Effects of a dyad acceptance and commitment therapy-based intervention on health-related quality of life in chronic heart failure patients and their family caregivers: a randomized controlled trial

Student thesis: PhD


Heart failure (HF) remains the major cause of morbidity and mortality. The trajectory of the disease is unpredictable, and the risk of hospitalization is high. Within this challenging context, family caregivers (FCs) play a crucial role in supporting and assisting HF patients in managing their disease and daily activities. Both patients and their FCs commonly experience ongoing fear, constant worry, persistent uncertainty and a sense of frustration. Attempting to reduce these negative experiences is often associated with anxiety, depression, HF self-care behaviors, caregiving burden, and impaired health-related quality of life (HRQOL) for patients and FCs. Rather than trying to resist or avoid difficult thoughts and feelings that emerge in the face of challenging circumstances, Acceptance and commitment therapy (ACT) encourages accepting and embracing these challenges with openness and compassion and promotes values-driven action by developing psychological flexibility (PF). While previous research has found positive effects of ACT on people with chronic health conditions and/or their FCs, few studies have explored the utility of ACT in HF, and none has investigated the application of ACT in dyads of patients with HF and their FCs.
To evaluate the effects of a dyad ACT-based intervention conducted in groups delivered through videoconferencing sessions, compared to HF education lectures as a control condition, on HRQOL, PF, HF self-care behaviors, caregiving burden, self-compassion, relationship quality, and healthcare service utilization, among patients with chronic HF and their FCs, immediately after the intervention (T1) and at the three-month follow-up (T2).
Design, setting, and participants:
This was a parallel-group, assessor-blind, stratified, randomized controlled trial (RCT) with a four-week intervention period and a three-month follow-up period. Patients documented as having been hospitalized because of chronic HF in the past one year, with a New York Heart Association (NYHA) Classification of I to III, and without cognitive impairment, along with their primary FCs, were recruited from the Cardiology Department of a public hospital in China.
Patient-FC dyads were randomly assigned to either the ACT-based intervention group or the control group and participated in four weekly 2-hour videoconferencing sessions via smartphones. The ACT-based intervention group received 1.5 hours of dyad ACT interventions and 0.5 hours of brief HF education per session, while the control group received HF education lectures. The content of the HF education for both groups was based on the latest Chinese HF clinical guideline.
The dyad ACT intervention aimed to enhance the PF of patients and their FCs by exploring the participant’s control agendas; identifying values associated with psychosocial struggles and cultivating the willingness to engage in alternative behaviors that align with their values; overcoming emotional and cognitive barriers; and expanding self-compassion and self-understanding towards others. The dyad ACT-based intervention protocol was developed under the PF model and based on previous relevant evidence on the effectiveness of ACT on chronic disease management for patients and FCs. Before this RCT was fully implemented, a pilot RCT involving 16 dyads of patients with chronic HF and their FCs was conducted to examine the feasibility of study procedure and data collection, and feasibility, acceptability and preliminary effects of dyad ACT-based intervention. Dyad ACT-based intervention was co-facilitated by two registered nurses in mainland China who had received ACT training under the supervision of a nurse educator with extensive experience in ACT training.
Main outcomes and measures:
Data for both patients and their FCs were collected through smartphone interviews at three time points: baseline (T0), T1, and T2 by blinded research assistants.
The primary outcomes for patients were HRQOL, which encompassed disease-specific HRQOL measured using the Cardiomyopathy Questionnaire (KCCQ-12) and generic HRQOL evaluated using the EuroQol 5-Dimension 5-Level (EQ-5D-5L) scale and the EQ visual analogue scale (EQ-VAS). For FCs, the primary outcomes focused on generic HRQOL assessed using EQ-5D-5L and EQ-VAS. Secondary outcomes comprised PF, HF self-care behaviors, relationship quality, healthcare service utilization, and others for patients and their FCs. Data were analyzed following the intention-to-treat principle and utilizing generalized estimating equations.
The study involved 160 dyads of patients with chronic HF (mean age 64.71±12.58 years, 55.0% male) and their FCs (mean age 55.93±14.28 years, 30.6% males, 65.2% were patient spouses).
In terms of primary outcomes, patients with chronic HF who received the ACT-based intervention demonstrated significant improvements in disease specific HRQOL at both T1 (β = 3.87, p < .001; Cohen’s d = 0.51, p < .001) and T2 (β = 5.81, p < .001; d = 0.75), with medium effect sizes compared with the control group. Additionally, there were significant enhancements with small-to-medium effect sizes in generic HRQOL measured using EQ-5D-5L at both T1 (β = 0.05, p < .001, d = 0.35) and T2 (β = 0.06, p < .001, d = 0.42), as well as evaluated using EQ-VAS at both T1 (β = 4.20, p = .001, d = 0.32) and T2 (β = 4.54, p = .010, d = 0.44). For FCs, those in the ACT-based intervention group exhibited better generic HRQOL as assessed using EQ-5D-5L at T1 (β = 0.02, p = .070, d = 0.21) and T2 (β = 0.03, p = .109, d = 0.20), as well as measured by EQ-VAS at T1 (β = 3.78, p = .088, d = 0.18) and T2 (β = 4.08, p = .071, d = 0.16),
when compared to the control group. However, these differences did not reach statistical significance and effect sizes were small.
Regarding the secondary outcomes, the ACT-based intervention group showed significant positive effects compared to the control group in HF self-care behaviors (d = 0.63-0.90) and caregiver burden (d = 0.30-0.39), as well as in PF, self-compassion, anxiety, and depression (d = 0.31-0.72) for both patients and FCs at T1 and T2. All p-values for the aforementioned outcomes ranged from < .001 to .044. However, patients perceived a significant improvement in relationship quality (d = 0.28) only at T1, and there were no significant differences between the groups in the frequency of healthcare service utilization. Additionally, no significant differences were found in the relationship quality of FCs at T1 and T2.
The four-week dyad ACT-based intervention delivered through videoconferencing on a group basis for patients with chronic HF and their FCs was effective at improving the patient HRQOL and HF self-care and enhancing the psychological well-being of both patients and FCs compared to HF education alone. However, the effects on HRQOL of FCs and some secondary health outcomes of patients and FCs were relatively small and did not reach statistical significance. These findings provide valuable insights for the future intervention targeting this specific population.
Date of Award24 Jan 2024
Original languageEnglish
SupervisorYim Wah Mak (Supervisor) & Wing Ka Grace Ho (Supervisor)


  • chronic heart failure
  • family caregivers
  • dyadic approach
  • acceptance and commitment therapy
  • randomized controlled trial

Cite this