Dyadic Health Literacy and Its Association with Care Collaboration and Satisfaction in Heart Failure Patient–Caregiver Dyads: A Cross-Sectional Study

Introduction

Heart failure (HF) represents a significant global public health challenge characterized by high prevalence, recurrent hospitalizations, and substantial morbidity and mortality.¹ The global prevalence of HF is estimated at 64 million cases, with over 13.7 million cases reported in China alone, imposing a considerable burden on healthcare systems and societies.^2,3 Patients with HF often experience multiple symptoms including dyspnea, fluid overload, and cognitive impairment,^4,5 which severely compromise functional status and diminish quality of life (QoL).^6,7 Given the progressive and debilitating nature of HF, effective management requires complex self-care regimens that extend beyond clinical settings into patients’ daily lives.⁸

The complexity and sustained demands of HF self-care—such as daily weight monitoring, dietary sodium restriction, medication adherence, and symptom recognition—frequently exceed patients’ capacity to manage independently. Consequently, informal caregivers, typically family members or friends, play an essential role by assisting with various tasks, ranging from activities of daily living and medication management to providing emotional support and facilitating communication with healthcare providers.^9,10 In this context, effective HF management is increasingly recognized as a dyadic phenomenon, fundamentally dependent on collaborative efforts between patients and their primary informal caregivers.^11,12 A growing body of evidence indicates that synergistic collaboration within dyads is associated with improved self-care behaviors, better patient outcomes, enhanced QoL for both members, and reduced caregiver burden compared to noncollaborative or incongruent relationships.^13–15

Effective dyadic HF management relies on shared illness-specific knowledge and the joint ability to translate this knowledge into daily practice. However, health literacy—the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions¹⁶—does not always translate into successful dyadic management. One reason for this may be that patients often manage HF together with their caregivers; consequently, dyadic health literacy—the shared and sufficient health literacy within the patient-caregiver dyads—is likely more important than either member’s health literacy alone for supporting collaborative care.¹⁷ For HF dyads, low dyadic health literacy may manifest as difficulties in reading medication labels and educational materials, comprehending verbal instructions, and accessing reliable health information online or through media.¹⁸ This deficiency is strongly linked to poor medication adherence, inadequate self-care capacity, increased hospitalization rates, and higher mortality.^19–21 Intervention studies have directly confirmed that improving health literacy can enhance dyadic outcomes. Zhao et al²² found that the FOCUS program (health education + online courses) improved symptom assessment, coping, relationship quality, and mental health in Chinese HF dyads. Bsharat and Karadag²³ reported that systematic health education improved postoperative QoL in Middle Eastern coronary artery bypass grafting (CABG) patients. Son et al²⁴ demonstrated that a dyadic mHealth intervention enhanced patients’ self-care adherence and caregivers’ contributions to self-care in Korean HF dyads. Therefore, shared and sufficient health literacy within the HF dyad is considered a key facilitator in translating knowledge into coordinated health behaviors, thereby improving dyadic health outcomes.

The theoretical foundation of dyadic HF management is well articulated in the theory of dyadic illness management proposed by Lyons and Lee.²⁵ The central premise of this theory is that congruence in illness appraisal between patient and caregiver serves as a key predictor of the quality of management behaviors and subsequent health outcomes. When both members share a common understanding of the illness and their respective roles, it fosters more collaborative and effective management strategies.^26–28 Guided by this framework, researchers have begun exploring different types of dyadic care. Empirical studies using the Dyadic Symptom Management Type (DSMT) scale—a concise single-item instrument used to classify how HF dyads manage daily care^29–31—have yielded important findings. For instance, congruent appraisal of care responsibility has been associated with better patient symptom perception.^14,15 Furthermore, dyad members’ satisfaction with their care arrangement has emerged as a strong, and sometimes stronger, predictor of self-care outcomes and dyadic QoL than congruence alone.¹⁴ This suggests that satisfaction holds comparable importance to congruence, highlighting the significance of emotional and relational dynamics in dyadic care.

