. Developing a working analytical framework The defined dyadic analysis codes and possible new themes which reflect the different matrices were discussed with coauthors, which formed the working analytical framework. 7. Applying analytical framework We used the analytical framework to test other pairs of data and develop further code as needed. 8. Interpreting data We explain the overlapping and contrasting elements in dyadic narratives. 2.5 Rigor In this study, we used Thomas and Magilvy’s framework of credibility, transferability, dependability and confirmability to achieve rigor [ 25 ] . We used peer examination to ensure credibility by examining manuscripts and extracting code, sending data to other researchers for their supplementary comments, and conducting ongoing reviews. Additionally, long-term engagement was also employed to enhance credibility. Before data collection, researchers participated in nursing activities as a nurse and established trust relationships with the participants. Transferability was achieved through a deep and rich description of the demographic and geographic boundaries of the study. Furthermore, participant descriptions and observational records were the main sources of data for drawing research conclusions, and audit trail was adopted to maintain and review the original data to increases the dependability of the findings. To ensure confirmability, reflexivity was employed. The researchers maintained a diary throughout the study, which allowed the researchers to control personal values, perceptions and prejudices. In addition, when differences emerged in the analysis, consensus was achieved through discussion. The corresponding author validated the final results. 2.6 Ethical considerations The study was conducted in accordance with the Helsinki Declaration and was approved by the ethics committee of the hospital (2024 − 219). Written informed consent was obtained from each participant. The content of interviews would be confidential, anonymous and used solely for this research. 3. Results A total of 17 pairs of participants (patient-spouse) were interviewed for this study. The mean age of the patients was 62.41 years, ranging from 44 to 77 years. The mean age of the spouses was 60.88 years, ranging from 42 to 75 years. The detailed demographic and clinical characteristics of the participants are presented in Table 2 . Table 2 Study participants’ socio-demographic and clinical characteristics. (N = 17 patient-spouse dyads). ID Sex Age(years) Ethnicity Education level Employment Time since diagnosis (years) Other chronic disease P1 Male 69 Han High school No 1 S1 Female 70 Han Middle school No Yes P2 Female 58 Han Primary school Yes 1 S2 Male 58 Han Middle school Yes No P3 Male 77 Han High school No 3 S3 Female 68 Han High school No Yes P4 Male 47 Dai Primary school Yes 1 S4 Female 42 Dai Primary school No No P5 Male 74 Han Middle school No 1 S5 Female 75 Han Middle school No No P6 Male 56 Bai High school Yes 6 S6 Female 54 Bai High school Yes No P7 Female 72 Han Middle school No 2 S7 Male 75 Han High school No Yes P8 Male 70 Han High school No 1 S8 Female 68 Han Primary school No Yes P9 Male 64 Han High school No 0.5 S9 Female 62 Han High school No No P10 Male 56 Han Primary school Yes 0.5 S10 Female 53 Han Primary school No Yes P11 Male 53 Hani Primary school Yes 1 S11 Female 49 Hani Primary school No No P12 Female 63 Han Middle school Yes 2 S12 Male 62 Han High school Yes No P13 Female 68 Han University No 0.5 S13 Male 72 Han High school No Yes P14 Male 60 Han University No 1 S14 Female 52 Han University Yes No P15 Male 58 Han Middle school Yes 2 S15 Female 55 Han Primary school Yes No P16 Male 44 Buyi Middle school No 2 S16 Female 48 Buyi Middle school Yes No P17 Female 72 Han Primary school No 5 S17 Male 72 Han Primary school No No Three themes and nine subthemes were revealed in this study. The detail information is shown in Table 3 . Table 3 Themes and sub-themes Themes Sub-themes Being haunted by symptoms λ Multiple and recurrent λ Fatigue as most concerning Diverse ways of coping with symptoms λ Depending on professional support λ Seeking help from the internet λ Turning to superstition λ Patients’ giving up companied with spouses’ fighting these symptoms Both decreased and strengthened family wellbeing λ Financial loss of the family λ Negative emotions around the family λ A beneficial experience 3.1 Theme 1: Being haunted by symptoms The participants reported a total of 12 symptoms, which they attributed to getting older, the effect of HF, and other factors. The symptoms are shown in Table 4 . Among these symptoms, breathlessness was the most commonly reported symptom. Participants felt that these symptoms were recurrent and not isolated, with fatigue being considered the most distressing HF symptom. Table 4 Symptoms reported by participants Reported symptom N (%) of patients Breathlessness 12(70.59%) Fatigue 9(52.94%) Chest pain 4(23.53%) Edema 4(23.53%) Poor quality sleep 3(17.65%) Digestive symptoms (Loss of appetite、 Abdominal bloating) 6(35.29%) Others (Cough、Dizzy、Gout、Palpitation、Hot flushes) 5(29.41%) 3.1.1 Multiple and recurrent Almost all participants agreed that the symptoms of HF were recurrent and difficult to completely be cured. And in most cases, the patients had more than just one symptom, it was typically accompanied by two to three additional symptoms. I feel sick all over right now, and these symptoms are recurrent and come back even after treatment. P2 Sometimes, she experiences discomfort characterized by chest tightness, a lack of strength, and difficult breathing. These symptoms often lead to insomnia and a persistent decline in her overall mood. After taking medication, she is getting better, however, the symptoms eventually return after a few days. S12 3.1.2 Fatigue as most concerning Many participants considered fatigue to be the most concerning symptom, which had a significant impact on mood, behavior, and social activities, thus reducing the quality of life. I often feel very tired, so I don't go out with my friends anymore and I don't have the mood to do these things, which make me feel really miserable. P7 Previously, we frequently went out for walks and excursions. However, he often feels fatigue. Subsequently, we no longer go out, and I even abandon square dancing, this symptom is torturing us too much. S9 3.2 Theme 2: Diverse ways of coping with symptoms Faced with the challenges posed by the symptoms of HF, participants chose to cope in different ways, including relying on professional personnel, actively seeking help from the internet, and even turning to superstitious. We also found out that dyad had controversial coping when faced with these symptoms. 3.2.1 Depending on professional support Some participants actively sought assistance from medical professionals, being convinced that the medical staff could offer them reliable medical resources and support to mitigate the symptoms. It is also noted that some spouses felt it alleviated their own burdens, which led them to rely on professionals as a coping strategy for these symptoms. Every time the symptoms flare up, I go to the hospital for treatment, it is the best way to cope with these annoying symptoms. P11 I feel easier when I send him to the hospital, the doctors will treat him. They will tell me how to take the medicine and daily precautions, including lifestyle, diet, exercise, etc. S1 3.2.2 Seeking help from the internet With the development of internet, many participants who lacked knowledge about diseases often turned to the internet for information to help them make decisions and provide daily life guidance to manage the symptoms. I see some tips for HF patients on Tik Tok, such as water intake, diet, and lifestyle habits, which is effective to manage his symptoms. F16 I often use Tik Tok to browse information about HF, including its prevalence, treatment and some methods to alleviate symptoms. S17 3.2.3 Turning to superstition Some participants said that the symptoms of HF caused them so much pain, and they had no idea what to do. Finally, they tried witchcraft to get some kind of power to help them alleviate symptoms. We didn't know what to do to ease the pain caused by these symptoms and we had to seek help from witchcraft according to folklore. She seems to be feeling better since a ceremony was held. S2 3.2.4 Patients’ giving up companied with spouses’ fighting these symptoms Some patients were severely affected by symptoms of HF and believed that the condition was difficult to be cured, so they gave up. However, their spouses still persisted and did their best to cope with these symptoms in order to alleviate the patients' suffering, even if they had to make some sacrifices, they were willing to do so. I feel unwell every day, the symptoms such as breathlessness and fatigue have been repeatedly tormenting me. I'm neither dead nor alive. There seems to be no hope of getting better. It's like I'm a salty fish waiting to die. P1 Whenever he showed pessimism, I would constantly comfort and encourage him. I always believe that even if there is only one percent hope, I am willing to try. I just hope that he will no longer be plagued by these symptoms and that everything will be fine with him. S1 I feel very depressed. Even though the sunset is beautiful, it's sad that it's nearing the end of the day (a line from an ancient poem) I have no intention to persist any longer. P5 I haven't asked him to do anything since he was feeling tired, All the household chores and childcare are my responsibility. I'm willing to do anything as long as he can feel a little less pain. S5 3.3 Theme 3: Both decreased and strengthened family wellbeing The symptoms of HF have had a significant impact on participants and their families, including economic losses and negative emotions, which seriously damaged the quality of family life. However, some participants believed that the shared experience of coping with symptoms had improved their lifestyles, strengthened their relationships with each other, and promoted family health. 