Despite these advances, significant gaps remain in the literature. Previous studies have primarily focused on outcomes related to congruence and satisfaction, such as their effects on self-care and QoL.^11,14,32 However, little is known about the factors that facilitate or hinder the development of collaborative and satisfactory dyadic care patterns. In particular, while individual health literacy has been extensively studied in heart failure populations, the role of dyadic health literacy in shaping these patterns has not yet been investigated. Therefore, guided by the theory of dyadic illness management, this study aimed to: (1) identify latent profiles of dyadic health literacy among HF patient-caregiver dyads; and (2) examine the associations between these distinct health literacy profiles and dyadic care collaboration as well as satisfaction within the dyad.

Material and Methods

Study Design, Settings, and Participants

A cross-sectional descriptive study was conducted and a convenience sampling method was used. A total of 231 HF patient-caregiver dyads were recruited from four tertiary hospitals in Beijing, China, between September 2023 and August 2024. The study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies. The sample size was determined based on established recommendations for latent profile analysis (LPA), which generally require a minimum of 200 participants.^33–35 To account for an anticipated 10% attrition rate, the target sample size was set at 223; the final sample exceeded this threshold.

Patients were included in the study if they (1) had a confirmed diagnosis of HF (meeting the diagnostic criteria of the 2018 Chinese Guidelines for the Diagnosis and Treatment of Heart Failure) for at least one year;³⁶ (2) classification within New York Heart Association (NYHA) functional class II to IV,³⁶ and (3) age of 18 years or older. Caregivers were eligible if they were aged 18 years or above and had provided care to the patient for at least one year. Exclusion criteria for dyads included: (1) presence of severe comorbidities such as respiratory failure or malignant tumors; and (2) severe hearing, visual, speech, cognitive, reading, or psychiatric impairments that would impede communication or questionnaire completion.

Measures

Dyadic Health Literacy

Health literacy was assessed using the Heart Failure Specific Health Literacy Scale (HFS-HLS), developed by Matsuoka et al in 2016 to evaluate health literacy in HF patients and their caregivers.³⁷ The scale comprises 12 items across three dimensions: functional, communicative, and critical health literacy. It uses a 4-point Likert scale from 1 to 4, with total scores ranging from 12 to 48; higher scores indicate better HF-specific health literacy. The Chinese version was translated by Yue and demonstrated good reliability and validity, with a Cronbach’s α coefficient of 0.87.³⁸

Dyadic Care Type and Satisfaction

Dyadic care type was evaluated using the DSMT, developed by Buck et al in 2013 to assess symptom and illness management patterns within HF patient‒caregiver dyads.²⁹ The DSMT is a single-item criterion-referenced instrument in which patients and caregivers each select one statement describing who primarily manages illness. Responses are classified into four types: Type I (patient-oriented), where the patient takes full responsibility for HF management; Type II (caregiver-oriented), where the caregiver takes full responsibility; Type III (collaborative), where the patient and caregiver manage HF together; and Type IV (incongruent), where the patient and caregiver disagree in their appraisal of who is responsible for HF management (i.e., selected different care types). The instrument has adequate face validity and has been applied in diverse HF populations.^14,15 The Chinese version was translated and culturally adapted by our research team, achieving a content validity index of 1.0.

Satisfaction with the assigned care type was also assessed within the DSMT framework. After selecting their management type, both patients and caregivers independently rated their satisfaction with HF management on a 5-point Likert scale from 1 (extremely dissatisfied) to 5 (extremely satisfied).

Demographic and Clinical Information

Participant characteristics were collected using a self-designed questionnaire. Patient data included gender, age, education level, disease duration, number of hospitalizations in the past year, NYHA functional classification, and comorbidities assessed via the age-adjusted Charlson Comorbidity Index (aCCI). Caregiver data included gender, age, education level, relationship to the patient, income level, caregiving experience (in years), daily hours of care provided, and comorbidities measured by the aCCI.

Data Collection Procedures

Data collection was performed by trained investigators through face-to-face interviews in private consultation rooms at the participating hospitals. Prior to questionnaire administration, all participants received detailed explanations regarding the study objectives, procedures, and their rights to withdraw at any time. Written informed consents were obtained from all participants before data collection commenced.