3.3.1 Financial loss of the family As patients may require multiple hospitalizations and spouses need to offer long-term care, some families lost their primary source of income, which imposed a significant economic burden on the household. We've been spending money on treatments over the years, and I am also a disabled person, I cannot go to work, we really don't have any more money. we borrowed the money for this hospitalization. S10 Because his symptoms often recur and each hospitalization costs so much money and he is unemployed, our children are still in school. I've had to take more than one job. S16 3.3.2 Negative emotions around the family Patients often experienced negative emotions such as irrational anger, emotional breakdown, sadness, and fear of relapse due to the suffering of their symptoms. When spouses felt the negative emotions from the patients, their own emotions were also affected, and to avoid influencing the patients, they usually chose to hide their emotions and bear these negative emotions alone. I don't feel happy anymore because I often feel difficult to breathe whenever I move around. I get irritated by even the smallest things. P6 When he is not feeling well, he becomes very irritable. I feel sad when I see him like this. S6 3.3.3 A beneficial experience Some participants chose to change their lifestyle and correct their previous unhealthy behaviors in order to reduce the risk of relapse. Additionally, some participants reported that their relationship with their spouse became closer, and they had more time together to discuss how to manage and cope with the symptoms of HF, which they considered to be a beneficial experience. In order to prevent his symptoms from recurring, she bought a book to regulate the diet, I was sick before, so she also pays attention to managing my diet. It is indeed beneficial to our health. S12 Previously, I frequently went out, which resulted in us spending minimal time together. Now, we share our days, we seem to be getting closer. I take daily walks with him and we collaborate to manage the symptoms. I feel very happy with this simple life. S9 My lifestyle has changed, and I have quit smoking and drinking. P9 4. Discussion This research explores the experiences and comprehension of HF symptoms by HF patients and their spouses, as well as their responses to the symptoms, providing direction for future research to develop dyadic care interventions. Our research revealed that couples regarded the symptoms of HF as recurrent, which caused them significant distress. This research finding is consistent with many studies in the literature [ 26 , 27 ] . Despite pharmacologic and nonpharmacologic interventions for HF are progressing, these treatments are not always effective [ 28 ] . Patients with HF often experience a cyclical process between symptom onset and control, causing long-term and ongoing distress to patients and their family [ 29 ] . Present evidence showed that 31.9% and 38.5% of HF patients were readmitted within 6 months and 1 year after discharge, respectively, some patients even developed HF-related symptoms immediately after discharge [ 26 , 27 ] . In addition, HF symptoms often emerge simultaneously rather than in isolation, as also reported in our study [ 30 ] . Bekelman et al. [ 31 ] indicated that patients with HF experienced as many as nine symptoms, including shortness of breath, fatigue, edema, pain, drowsiness, difficulty concentrating, feeling sad or anxious, worry and lack of appetite. In addition, these symptoms can interact with and enhance each other, severely impairing the well-being of the patients and their family [ 32 , 33 ] . There is growing evidence that clusters of symptoms may be more predictive of outcome than symptoms that occur in isolation [ 34 ] . Therefore, more attention to the symptom cluster is necessary. This finding also suggested that healthcare providers should conduct comprehensive symptom assessments and provide interventions targeted at these symptom clusters to help patients and their family members monitor symptoms regularly, promote effective symptom management, and thus enhance the quality of life for patients and their families [ 30 ] . In our study, fatigue was considered the most distressing symptom by the couples, which is consistent with previous studies conducted in hospitalized patients [ 35 , 36 ] . Fatigue is one of the most common symptoms in patients with HF, appearing at the early onset of the disease, throughout the disease, and worsening as the disease persists, significantly affecting the patient's daily life, causing a great physical and mental burden on the patient, and decreasing their quality of life [ 37 , 38 ] . Whitehead et al. [ 39 ] indicated that among family members of patients with HF, spouses are more likely to express concern about patients’ fatigue, especially since increased fatigue represents a decline in health. As a result, they have to spend more time and energy helping the patient manage fatigue, which could lead to increased caregiving and psychological burdens on spouses and impair their social health [ 40 ] . Despite the fact that fatigue can be extremely distressing to patients and their family, fatigue is rarely evaluated or treated [ 28 ] . Previous research suggested that healthcare professionals often do not discuss the potential experience of fatigue and its effects with individuals or families living with chronic conditions [ 41 ] . Hence, more research is needed to delve deeper into the fatigue experiences of HF patients and their families and develop targeted interventions to alleviate the suffering caused by fatigue. Couples have also adopted some methods to cope with these symptoms. In this study, patients and spouses believed that professional support was an effective way to reduce the burden of symptoms and caregiving. According to the health promotion model, individuals are more likely to engage in healthy behaviors when they receive support, guidance, and encouragement from healthcare providers [ 42 ] . When patients and their spouses feel safe during their interactions with healthcare providers, they also feel a reduction in the burden of self-care, which can help boost their confidence in symptom management [ 42 , 43 ] . Hodson et al. [ 44 ] also found that caregivers of HF patients felt supported when they were provided with direct information about the patient's needs and current health status, and reported positive care experiences. Hence, it is recommended that healthcare providers offer more resources and practical support to HF families, enabling patients and family members to be more proactive in symptom management. In addition to relying on professional support to cope with symptoms, couples also actively sought help from the internet in this study. With the promotion and popularization of smartphones and wearable devices, mobile health (mHealth) has become a new option to support HF self-management [ 45 ] . mHealth is widely used in the fields of symptom monitoring and assessment, recurrence warning, and health information inquiry for chronic disease patients due to its real-time, convenient, interactive, and user-friendly features [ 46 , 47 ] . However, due to the influence of age and education level, the use of mHealth is relatively low [ 48 ] . Additionally, the quality of online information is uneven, making it difficult to effectively distinguish between reliable and unreliable sources, further hindering the effectiveness of mHealth in managing symptoms for HF patients and their caregivers [ 48 , 49 ] . Therefore, it is highlighted that medical professionals can provide simple mHealth usage training for the families of elderly HF patients and guide them in correctly identifying healthcare information to promote self-management. Our study also revealed that some participants turned to witchcraft to cope the pain associated with HF symptoms. Throughout history, the most obvious purpose of witchcraft beliefs has been to provide explanation for unfortunate events in people’s lives, which can help with coping [ 50 ] . When individuals are overwhelmed by the challenges posed by some calamities (e.g., illness), they believe that witchcraft can help them to find the source of the calamity and eliminate the suffering through some mystical powers, rituals, or medicines, which enhances and inspires them to have the courage and strength to overcome and conquer the disease [ 51 , 52 ] . According to the latest surveys carried out in dozens of countries and on multiple continents over the past ten years, witchcraft beliefs are so prevalent in the modern world, and are especially prevalent in developing countries [ 50 , 53 ] . However, witchcraft beliefs have a range of harms to the healthcare delivery and patients’ wellbeing [ 53 , 54 ] . Miranda et al reported that witchcraft beliefs might delay or prevent people from seeking medical assistance or made them less likely to follow medical advice [ 55 ] . Therefore, further research is necessary to explore ways to avoid the negative effects of witchcraft beliefs in the symptom management of HF patients. Our study found that couples had controversial coping when faced with these symptoms. Alpert et al. [ 7 ] pointed out that, as the disease progressed, the burden of symptoms on the patient became more severe and their physical, psychological and social functioning deteriorated. In addition, due to an increased awareness of the burden on their caregivers, patients often develop thoughts of giving up symptom management. In this study, we also found that spouses continued to cope with HF symptoms with a positive mindset even when the patient giving up. In China, influenced by Confucianism, Chinese culture emphasizes collectivism and highlights the interdependence of family members. The mutual dependence between family members stimulates a sense of responsibility to respond to the care needs of one's spouse, and it is also influenced by the traditional Chinese virtue of loyalty, spouse of patients with HF follows through on their commitment to their marriage and supports their partner in adversity, even if it requires making some "sacrifices" (which are defined as stopping something you enjoy in order to allow yourself to participate in something of greater value) [ 44 , 56 , 57 ] . Consequently, in the face of the suffering and negative mentality brought about by HF symptoms to the patients, the spouses still actively engage in the treatment, even if it requires them to sacrifice their own time and the hobbies that they once enjoyed. It is suggested that medical staff should understand the different attitudes toward symptom management of HF patients and their spouses, which can facilitate the symptom management in the family level. Finally, we discovered that the symptom experiences of HF patients and their spouses were a double-edged sword for family health. First, couples believed that HF symptoms had caused a significant economic burden on the family, which is consistent with the current research findings [ 58 , 59 ] . Due to the aggravation of symptoms and the continuous deterioration of bodily functions, some patients are compelled to resign from their jobs, or caregivers are obliged to quit their jobs to undertake the duty of care, resulting in a sharp decline in family income. Some elderly patients merely rely on scanty pensions to sustain their treatment, which undoubtedly imposes colossal economic burdens on patients and their families [ 60 ] . This recommend that the government should enhance financial support, broaden the coverage of medical insurance and offer more resources. Secondly, we found that negative emotions of HF patients often transferred to their partners, seriously damaging the psychological health of the family. HF patients frequently experience anxiety, depression and a sense of worthlessness because the uncontrolled symptoms, which prevent them from leading an active life and working as they did before [ 61 ] . Previous research has indicated that dyads can exert a strong influence on each other's emotions, confidence, and behaviors [ 5 ] . Therefore, spouses may also have negative emotions. Moreover, factors such as caregiving stress, psychosocial expenditure, and role conflicts intensify the psychological burden of spouses [ 62 ] . However, due to the mutual "protection" consideration between couples, they often avoid