Clinical information, including diagnosis confirmation, disease duration, NYHA functional classification, and comorbidities, was extracted from electronic medical records. Questionnaires, including the HFS-HLS and the DSMT, were administered separately to patients and caregivers. Each questionnaire was reviewed immediately upon completion by the investigator to identify any missing items or ambiguous responses. When omissions or inconsistencies were detected, participants were asked to clarify or complete the missing information on the spot. This process ensured completeness and accuracy of the collected data. As a result, no missing data were present in the final dataset and therefore no additional statistical methods for handling missing data were required.

Data Analysis

Data were analyzed using IBM SPSS (version 26.0) and Mplus (version 8.3). Data completeness was ensured through immediate on-site review of questionnaires; no missing data were identified in the final dataset. Descriptive statistics summarized sample characteristics: continuous variables were presented as mean ± standard deviation (SD), and categorical variables as frequencies and percentages. LPA was conducted in Mplus 8.3 to identify distinct subgroups of dyadic health literacy based on HFS-HLS scores.³⁹ Model selection was guided by fit indices: lower Akaike information criterion (AIC), Bayesian information criterion (BIC), and sample-size-adjusted BIC (aBIC) values indicated better model fit. The Vuong-Lo-Mendell-Rubin (LMR) test and bootstrap likelihood ratio test (BLRT) compared k-profile models against k-1 profile models; a significant p-value below 0.05 supported retention of the model with more profiles. Classification accuracy was evaluated using entropy, with values between 0.8 and 1.0 indicating high confidence in profile assignment.⁴⁰ Chi-square tests were used to compare categorical variables, while analysis of variance (ANOVA) was employed for continuous variables. Binary logistic regression was performed to examine associations between health literacy profiles and dyadic collaboration and satisfaction, adjusting for age, gender, educational level of both patients and their caregivers, patients’ NYHA functional classification, daily caregiving hours, and type of relationship between patients and caregivers, which are associated with health literacy and dyadic care outcomes based on the theory of dyadic illness management.²¹ A P-value below 0.05 was considered statistically significant.

Ethical Approval

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and approved by the Ethics Committee of the Health Science Center, Peking University (Ref ID: IRB00001052--23100). Written informed consent was obtained from all participants.

Results

HF Patient-Caregiver Dyad Characteristics

A total of 242 dyads were initially invited; 11 declined participation. Ultimately, 231 dyads were included, yielding a response rate of 95.45%. Participant characteristics are summarized in Table 1. The mean age of patients was 66.78 years (SD=15.42), with a majority being male (61.5%). Over half of the patients (58.0%) were classified as NYHA functional classification III or IV. Caregivers had a mean age of 54.54 years (SD=13.74), most were female (64.5%), and nearly half were spouses (49.4%).

Table 1 Characteristics of Heart Failure Patients (n=231) and Their Caregivers (n=231)

Patients exhibited moderate health literacy on the HFS-HLS (mean score: 28.11±7.85). Among subscales, communicative health literacy scored highest (10.98±3.13), while functional health literacy scored lowest (8.42±3.38). Similarly, caregivers demonstrated moderate health literacy (mean score=31.21±7.67), with the highest and lowest scores observed in communicative (12.03±2.98) and functional health literacy (9.22±3.58), respectively.

Regarding dyadic collaboration, the majority of dyads (63.6%) adopted a collaboratively oriented style. Patients reported significantly higher satisfaction with their care arrangement than caregivers.

Latent Profiles of Dyadic Health Literacy

Fit indices for the LPA are presented in Table 2. The two-class model demonstrated optimal fit (AIC=7052.51, BIC=7117.92, aBIC=7057.70, and entropy=0.81) and was selected as the final solution. Based on health literacy levels, dyads were categorized into two distinct profiles (Figure 1): profile 1, labeled as the “low dyadic health literacy” (33.3%, n=77), and profile 2, labeled “high dyadic health literacy” (66.7%, n=154).

Table 2 Fit Statistics: Patient-Caregiver Dyadic Health Literacy Latent Profile Analysis Models

Figure 1 Dyadic health literacy profiles of heart failure patient-caregiver dyads. Abbreviations: HFS-HLS, Heart Failure Specific Health Literacy Scale; HF, Heart Failure. Notes: PQ1, functional health literacy (patients); PQ2, communicative health literacy (patients); PQ3, critical health literacy (patients); CQ1, functional health literacy (caregivers); CQ2, communicative health literacy (caregivers); CQ3, critical health literacy (caregivers); G1, the low dyadic health literacy group; G2, the high dyadic health literacy group.