discussing their own negative emotions with each other, particularly under the influence of family culture in China, and it has become a habit for family members to conceal their emotions within the family, which leads to insufficient stress relief and the persistence of negative emotions in the family [ 63 ] . There is evidence that good family communication is conducive to offering emotional support for patients and their spouses, cultivating the closeness among spouses, and enabling them to confront stressors with a positive mindset [ 49 ] . Therefore, healthcare professionals can utilize the family advantage perspective to provide targeted interventions for couples and families to promote communication and collaboration between patients and their spouses, and enhance family symptom management. Interestingly, our study also found that couples perceived that HF symptom experience had improved their lifestyle, enhanced their intimacy, and was a beneficial experience for the family. Changes in one's perception of oneself and self-care are considered as one of the dimensions of Tedeschi and Calhoun's model, which allows participants to gain wisdom in facing difficulties and produce positive changes in their lifestyle and relationships. Participants who accept HF symptoms can effectively take care of themselves by using self-care problem-focused coping skills (positive coping, problem-solving, planning, and information-seeking) to adjust to a healthy lifestyle and improve their relationships with others [ 64 , 65 ] . Furthermore, Chinese family culture emphasizes the unity and functionality of the family, as well as the responsibilities and contributions of individuals within the family, which makes HF patients and their spouses more united in facing the challenges brought by symptoms, and this intimate relationship can help them experience happiness and fulfillment while receiving support, and promote the process of symptom management [ 63 , 65 ] . However, current research primarily focuses on the negative impact of HF symptoms on patients or their family members. It is necessary for future research to explore the positive experiences of HF patients and their families regarding HF symptoms. Limitations Our results should be considered in the context of several limitations. First, like any other qualitative study, our research findings are limited to similar research populations, data collected from a single center, and a smaller sample size. However, our data has reached saturation, and the research results reflect the views of the participants. Second, the data in this study are cross-sectional, which may not be able to reflect the changes in symptom experiences of HF patients and their spouses over time. Future studies may consider a longitudinal design. Conclusions This study, on a dyadic basis, deeply explored the authentic experiences and valuable information of HF patients and their spouses regarding HF symptoms. Our research highlights that medical staff should enhance their attention to the symptom cluster of HF and fatigue symptoms and formulate targeted measures to lower the readmission rate of patients. In the face of the challenges posed by HF symptoms, HF patients and their spouses will adopt multiple approaches to cope with them. However, the use of mHealth should be exercised with caution, and vigilance against the negative impacts of witchcraft is necessary. At the same time, it is suggested that medical staff should accurately identify the different attitudes toward HF symptoms of patients and their spouses, and guide patients and spouses to make active adjustments to cope with HF symptoms. Furthermore, our research has also discovered the two-sided effect of HF symptom experiences on family health. It emphasizes the significance of family communication and the necessity to further explore the positive experiences of HF symptoms in order to enhance family wellbeing. Declarations Funding This research was supported by the Reserve Talent Project of Academic and Technological Leaders for Young and Middle-aged People in Yunnan Province, China, No. 202205AC160017 and the Joint Special Project-General Project of Kunming Medical University, China, No 202301AY070001-153. Conflicts of Interest The authors have no conflicts of interest in this study. Ethics approval This study was conducted in accordance with the Helsinki Declaration and was approved by the First Affiliated Hospital of Kunming Medical University Ethics Committee ((2024-219). Informed Consent All participants provided informed consent prior to enrolment in the study, including consent for publication of anonymized quotes. Acknowledgments The authors thank the participants who voluntarily participated in this study. Consent for publication All participants have provided written consents for the research team to use their de-identifed data in this manuscript, including information provided through demographic surveys. Data Availability The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Author contributions Min Zhou (first author) contributed to the study design, data collection and analysis, and writing the manuscript. Fang Ma (corresponding author) was responsible for designing the study and revising the manuscript. Jingran Yang, Yimei Zhang, Yu Wang were responsible for data collection. Ruijie Yanglan, Qinlan Li were responsible for the data analysis. Yangjuan Bai, Wei Wei contributed to the review of the manuscript. All authors read and approved the final manuscript. References Savarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global burden of heart failure: A comprehensive and updated review of epidemiology. Cardiovascular Res. 2023;118:3272–87. https://doi.org/10.1093/cvr/cvac013 . Bozkurt B, Khalaf S. Heart Failure in Women. Methodist Debakey Cardiovasc J. 2017;13:216–23. https://doi.org/10.14797/mdcj-13-4-216 . Liu X, Yu H, Pei J, Chu J, Pu J, Zhang S. Clinical characteristics and long-term prognosis in patients with chronic heart failure and reduced ejection fraction in China. Heart Lung Circulation. 2014;23:818–26. https://doi.org/10.1016/j.hlc.2014.02.022 . 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Never forsake—The positive experiences of dyadic coping among patients with acute leukemia and their spouses: A qualitative study. Eur J Oncol Nurs. 2023;62:102262. https://doi.org/10.1016/j.ejon.2022.102262 . Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349–57. https://doi.org/10.1093/intqhc/mzm042 . Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145:e895–1032. https://doi.org/10.1161/CIR.0000000000001063 . Taylor B, De Vocht H. Interviewing Separately or as Couples? Considerations of Authenticity of Method. Qual Health Res. 2011;21:1576–87. https://doi.org/10.1177/1049732311415288 . 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Paz LFDA, Medeiros CDA, Martins SM, Bezerra SMMDS, Oliveira Junior WD, Silva MBA. Quality of life related to health for heart failure patients. Rev Bras Enferm. 2019;72:140–6. https://doi.org/10.1590/0034-7167-2018-0368 . Hu Y, Jiang J, Xu L, Wang C, Wang P, Yang B, et al. Symptom clusters and quality of life among patients with chronic heart failure: A cross-sectional study. Japan J Nurs Sci. 2021;18:e12366. https://doi.org/10.1111/jjns.12366 . Bekelman DB, Havranek EP, Becker DM, Kutner JS, Peterson PN, Wittstein IS, et al. Symptoms, depression, and quality of life in patients with heart failure. J Card Fail. 2007;13:643–8. https://doi.org/10.1016/j.cardfail.2007.05.005 . Son Y-J, Won MH. Symptom Clusters and Their Impacts on Hospital Readmission in Patients With Heart Failure: A Cross-Sectional Study. Res Theory Nurs Pract. 2018;32:311–27. https://doi.org/10.1891/1541-6577.32.3.311 . Yu DS, Chan HY, Leung DY, Hui E, Sit JW. Symptom clusters and quality of life among patients with advanced heart failure. J Geriatr Cardiol. 2016;13:408–14. https://doi.org/10.11909/j.issn.1671-5411.2016.05.014 . Koshy AO, Gallivan ER, McGinlay M, Straw S, Drozd M, Toms AG, et al. Prioritizing symptom management in the treatment of chronic heart failure. ESC Heart Fail. 2020;7:2193–207. https://doi.org/10.1002/ehf2.12875 . Khan RF, Feder S, Goldstein NE, Chaudhry SI. Symptom Burden Among Patients Who Were Hospitalized for Heart Failure. JAMA Intern Med. 2015;175:1713–5. https://doi.org/10.1001/jamainternmed.2015.3871 . Nguyen TT, Nguyen TX, Nguyen TTH, Nguyen TN, Nguyen HTT, Nguyen HTT, et al. Symptom Burden among Hospitalised Older Patients with Heart Failure in Hanoi. Vietnam IJERPH. 2022;19:13593. https://doi.org/10.3390/ijerph192013593 . Falk K, Patel H, Swedberg K, Ekman I. Fatigue in patients with chronic heart failure - a burden associated with emotional and symptom distress. Eur J Cardiovasc Nurs. 2009;8:91–6. https://doi.org/10.1016/j.ejcnurse.2008.07.002 . Zambroski CH, Moser DK, Bhat G, Ziegler C. Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure. Eur J Cardiovasc Nurs. 2005;4:198–206. https://doi.org/10.1016/j.ejcnurse.2005.03.010 . Whitehead L. The Family Experience of Fatigue in Heart Failure. J Fam Nurs. 2017;23:138–56. https://doi.org/10.1177/1074840716684232 . Falk K, Granger BB, Swedberg K, Ekman I. Breaking the vicious circle of fatigue in patients with chronic heart failure. Qual Health Res. 2007;17:1020–7. https://doi.org/10.1177/1049732307306914 . Hewlett S, Cockshott Z, Byron M, Kitchen K, Tipler S, Pope D, et al. Patients’ perceptions of fatigue in rheumatoid arthritis: overwhelming, uncontrollable, ignored. Arthritis Rheum. 2005;53:697–702. https://doi.org/10.1002/art.21450 . Babygeetha A, Devineni D. Social Support and Adherence to Self-Care Behavior Among Patients With Coronary Heart Disease and Heart Failure: A Systematic Review. Eur J Psychol. 2024;20:63–77. https://doi.org/10.5964/ejop.12131 . Mcharo TL, Iseselo MK, Kahema SE, Tarimo EAM. Experiences of family caregivers in caring for patients with heart failure admitted at Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania: A qualitative study. PLoS ONE. 2023;18:e0280698. https://doi.org/10.1371/journal.pone.0280698 . Hodson AR, Peacock S, Holtslander L. Family caregiving for persons with advanced heart failure: An integrative review. Palliat Support Care. 2019;17:720–34. https://doi.org/10.1017/S1478951519000245 . Jin X, Zhang Y, Zhou M, Zhang X, Mei Q, Bai Y, et al. Experiences With mHealth Use Among Patient-Caregiver Dyads With Chronic Heart Failure: Qualitative Study. J Med Internet Res. 2024;26:e57115. https://doi.org/10.2196/57115 . Shin JY, Chaar D, Kedroske J, Vue R, Chappell G, Mazzoli A, et al. Harnessing mobile health technology to support long-term chronic illness management: exploring family caregiver support needs in the outpatient setting. JAMIA Open. 2020;3:593–601. https://doi.org/10.1093/jamiaopen/ooaa053 . Moses JC, Adibi S, Shariful Islam SM, Wickramasinghe N, Nguyen L. Application of Smartphone Technologies in Disease Monitoring: A Systematic Review. Healthc (Basel). 2021;9:889. https://doi.org/10.3390/healthcare9070889 . Zhang N, Li Q, Chen S, Wu Y, Xin B, Wan Q, et al. Effectiveness of nurse-led electronic health interventions on illness management in patients with chronic heart failure: A systematic review and meta-analysis. Int J Nurs Stud. 2024;150:104630. https://doi.org/10.1016/j.ijnurstu.2023.104630 . Yang F, Cui S, Cai M, Feng F, Zhao M, Sun M, et al. The experiences of family resilience in patients with permanent colostomy and their spouses: A dyadic qualitative study. Eur J Oncol Nurs. 2024;70:102590. https://doi.org/10.1016/j.ejon.2024.102590 . Gershman B. Witchcraft beliefs around the world: An exploratory analysis. PLoS ONE. 2022;17:e0276872. https://doi.org/10.1371/journal.pone.0276872 . Neki JS, Joinet B, Ndosi N, Kilonzo G, Hauli JG, Duvinage G. Witchcraft and psychotherapy. Br J Psychiatry. 1986;149:145–55. https://doi.org/10.1192/bjp.149.2.145 . Jia H. [Witchcraft medicine and folklore in Wushierbingfang ('Prescriptions for fifty-two diseases’)]. Zhonghua Yi Shi Za Zhi. 2010;40:114–9. Witchcraft beliefs as a cultural legacy of the Atlantic slave trade. Evidence from two continents. Eur Econ Rev. 2020;122:103362. https://doi.org/10.1016/j.euroecorev.2019.103362 . Chow EOW, Wong YY, Fok DYH, Liao X, Li C. Positive life stories of Stroke-Survivor’s spousal caregiving in Hong Kong: Lessons for policy and practice. Soc Sci Med. 2021;291:114476. https://doi.org/10.1016/j.socscimed.2021.114476 . Australian N, University, Canberra, Australia, Forsyth M, Taylor J, University of Newcastle, Newcastle, New South Wales, Australia, Housen T et al. University of Newcastle, Newcastle, New South Wales, Australia,. Sorcery and witchcraft beliefs on the front line of public health response in Papua New Guinea and beyond. WPSAR. 2024;15:14–8. https://doi.org/10.5365/wpsar.2024.15.3.1171 Chow EOW, Wong YY, Fok DYH, Liao X, Li C. Positive life stories of Stroke-Survivor’s spousal caregiving in Hong Kong: Lessons for policy and practice. Soc Sci Med. 2021;291:114476. https://doi.org/10.1016/j.socscimed.2021.114476 . Chen YC. Chinese values, health and nursing. J Adv Nurs. 2001;36:270–3. https://doi.org/10.1046/j.1365-2648.2001.01968.x . Shafie AA, Tan YP, Ng CH. Systematic review of economic burden of heart failure. Heart Fail Rev. 2018;23:131–45. https://doi.org/10.1007/s10741-017-9661-0 . Stafylas P, Farmakis D, Kourlaba G, Giamouzis G, Tsarouhas K, Maniadakis N, et al. The heart failure pandemic: The clinical and economic burden in Greece. Int J Cardiol. 2017;227:923–9. https://doi.org/10.1016/j.ijcard.2016.10.042 . Zhang A, Zheng X, Shen Q, Zhang Q, Leng H. Family management experience of parents of children with chronic heart failure: A qualitative study. J Pediatr Nurs. 2023;73:e36–42. https://doi.org/10.1016/j.pedn.2023.07.006 . Petruzzo A, Paturzo M, Naletto M, Cohen MZ, Alvaro R, Vellone E. The lived experience of caregivers of persons with heart failure: A phenomenological study. Eur J Cardiovasc Nurs. 2017;16:638–45. https://doi.org/10.1177/1474515117707666 . Wang Z, Tocchi C. Partners’ Experience of Informal Caregiving for Patients With Heart Failure: A Meta-ethnography. J Cardiovasc Nurs. 2023;38:E40–54. https://doi.org/10.1097/JCN.0000000000000903 . Guo Y. Research on the Intervention of Medical Social Work in End-of-life Care Services for Terminally Ill Cancer Patients: A Perspective Based on Chinese Family Culture. IJCEMR. 2023;7:677–81. https://doi.org/10.26855/ijcemr.2023.10.029 . Tedeschi RG, Calhoun LG. The Posttraumatic Growth Inventory: measuring the positive legacy of trauma. J Trauma Stress. 1996;9:455–71. https://doi.org/10.1007/BF02103658 . Moshki M, Khajavi A, Minaee S, Vakilian F, Hashemizadeh H. Perceived benefits of the disease: A qualitative study of patients’ experiences of heart failure. Nurs Health Sci. 2020;22:464–71. https://doi.org/10.1111/nhs.12682 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7268167","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":508374402,"identity":"7bf33907-a69e-42a9-b677-f9f70fad0124","order_by":0,"name":"Min Zhou","email":"","orcid":"","institution":"The First Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Zhou","suffix":""},{"id":508374403,"identity":"1d10abc9-c5fe-4fb4-b3ee-229f04027051","order_by":1,"name":"Jingran Yang","email":"","orcid":"","institution":"The First Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jingran","middleName":"","lastName":"Yang","suffix":""},{"id":508374404,"identity":"7b562e59-d5b9-4cab-8338-4b4e85992781","order_by":2,"name":"Yimei Zhang","email":"","orcid":"","institution":"The First Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yimei","middleName":"","lastName":"Zhang","suffix":""},{"id":508374405,"identity":"c418c3b3-1a92-4ffc-855d-008ed4a66448","order_by":3,"name":"Yu Wang","email":"","orcid":"","institution":"The First Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Wang","suffix":""},{"id":508374407,"identity":"e1e1df98-3639-4310-b28f-f37439d5e542","order_by":4,"name":"Ruijie Yanglan","email":"","orcid":"","institution":"The First Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ruijie","middleName":"","lastName":"Yanglan","suffix":""},{"id":508374409,"identity":"0cc7e49e-4569-4e22-a190-a513b2ab0fa5","order_by":5,"name":"Qinlan Li","email":"","orcid":"","institution":"The First Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qinlan","middleName":"","lastName":"Li","suffix":""},{"id":508374411,"identity":"949fbda1-04e2-458c-be8a-e04760c26d6a","order_by":6,"name":"Yangjuan Bai","email":"","orcid":"","institution":"The First Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yangjuan","middleName":"","lastName":"Bai","suffix":""},{"id":508374412,"identity":"e5ee080e-5484-4586-84c5-9ace552c03e2","order_by":7,"name":"Wei Wei","email":"","orcid":"","institution":"The First Affiliated Hospital of Kunming Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Wei","suffix":""},{"id":508374413,"identity":"6fa59cb2-d69e-4469-bb4f-e341ad3d9d7f","order_by":8,"name":"Fang Ma","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYFACHijNzsBw4IOBjRwJWpgZGA7OKEgzJk0LM8+Hw4kENZi39x588KPGLpq/mfngYRsD5gQG9sNHN+DTInPmXLJhz7Hk3BmH2RIO5xiw5THwpKXdwKdFQiLHTJqxgTm34TCPAVALTzGDBI8Zfi3yb8x/MzbU584/zP/hsIWBRGIDQS1ABcyMDYdzNxzmYTjMYGBAhBaevGTJnmPHczceZjM42GOQYMxG0C/sZw9++FFTnTvvePPjDz/+/JfjZz98DK8WTMBGmvJRMApGwSgYBdgAAHJoSMhoKUk9AAAAAElFTkSuQmCC","orcid":"","institution":"The First Affiliated Hospital of Kunming Medical University","correspondingAuthor":true,"prefix":"","firstName":"Fang","middleName":"","lastName":"Ma","suffix":""}],"badges":[],"createdAt":"2025-08-01 06:53:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7268167/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7268167/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108511158,"identity":"0f88058b-b9ea-4663-880d-bef1cada2f5d","added_by":"auto","created_at":"2026-05-05 12:42:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":535959,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7268167/v1/182fcee4-073f-438b-862e-ae80e2a26a1d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Patients with heart failure and their spouses’ experiences of heart failure symptom: a dyadic qualitative study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eHeart Failure (HF) is a complex and life-threatening syndrome marked by high rates of morbidity, mortality, hospitalization, and economic burden, and it has emerged as a significant public health concern in the 21st century\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. According to the survey, the number of adults with HF is over 64\u0026nbsp;million worldwide and increasing by 2\u0026nbsp;million per year. It is expected that the prevalence of HF will increase by 46% in the next 20 years \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e, and about 60% of HF patients die within 5 years of diagnosis, with a mortality rate of up to 50% \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003ePatients with HF experience a diminished quality of life due to symptoms including dyspnea, fatigue, and depression, as well as adverse health outcomes characterized by frequent exacerbations and readmissions\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Studies have shown that over 50% of HF patients are readmitted to the hospital within 6 months due to HF-related symptoms, which leads to a significant consumption of medical resources and generates high medical costs, especially in emergency departments and other medical institutions\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Furthermore, as they age, patients face a greater symptom burden, which seriously affects their daily activities and psychological state\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. A study interviewed 287 HF patients from the time of their first hospitalization to six months after admission, and the results showed that more than half of the patients were willing to trade survival time for improved symptom control shortly after discharge\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. In recent years, symptom management of HF has been increasingly recognized. However, due to the fact that patients with HF often cannot recognize their early symptoms very well, and they might be used to having symptoms, or unaware of the worsening of their symptoms, HF patients are always under great pressure in managing their symptoms\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Hence, it is necessary to explore HF patients\u0026rsquo; experiences of HF symptoms for better symptom management based on patients\u0026rsquo; perspectives.\u003c/p\u003e\u003cp\u003eFamily members are considered to be an important resource for HF patients, who can monitor and manage patients\u0026rsquo; existing symptoms, and respond to new symptoms quickly\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Studies have shown that caregivers, especially spouses, can enhance patients' self-management and perception of symptoms, leading to improvements in quality of life \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Since HF is increasingly carried out at home by individuals and their informal caregivers (dyads), patients\u0026rsquo; care has been shifted from clinician to dyadic focused care. The theory of dyadic illness management calls for the need for understanding the dyadic experiences in symptom management \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. However, in HF, the literature that explores the experience of HF symptom in the form of dyads remains limited, and the majority of it is quantitative research\u003csup\u003e[\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. Because symptoms are subjective and multidimensional, there are some limitations to using scales or questionnaires to assess symptom experience alone\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Dyadic qualitative approaches offer an optimal method for evaluating an individual's emotions, interactions, perceptions, and behaviors, providing couples with an opportunity to narrate their stories beyond the confines of quantitative measurements, thus deepening our comprehension of dyadic experience of symptoms\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Therefore, this study used dyadic qualitative research methods to explore the experiences of HF symptoms among HF patients and their spouses, as well as the process of managing HF symptoms, and provide direction for future research on dyadic care interventions related to HF symptom management for medical professionals.