Factors Associated with Dyadic Health Literacy Profiles

Significant differences were observed between the two health literacy profiles across patient-, caregiver-, and dyad-level variables (Table 3). Binary logistic regression further identified several factors significantly associated with membership in the high dyadic health literacy group (Figure 2). Male patient gender (OR=2.95, 95% CI: 1.34–9.26, P=0.007) and male caregiver gender (OR=2.55, 95% CI: 1.21–5.34, P=0.014) were significantly associated with greater odds of belonging to the high literacy profile. In patients, a higher number of hospitalizations was associated with lower health literacy (OR=1.981, 95% CI: 1.035–3.793, P=0.039). Among caregivers, lower education levels were associated with reduced odds of high dyadic health literacy relative to university/college education: illiterate/primary school (OR=0.092, 95% CI: 0.019–0.443, P=0.003), middle school (OR=0.223, 95% CI: 0.078–0.640, P=0.005), and high school/vocational school (OR=0.380, 95% CI: 0.148–0.980, P=0.045). The model explained 27.3% of the total variance.

Table 3 Comparison of Characteristics Between the Low and High Dyadic Health Literacy Profiles

Figure 2 Forest plot of the binary logistic regression results for health literacy classes. Abbreviations: OR, Odds Ratio; CI, Confidence Interval.

Table 4 presents the associations between dyadic health literacy and dyadic care type as well as satisfaction. Compared to dyads in the high health literacy profile, those in the low health literacy profile had significantly lower odds of caregiver satisfaction (OR=0.285, 95% CI: 0.129–0.627; P=0.002) and significantly lower odds of adopting collaborative care (OR=0.196, 95% CI: 0.097–0.396, P<0.001). These findings indicate that low dyadic health literacy was associated with approximately 71.5% lower odds of caregiver satisfaction and 80.4% lower odds of collaborative care.

Table 4 Binary Logistic Regression Analyses of Dyadic Health Literacy Associated with Dyadic Care Type and Satisfaction

Discussion

This study found that health literacy levels among patients with HF and their informal caregivers were generally moderate, consistent with prior research.^38,41,42 Critical health literacy received the lowest scores from both groups, likely due to the predominantly older age and limited formal education of participants. These factors may constrain the ability to critically evaluate, filter, and apply complex health information. As a result, participants rarely questioned the reliability or relevance of HF-related information regarding diagnosis, treatment, or self-care. Within the Chinese cultural context, which emphasizes deference to medical authority, patient‒caregiver dyads often adopt a passive role in care planning, potentially inhibiting the development of individualized and adaptive disease management strategies.⁴³ These findings underscore the need for healthcare providers to prioritize enhancing critical health literacy through patient education, guiding dyads in analyzing health information and supporting shared decision-making.

A notable discrepancy in health literacy was observed between patients and caregivers, with caregivers exhibiting higher scores—contrary to earlier reports by Bidwell et al¹⁷ This difference may reflect the distinct roles within the dyad. Given the unpredictability, acute symptom onset, and high burden of HF, caregivers are often required to assume substantial responsibilities in daily disease management. Effective support necessitates adequate health literacy,⁴⁴ yet clinical communication practices frequently focus on patients, potentially marginalizing caregivers.^45,46 Consequently, caregivers must independently seek knowledge through various channels, increasing their informational burden. Therefore, healthcare professionals should actively engage and educate caregivers during clinical encounters to equip them with the necessary health literacy for meaningful participation in care.

According to the DSMT, the collaboratively oriented dyadic type was most prevalent (63.6%), followed by caregiver-oriented (17.3%). Both proportions exceed those reported in studies from the United States, Italy, and Spain.^13,15,31 These findings suggest that within the Chinese cultural context—where filial piety and family-centered values are emphasized—patients and caregivers are more inclined toward collaborative illness management, with caregivers playing a particularly active role. This encourages patients and caregivers to form closely collaborative illness management relationships. Compared to Western individualistic cultures, Chinese families place greater emphasis on collective responsibility and interdependence. Caregivers not only undertake more practical daily care tasks but also play an active role in illness cognition and decision-making processes.These results suggest that when developing dyad-centered health interventions, the influence of cultural values on illness management behaviors should be fully considered. Particularly in the Chinese context, it is essential to recognize and support the collaborative role of families in HF disease management.