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Design\u003c/h2\u003e\u003cp\u003eThis study was conducted using a descriptive phenomenology qualitative design based on semi-structured and in-depth interviews. It provides a direct and comprehensive understanding of dyadic symptoms experienced in HF. The study is reported following the recommendation of the Consolidated Criteria for Reporting Qualitative Research (COREQ) \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Participants and setting\u003c/h2\u003e\u003cp\u003ePatients with CHF and their spouses who were hospitalized in the cardiovascular medicine department of a tertiary hospital located in Kunming, Yunnan Province, were recruited for interviews. Participants were selected using purposive sampling. The first author was responsible for recruiting participants face-to-face. The inclusion criteria of participants were as follows: a. Patients with HF: (i) aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years; (ii) met the diagnostic criteria for HF of the 2022 AHA/ACC/HFSA Guidelines for the Management of Heart Failure\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e; (iii) had cardiac function classes I-III; (iv) married, spouse is the primary caregiver; (ⅴ) willing to participate in this study and had normal comprehension and verbal ability. b. spouses of patients with HF: (i) aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years; (ii) Patient's spouse with primary caregiving responsibilities; (iii) willing to participate in this study and had normal comprehension and verbal ability. Notably, only patient-spouse pairs in which both the patient and spouse met the inclusion criteria were included in the study. The size of the sample of participants was determined by data saturation, meaning that when no new themes emerged.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data collection\u003c/h2\u003e\u003cp\u003eSemi-structured, face-to-face interviews were conducted with participants between September 2024 and November 2024. The initial interview guide was prepared after reviewing literature and discussing among the research team, and was adjusted based on feedback from participants during the interview process. A pilot study was conducted with two pairs of participants (patient-spouse) before the formal interview. The interview guide cited from supplementary file.\u003c/p\u003e\u003cp\u003eSeparate interviews were conducted to avoid potential power imbalances between patients and their spouses, which could affect their ability to express their own individual views more freely \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Interviews were conducted by the first author who had undergone systematic qualitative research training. Another researcher was responsible for taking field notes (including participants' emotions, body language, and environmental information). We chose the most appropriate time and location for the interview based on the participants' preferences and physical condition. The interview with patients were conducted at their bedside due to their poor condition, and we used bed curtains to create a more comfortable and undisturbed environment. Spouse chose the time of interview and its\u0026rsquo; location at meeting room of the department, which offered a quiet environment. Participants were encouraged to talk widely and freely about their experiences and perspectives.\u003c/p\u003e\u003cp\u003eDuring the interview, an objective record was maintained using recording and note-taking methods. Before the end of each interview, the interviewer would provide a brief summary of the interview, allowing the participant to clarify and share additional information. The duration of the interviews varied from 10 to 30 minutes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Data Analysis\u003c/h2\u003e\u003cp\u003eWithin 24 hours, two researchers carried out verbatim transcriptions of the audio recordings and cross-checked their accuracy. We used the framework method developed by Nicole et al\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. for data analysis in this research, which includes the following eight stages: Transcription, familiarization with the interview, coding, charting codes into table of themes, dyadic analysis, developing a working analytical framework, applying analytical framework, interpreting data. This framework analysis method goes beyond individual experiences and can more clearly identify similarities and differences within and between dyads. The specific stages for data analysis are outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Microsoft Word and Excel were used for managing data analysis for this study.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStages of Dyadic Analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStage\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDescription\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. Transcription\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAll audio recordings were transcribed verbatim by two researchers.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Familiarization with the interview\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe researchers listened to the recordings repeatedly and reviewed the interview recordings and contextual or reflective notes.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. Coding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAfter reading the transcript, we coded patients with heart failure and spouses separately. Codes were either relevant to both members of the dyad or just one.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Charting codes into table of themes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA table of general themes were created based on the questions asked and the codes from the participants\u0026rsquo; transcripts, including the description of symptoms of heart failure, management and coping strategies for symptoms, and the impact of symptoms. The codes of transcripts from patients and their spouses were placed under each theme with detailed quotes. Codes that did not reflect general themes were placed under the theme \u0026ldquo;Other\u0026rdquo; until such point that a theme was derived, or clarity sought to its appropriate coding.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Dyadic analysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe dyadic codes were created, containing a summary of individual codes based on the patients and their spouses. This involved exploring the extent of agreement between members of the dyad.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. Developing a working analytical framework\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe defined dyadic analysis codes and possible new themes which reflect the different matrices were discussed with coauthors, which formed the working analytical framework.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7. Applying analytical framework\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWe used the analytical framework to test other pairs of data and develop further code as needed.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8. Interpreting data\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eWe explain the overlapping and contrasting elements in dyadic narratives.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Rigor\u003c/h2\u003e\u003cp\u003eIn this study, we used Thomas and Magilvy\u0026rsquo;s framework of credibility, transferability, dependability and confirmability to achieve rigor\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. We used peer examination to ensure credibility by examining manuscripts and extracting code, sending data to other researchers for their supplementary comments, and conducting ongoing reviews. Additionally, long-term engagement was also employed to enhance credibility. Before data collection, researchers participated in nursing activities as a nurse and established trust relationships with the participants. Transferability was achieved through a deep and rich description of the demographic and geographic boundaries of the study. Furthermore, participant descriptions and observational records were the main sources of data for drawing research conclusions, and audit trail was adopted to maintain and review the original data to increases the dependability of the findings. To ensure confirmability, reflexivity was employed. The researchers maintained a diary throughout the study, which allowed the researchers to control personal values, perceptions and prejudices. In addition, when differences emerged in the analysis, consensus was achieved through discussion. The corresponding author validated the final results.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6 Ethical considerations\u003c/h2\u003e\u003cp\u003e The study was conducted in accordance with the Helsinki Declaration and was approved by the ethics committee of the hospital (2024\u0026thinsp;\u0026minus;\u0026thinsp;219). Written informed consent was obtained from each participant. The content of interviews would be confidential, anonymous and used solely for this research.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 17 pairs of participants (patient-spouse) were interviewed for this study. The mean age of the patients was 62.41 years, ranging from 44 to 77 years. The mean age of the spouses was 60.88 years, ranging from 42 to 75 years. The detailed demographic and clinical characteristics of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStudy participants\u0026rsquo; socio-demographic and clinical characteristics. (N\u0026thinsp;=\u0026thinsp;17 patient-spouse dyads).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge(years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEthnicity\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eEducation level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eEmployment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eTime since diagnosis (years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eOther chronic disease\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDai\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDai\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBai\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBai\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHani\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHani\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUniversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUniversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUniversity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBuyi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBuyi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMiddle school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eS17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eHan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePrimary school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThree themes and nine subthemes were revealed in this study. The detail information is shown in Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and sub-themes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub-themes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBeing haunted by symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eλ Multiple and recurrent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eλ Fatigue as most concerning\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiverse ways of coping with symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eλ Depending on professional support\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eλ Seeking help from the internet\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eλ Turning to superstition\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eλ Patients\u0026rsquo; giving up companied with spouses\u0026rsquo; fighting these symptoms\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth decreased and strengthened family wellbeing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eλ Financial loss of the family\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eλ Negative emotions around the family\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eλ A beneficial experience\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Theme 1: Being haunted by symptoms\u003c/h2\u003e\u003cp\u003eThe participants reported a total of 12 symptoms, which they attributed to getting older, the effect of HF, and other factors. The symptoms are shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Among these symptoms, breathlessness was the most commonly reported symptom. Participants felt that these symptoms were recurrent and not isolated, with fatigue being considered the most distressing HF symptom.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSymptoms reported by participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eReported symptom\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN (%) of patients\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBreathlessness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12(70.59%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFatigue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9(52.94%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest pain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4(23.53%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEdema\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4(23.53%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePoor quality sleep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3(17.65%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDigestive symptoms (Loss of appetite、\u003c/p\u003e\u003cp\u003eAbdominal bloating)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6(35.29%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers (Cough、Dizzy、Gout、Palpitation、Hot flushes)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5(29.41%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003e3.1.1 Multiple and recurrent\u003c/h2\u003e\u003cp\u003eAlmost all participants agreed that the symptoms of HF were recurrent and difficult to completely be cured. And in most cases, the patients had more than just one symptom, it was typically accompanied by two to three additional symptoms.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI feel sick all over right now, and these symptoms are recurrent and come back even after treatment. P2\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eSometimes, she experiences discomfort characterized by chest tightness, a lack of strength, and difficult breathing. These symptoms often lead to insomnia and a persistent decline in her overall mood. After taking medication, she is getting better, however, the symptoms eventually return after a few days. S12\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e\u003cem\u003e3.1.2 Fatigue\u003c/em\u003e as most concerning\u003c/h2\u003e\u003cp\u003eMany participants considered fatigue to be the most concerning symptom, which had a significant impact on mood, behavior, and social activities, thus reducing the quality of life.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI often feel very tired, so I don't go out with my friends anymore and I don't have the mood to do these things, which make me feel really miserable. P7\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePreviously, we frequently went out for walks and excursions. However, he often feels fatigue. Subsequently, we no longer go out, and I even abandon square dancing, this symptom is torturing us too much. S9\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Theme 2: Diverse ways of coping with symptoms\u003c/h2\u003e\u003cp\u003eFaced with the challenges posed by the symptoms of HF, participants chose to cope in different ways, including relying on professional personnel, actively seeking help from the internet, and even turning to superstitious. We also found out that dyad had controversial coping when faced with these symptoms.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003e3.2.1 Depending on professional support\u003c/h2\u003e\u003cp\u003eSome participants actively sought assistance from medical professionals, being convinced that the medical staff could offer them reliable medical resources and support to mitigate the symptoms. It is also noted that some spouses felt it alleviated their own burdens, which led them to rely on professionals as a coping strategy for these symptoms.\u003c/p\u003e\u003cp\u003e\u003cem\u003eEvery time the symptoms flare up, I go to the hospital for treatment, it is the best way to cope with these annoying symptoms. P11\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI feel easier when I send him to the hospital, the doctors will treat him. They will tell me how to take the medicine and daily precautions, including lifestyle, diet, exercise, etc. S1\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e3.2.2 Seeking help from the internet\u003c/h2\u003e\u003cp\u003eWith the development of internet, many participants who lacked knowledge about diseases often turned to the internet for information to help them make decisions and provide daily life guidance to manage the symptoms.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI see some tips for HF patients on Tik Tok, such as water intake, diet, and lifestyle habits, which is effective to manage his symptoms. F16\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI often use Tik Tok to browse information about HF, including its prevalence, treatment and some methods to alleviate symptoms. S17\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e3.2.3 Turning to superstition\u003c/h2\u003e\u003cp\u003eSome participants said that the symptoms of HF caused them so much pain, and they had no idea what to do. Finally, they tried witchcraft to get some kind of power to help them alleviate symptoms.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe didn't know what to do to ease the pain caused by these symptoms and we had to seek help from witchcraft according to folklore. She seems to be feeling better since a ceremony was held. S2\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\u003ch2\u003e3.2.4 Patients\u0026rsquo; giving up companied with spouses\u0026rsquo; fighting these symptoms\u003c/h2\u003e\u003cp\u003eSome patients were severely affected by symptoms of HF and believed that the condition was difficult to be cured, so they gave up. However, their spouses still persisted and did their best to cope with these symptoms in order to alleviate the patients' suffering, even if they had to make some sacrifices, they were willing to do so.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI feel unwell every day, the symptoms such as breathlessness and fatigue have been repeatedly tormenting me. I'm neither dead nor alive. There seems to be no hope of getting better. It's like I'm a salty fish waiting to die. P1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eWhenever he showed pessimism, I would constantly comfort and encourage him. I always believe that even if there is only one percent hope, I am willing to try. I just hope that he will no longer be plagued by these symptoms and that everything will be fine with him. S1\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI feel very depressed. Even though the sunset is beautiful, it's sad that it's nearing the end of the day (a line from an ancient poem) I have no intention to persist any longer.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eP5\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eI haven't asked him to do anything since he was feeling tired, All the household chores and childcare are my responsibility. I'm willing to do anything as long as he can feel a little less pain. S5\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Theme 3: Both decreased and strengthened family wellbeing\u003c/h2\u003e\u003cp\u003eThe symptoms of HF have had a significant impact on participants and their families, including economic losses and negative emotions, which seriously damaged the quality of family life. However, some participants believed that the shared experience of coping with symptoms had improved their lifestyles, strengthened their relationships with each other, and promoted family health.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\u003ch2\u003e3.3.1 Financial loss of the family\u003c/h2\u003e\u003cp\u003eAs patients may require multiple hospitalizations and spouses need to offer long-term care, some families lost their primary source of income, which imposed a significant economic burden on the household.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe've been spending money on treatments over the years, and I am also a disabled person, I cannot go to work, we really don't have any more money. we borrowed the money for this hospitalization. S10\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eBecause his symptoms often recur and each hospitalization costs so much money and he is unemployed, our children are still in school. I've had to take more than one job.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eS16\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\u003ch2\u003e3.3.2 Negative emotions around the family\u003c/h2\u003e\u003cp\u003ePatients often experienced negative emotions such as irrational anger, emotional breakdown, sadness, and fear of relapse due to the suffering of their symptoms. When spouses felt the negative emotions from the patients, their own emotions were also affected, and to avoid influencing the patients, they usually chose to hide their emotions and bear these negative emotions alone.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI don't feel happy anymore because I often feel difficult to breathe whenever I move around. I get irritated by even the smallest things. P6\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eWhen he is not feeling well, he becomes very irritable. I feel sad when I see him like this. S6\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003e3.3.3 A beneficial experience\u003c/h2\u003e\u003cp\u003eSome participants chose to change their lifestyle and correct their previous unhealthy behaviors in order to reduce the risk of relapse. Additionally, some participants reported that their relationship with their spouse became closer, and they had more time together to discuss how to manage and cope with the symptoms of HF, which they considered to be a beneficial experience.