LPA revealed two distinct health literacy profiles. The low literacy group was characterized by older dyads, lower education levels, and patients with more severe illness. The high literacy group included younger, more educated dyads with higher household income. Binary logistic regression identified patient gender, caregiver gender, caregiver education level, and patient hospitalization frequency as significant predictors of profile membership.

A notable finding was the gender disparity: both male patients and male caregivers were more likely to belong to the high dyadic health literacy group. This aligns with health literacy surveys in Chinese populations, which consistently report higher levels among males, particularly in older generations where men had greater access to formal education.^47,48 These results highlight the need for targeted interventions to support female-dominated dyads. Moreover, caregiver education level—but not patient education—was a significant predictor of dyadic health literacy profile membership,⁴⁹ suggesting that caregivers may play a particularly influential role in shaping the dyad’s shared health literacy capabilities. Patients in the low dyadic health literacy group experienced more frequent hospitalizations, consistent with evidence linking low health literacy to higher readmission rates.^50,51 Low literacy impedes communication with providers, leading to poor disease understanding, suboptimal self-care, and medication errors. To mitigate these risks, clinicians should employ clear verbal explanations, easy-to-understand counseling, and nonverbal techniques such as gestures and facial expressions.⁵²

Dyads in the high health literacy group were more likely to adopt a collaborative care orientation. Higher dyadic health literacy may enhance information acquisition, strengthens motivation to participate in management, and facilitates mutual communication and shared decision-making, enabling effective role division and joint involvement. These findings point to the importance of promoting knowledge sharing within dyads to support efficient and harmonious collaboration.

Furthermore, high dyadic health literacy was associated with greater caregiver satisfaction with the care arrangement, though no significant association was found for patient satisfaction. This aligns with finding of Irani et al¹⁴ who found that satisfaction with dyadic care type was a stronger contributor to QoL than congruence alone. Caregivers often juggle multiple roles—including occupational, domestic, and caregiving duties—and those with higher health literacy may be better equipped to manage these demands, whether acting independently or collaboratively. This capacity may contribute to greater fulfillment and positive affect, which may enhance overall dyadic well-being. The study indicate that caregiver satisfaction is a significant factor in illness management, alongside collaborative engagement.

Notably, health literacy may influence dyadic congruence. Prior research indicates that congruence in illness appraisal between patient and caregiver—such as agreement on management responsibility—is positively associated with caregiver mental QoL and patient symptom perception.^14,15 Enhanced health literacy likely supports the development of a shared illness understanding, which in turn fosters greater congruence and more synchronized care behaviors.

In summary, this study underscores that enhancing health literacy can promote both collaborative engagement and caregiver satisfaction in HF dyads. Future interventions should integrate health literacy education with skills training in communication and shared decision-making, supporting dyads in forming more effective and harmonious partnerships in illness management.

Limitations

This study has several limitations. First, as the study is cross-sectional in nature, the causal relationship between dyadic health literacy and care types cannot be established. Second, convenience sampling was employed, and participants were recruited from the selected hospitals in Beijing. Therefore, the sample may not be fully representative of the broader population of patients with heart failure and their caregivers, potentially introducing selection bias. Third, data on health literacy, dyadic collaboration and satisfaction were collected using self-reported questionnaires, which may be subject to recall and social desirability bias. Finally, the DSMT scale is a single-item measure, making it more susceptible to measurement error and limiting its ability to capture the full complexity and comprehensiveness of dyadic illness management.

Conclusions

This study identified two distinct profiles of dyadic health literacy among HF patient‒caregiver dyads and revealed significant associations with care type and satisfaction. These findings suggest two key implications for clinical practice. First, identifying latent health literacy profiles may enable healthcare professionals to recognize at-risk dyads—particularly those with older age, lower education, or noncollaborative care—and deliver targeted, personalized education. Second, the findings suggest that dyadic health literacy plays an important role in fostering collaborative and satisfying illness management, highlighting the potential value of strengthening health literacy as a foundational component of dyadic HF care.