\u003c/p\u003e\u003cp\u003e\u003cem\u003eIn order to prevent his symptoms from recurring, she bought a book to regulate the diet, I was sick before, so she also pays attention to managing my diet. It is indeed beneficial to our health. S12\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePreviously, I frequently went out, which resulted in us spending minimal time together. Now, we share our days, we seem to be getting closer. I take daily walks with him and we collaborate to manage the symptoms. I feel very happy with this simple life. S9\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eMy lifestyle has changed, and I have quit smoking and drinking. P9\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis research explores the experiences and comprehension of HF symptoms by HF patients and their spouses, as well as their responses to the symptoms, providing direction for future research to develop dyadic care interventions. Our research revealed that couples regarded the symptoms of HF as recurrent, which caused them significant distress. This research finding is consistent with many studies in the literature \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. Despite pharmacologic and nonpharmacologic interventions for HF are progressing, these treatments are not always effective\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. Patients with HF often experience a cyclical process between symptom onset and control, causing long-term and ongoing distress to patients and their family\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. Present evidence showed that 31.9% and 38.5% of HF patients were readmitted within 6 months and 1 year after discharge, respectively, some patients even developed HF-related symptoms immediately after discharge\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. In addition, HF symptoms often emerge simultaneously rather than in isolation, as also reported in our study\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. Bekelman et al.\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e indicated that patients with HF experienced as many as nine symptoms, including shortness of breath, fatigue, edema, pain, drowsiness, difficulty concentrating, feeling sad or anxious, worry and lack of appetite. In addition, these symptoms can interact with and enhance each other, severely impairing the well-being of the patients and their family\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e. There is growing evidence that clusters of symptoms may be more predictive of outcome than symptoms that occur in isolation\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e. Therefore, more attention to the symptom cluster is necessary. This finding also suggested that healthcare providers should conduct comprehensive symptom assessments and provide interventions targeted at these symptom clusters to help patients and their family members monitor symptoms regularly, promote effective symptom management, and thus enhance the quality of life for patients and their families\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn our study, fatigue was considered the most distressing symptom by the couples, which is consistent with previous studies conducted in hospitalized patients\u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]\u003c/sup\u003e. Fatigue is one of the most common symptoms in patients with HF, appearing at the early onset of the disease, throughout the disease, and worsening as the disease persists, significantly affecting the patient's daily life, causing a great physical and mental burden on the patient, and decreasing their quality of life\u003csup\u003e[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/sup\u003e. Whitehead et al.\u003csup\u003e[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]\u003c/sup\u003e indicated that among family members of patients with HF, spouses are more likely to express concern about patients\u0026rsquo; fatigue, especially since increased fatigue represents a decline in health. As a result, they have to spend more time and energy helping the patient manage fatigue, which could lead to increased caregiving and psychological burdens on spouses and impair their social health\u003csup\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e. Despite the fact that fatigue can be extremely distressing to patients and their family, fatigue is rarely evaluated or treated \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. Previous research suggested that healthcare professionals often do not discuss the potential experience of fatigue and its effects with individuals or families living with chronic conditions\u003csup\u003e[\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]\u003c/sup\u003e. Hence, more research is needed to delve deeper into the fatigue experiences of HF patients and their families and develop targeted interventions to alleviate the suffering caused by fatigue.\u003c/p\u003e\u003cp\u003eCouples have also adopted some methods to cope with these symptoms. In this study, patients and spouses believed that professional support was an effective way to reduce the burden of symptoms and caregiving. According to the health promotion model, individuals are more likely to engage in healthy behaviors when they receive support, guidance, and encouragement from healthcare providers\u003csup\u003e[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/sup\u003e. When patients and their spouses feel safe during their interactions with healthcare providers, they also feel a reduction in the burden of self-care, which can help boost their confidence in symptom management\u003csup\u003e[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/sup\u003e. Hodson et al.\u003csup\u003e[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]\u003c/sup\u003e also found that caregivers of HF patients felt supported when they were provided with direct information about the patient's needs and current health status, and reported positive care experiences. Hence, it is recommended that healthcare providers offer more resources and practical support to HF families, enabling patients and family members to be more proactive in symptom management.\u003c/p\u003e\u003cp\u003eIn addition to relying on professional support to cope with symptoms, couples also actively sought help from the internet in this study. With the promotion and popularization of smartphones and wearable devices, mobile health (mHealth) has become a new option to support HF self-management\u003csup\u003e[\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]\u003c/sup\u003e. mHealth is widely used in the fields of symptom monitoring and assessment, recurrence warning, and health information inquiry for chronic disease patients due to its real-time, convenient, interactive, and user-friendly features\u003csup\u003e[\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]\u003c/sup\u003e. However, due to the influence of age and education level, the use of mHealth is relatively low\u003csup\u003e[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]\u003c/sup\u003e. Additionally, the quality of online information is uneven, making it difficult to effectively distinguish between reliable and unreliable sources, further hindering the effectiveness of mHealth in managing symptoms for HF patients and their caregivers\u003csup\u003e[\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]\u003c/sup\u003e. Therefore, it is highlighted that medical professionals can provide simple mHealth usage training for the families of elderly HF patients and guide them in correctly identifying healthcare information to promote self-management.\u003c/p\u003e\u003cp\u003eOur study also revealed that some participants turned to witchcraft to cope the pain associated with HF symptoms. Throughout history, the most obvious purpose of witchcraft beliefs has been to provide explanation for unfortunate events in people\u0026rsquo;s lives, which can help with coping\u003csup\u003e[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]\u003c/sup\u003e. When individuals are overwhelmed by the challenges posed by some calamities (e.g., illness), they believe that witchcraft can help them to find the source of the calamity and eliminate the suffering through some mystical powers, rituals, or medicines, which enhances and inspires them to have the courage and strength to overcome and conquer the disease\u003csup\u003e[\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]\u003c/sup\u003e. According to the latest surveys carried out in dozens of countries and on multiple continents over the past ten years, witchcraft beliefs are so prevalent in the modern world, and are especially prevalent in developing countries\u003csup\u003e[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]\u003c/sup\u003e. However, witchcraft beliefs have a range of harms to the healthcare delivery and patients\u0026rsquo; wellbeing\u003csup\u003e[\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]\u003c/sup\u003e. Miranda et al reported that witchcraft beliefs might delay or prevent people from seeking medical assistance or made them less likely to follow medical advice\u003csup\u003e[\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]\u003c/sup\u003e. Therefore, further research is necessary to explore ways to avoid the negative effects of witchcraft beliefs in the symptom management of HF patients.\u003c/p\u003e\u003cp\u003eOur study found that couples had controversial coping when faced with these symptoms.\u003c/p\u003e\u003cp\u003eAlpert et al.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e pointed out that, as the disease progressed, the burden of symptoms on the patient became more severe and their physical, psychological and social functioning deteriorated. In addition, due to an increased awareness of the burden on their caregivers, patients often develop thoughts of giving up symptom management. In this study, we also found that spouses continued to cope with HF symptoms with a positive mindset even when the patient giving up. In China, influenced by Confucianism, Chinese culture emphasizes collectivism and highlights the interdependence of family members. The mutual dependence between family members stimulates a sense of responsibility to respond to the care needs of one's spouse, and it is also influenced by the traditional Chinese virtue of loyalty, spouse of patients with HF follows through on their commitment to their marriage and supports their partner in adversity, even if it requires making some \"sacrifices\" (which are defined as stopping something you enjoy in order to allow yourself to participate in something of greater value)\u003csup\u003e[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e]\u003c/sup\u003e. Consequently, in the face of the suffering and negative mentality brought about by HF symptoms to the patients, the spouses still actively engage in the treatment, even if it requires them to sacrifice their own time and the hobbies that they once enjoyed. It is suggested that medical staff should understand the different attitudes toward symptom management of HF patients and their spouses, which can facilitate the symptom management in the family level.\u003c/p\u003e\u003cp\u003eFinally, we discovered that the symptom experiences of HF patients and their spouses were a double-edged sword for family health. First, couples believed that HF symptoms had caused a significant economic burden on the family, which is consistent with the current research findings\u003csup\u003e[\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]\u003c/sup\u003e. Due to the aggravation of symptoms and the continuous deterioration of bodily functions, some patients are compelled to resign from their jobs, or caregivers are obliged to quit their jobs to undertake the duty of care, resulting in a sharp decline in family income. Some elderly patients merely rely on scanty pensions to sustain their treatment, which undoubtedly imposes colossal economic burdens on patients and their families\u003csup\u003e[\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e]\u003c/sup\u003e. This recommend that the government should enhance financial support, broaden the coverage of medical insurance and offer more resources. Secondly, we found that negative emotions of HF patients often transferred to their partners, seriously damaging the psychological health of the family. HF patients frequently experience anxiety, depression and a sense of worthlessness because the uncontrolled symptoms, which prevent them from leading an active life and working as they did before\u003csup\u003e[\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]\u003c/sup\u003e. Previous research has indicated that dyads can exert a strong influence on each other's emotions, confidence, and behaviors\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Therefore, spouses may also have negative emotions. Moreover, factors such as caregiving stress, psychosocial expenditure, and role conflicts intensify the psychological burden of spouses\u003csup\u003e[\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]\u003c/sup\u003e. However, due to the mutual \"protection\" consideration between couples, they often avoid discussing their own negative emotions with each other, particularly under the influence of family culture in China, and it has become a habit for family members to conceal their emotions within the family, which leads to insufficient stress relief and the persistence of negative emotions in the family\u003csup\u003e[\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]\u003c/sup\u003e. There is evidence that good family communication is conducive to offering emotional support for patients and their spouses, cultivating the closeness among spouses, and enabling them to confront stressors with a positive mindset\u003csup\u003e[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]\u003c/sup\u003e. Therefore, healthcare professionals can utilize the family advantage perspective to provide targeted interventions for couples and families to promote communication and collaboration between patients and their spouses, and enhance family symptom management. Interestingly, our study also found that couples perceived that HF symptom experience had improved their lifestyle, enhanced their intimacy, and was a beneficial experience for the family. Changes in one's perception of oneself and self-care are considered as one of the dimensions of Tedeschi and Calhoun's model, which allows participants to gain wisdom in facing difficulties and produce positive changes in their lifestyle and relationships. Participants who accept HF symptoms can effectively take care of themselves by using self-care problem-focused coping skills (positive coping, problem-solving, planning, and information-seeking) to adjust to a healthy lifestyle and improve their relationships with others \u003csup\u003e[\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]\u003c/sup\u003e. Furthermore, Chinese family culture emphasizes the unity and functionality of the family, as well as the responsibilities and contributions of individuals within the family, which makes HF patients and their spouses more united in facing the challenges brought by symptoms, and this intimate relationship can help them experience happiness and fulfillment while receiving support, and promote the process of symptom management \u003csup\u003e[\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]\u003c/sup\u003e. However, current research primarily focuses on the negative impact of HF symptoms on patients or their family members. It is necessary for future research to explore the positive experiences of HF patients and their families regarding HF symptoms.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eOur results should be considered in the context of several limitations. First, like any other qualitative study, our research findings are limited to similar research populations, data collected from a single center, and a smaller sample size. However, our data has reached saturation, and the research results reflect the views of the participants. Second, the data in this study are cross-sectional, which may not be able to reflect the changes in symptom experiences of HF patients and their spouses over time. Future studies may consider a longitudinal design.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study, on a dyadic basis, deeply explored the authentic experiences and valuable information of HF patients and their spouses regarding HF symptoms. Our research highlights that medical staff should enhance their attention to the symptom cluster of HF and fatigue symptoms and formulate targeted measures to lower the readmission rate of patients. In the face of the challenges posed by HF symptoms, HF patients and their spouses will adopt multiple approaches to cope with them. However, the use of mHealth should be exercised with caution, and vigilance against the negative impacts of witchcraft is necessary. At the same time, it is suggested that medical staff should accurately identify the different attitudes toward HF symptoms of patients and their spouses, and guide patients and spouses to make active adjustments to cope with HF symptoms. Furthermore, our research has also discovered the two-sided effect of HF symptom experiences on family health. It emphasizes the significance of family communication and the necessity to further explore the positive experiences of HF symptoms in order to enhance family wellbeing.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e This research was supported by the Reserve Talent Project of Academic and Technological Leaders for Young and Middle-aged People in Yunnan Province, China, No. 202205AC160017 and the Joint Special Project-General Project of Kunming Medical University, China, No 202301AY070001-153. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e The authors have no conflicts of interest in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e This study was conducted in accordance with the Helsinki Declaration and was approved by the First Affiliated Hospital of Kunming Medical University Ethics Committee ((2024-219).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent\u003c/strong\u003e All participants provided informed consent prior to enrolment in the study, including consent for publication of anonymized quotes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e The authors thank the participants who voluntarily participated in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e All participants have provided written consents for the research team to use their de-identifed data in this manuscript, including information provided through demographic surveys.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e Min Zhou (first author) contributed to the study design, data collection and analysis, and writing the manuscript. Fang Ma (corresponding author) was responsible for designing the study and revising the manuscript. Jingran Yang, Yimei Zhang, Yu Wang were responsible for data collection. Ruijie Yanglan, Qinlan Li were responsible for the data analysis. Yangjuan Bai, Wei Wei contributed to the review of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSavarese G, Becher PM, Lund LH, Seferovic P, Rosano GMC, Coats AJS. Global burden of heart failure: A comprehensive and updated review of epidemiology. 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Nurs Health Sci. 2020;22:464\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/nhs.12682\u003c/span\u003e\u003cspan address=\"10.1111/nhs.12682\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"heart failure, symptom management, spouses, dyadic qualitative study","lastPublishedDoi":"10.21203/rs.3.rs-7268167/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7268167/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHeart failure symptoms severely diminish the quality of life of patients, and the importance of symptom management has been widely recognized. However, patients still face significant pressure in managing symptoms. Family members are considered to be an important resource for symptom management and the need for understanding the dyadic experiences in symptom management is highlighted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on face-to-face and semi-structured interviews, a dyadic descriptive phenomenological research design was employed. Patients with heart failure who met the inclusion criteria and their spouses were invited to participate in interviews, and the data were analyzed using framework analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 17 dyads participated in the study. Based on the framework analysis approach, four themes and nine subthemes were developed: (1) being haunted by symptoms (2) diverse ways of coping with symptoms (3)both decreased and strengthened family wellbeing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study explores the symptom experiences of heart failure patients and their spouses, highlighting that medical staff should offer practical resources and support to heart failure family, accurately identify the distinct attitudes within the family in coping with symptoms, and facilitate family communication to enhance family closeness, thereby improving family health. It also emphasizes that more research is needed to focus on the positive experiences of heart failure symptoms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e","manuscriptTitle":"Patients with heart failure and their spouses’ experiences of heart failure symptom: a dyadic qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-06 07:54:22","doi":"10.21203/rs.3.rs-7268167/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ed7d577d-1bc0-4b4e-8b83-df9e2a178ef4","owner":[],"postedDate":"September 6th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-05T12:32:56+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-05T12:40:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-06 07:54:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7268167","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7268167","identity":"rs-7268167","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}