Dyadic coping and fear of cancer progression among patients with hepatocellular carcinoma and their spouses in China: An actor-partner interdependence model.

Introduction
Hepatocellular carcinoma (HCC) is one of the deadliest cancers.1 The International Agency for Research on Cancer reported 865,200 new cases and 757,900 deaths from HCC worldwide in 2022,2 with China having one of the highest prevalences of HCC. Patients with HCC require routine testing to contend with the 70% probability of metastasis and recurrence within five years. Furthermore, the effectiveness of treatments in preventing recurrence remains uncertain.1 Fear of cancer progression (FoP) is defined as fear of the biopsy-psychosocial consequences of cancer recurrence and metastasis.3 It is not limited to patients with cancer; family members may also experience varied degrees of FoP.4 Low levels of FoP are considered normal and even beneficial, as they enhance patients' vigilance regarding disease progression. In contrast, high levels of FoP are associated with psychological distress and lower quality of life, as well as detrimental effects on health behaviors and functional impairments.5 FoP has a common effect on couples, based on their intimate, marital, and familial relationships.6 According to previous studies, spouses' FoP was more severe than patients’, resulting in lasting psychological stress for both groups.7
HCC diagnosis is a stressor that affects patients as well as their spouses. It represents a dyadic stress with interdependent characteristics within the relational context, in which partners' responses to external stressors are referred to as dyadic coping.8 Dyadic coping refers to coping measures, such as communication and support, used by couples to cope with stress. Researchers have proposed this concept over the past century. Dyadic coping involves the interdependence and interaction of stress-coping between couples.9 The concept of dyadic coping is grounded in Lazarus and Folkman's stress and coping theory, and has been elaborated into several models. Among these, the systemic transactional model (STM) is considered the most comprehensive, as it encompasses dimensions from other models, offers a broader conceptual framework, and has guided much of the research in the field.8
According to the STM, dyadic coping refers to how couples interact when coping with stress. It involves stress communication, supportive dyadic coping (SDC), delegated dyadic coping (DDC), and common dyadic coping (CDC), all of which the spouse's stress is shared and managed jointly.10 Stress communication refers to openly expressing one's own stress to the partner and encouraging reciprocal disclosure; SDC involves providing empathic understanding and/or problem-focused assistance, as well as offering useful advice to help the partner manage stress; DDC is characterized by taking over the partner's responsibilities or tasks to reduce the burden; CDC denotes joint efforts to solve problems, share emotions, or relax together in response to stress.11 Since these dimensions represent constructive strategies that couples employ to alleviate each other's stress, they are collectively referred to as positive dyadic coping. Additionally, dyadic coping can also be negative, which involved hostile (e.g., blaming the partner), ambivalent (e.g., providing support while believing the partner should handle the stress independently), superficial (e.g., not taking the partner's stress seriously), and avoidance behaviors (e.g., withdrawing when the partner is stressed).8 Compared with couples from Switzerland and the United States, Chinese couples report lower levels of SDC, DDC, and CDC, but higher levels of negative dyadic coping.12 A study of Chinese couples with breast cancer further demonstrated significant differences in stress communication, SDC, and DDC across different latent subgroups of dyadic coping.13
Existing literature indicates that higher levels of dyadic coping are associated with lower FoP and better psychosocial adjustment among couples coping with cancer.14 Dyadic coping may also contribute to stress reduction in couples and strengthen marital relationships.15 Consistent with this, a recent meta-analysis showed that couple-based dyadic interventions can help alleviate psychological distress in both patients and their partners.16 However, only a few studies have specifically examined the association between dyadic coping and FoP in patients and their spouses. Nevertheless, research on couples facing colorectal cancer has identified significant differences in FoP across latent subgroups of dyadic coping.17 Yet, little is known about the interactive effects and mutual influences of specific dyadic coping dimensions on FoP, particularly in patients with HCC and their spouses.
The actor–partner interdependence model (APIM) is a widely used model of dyadic relationships that considers the interdependence of two-person relationships with appropriate statistical techniques.18 This study examined the association between dyadic coping and FoP in patients with HCC and their spouses to comprehend its beneficial effects and guide couple-based interventions. The effect of the individual predictor variables in the APIM on their outcome variables is considered the actor effect, whereas the effect on their spouse is considered the partner effect. Structural equation modeling (SEM) was used to establish the APIM to examine the effect of dyadic coping on FoP. The following hypotheses were proposed.H1Patients' and spouses' dyadic coping will have interdependent (actor and partner) effects on each other's FoP.
H2aPositive dyadic coping will be negatively associated with FoP in both patients and spouses.
H2bNegative dyadic coping will be positively associated with FoP in both patients and spouses.

Methods

Study design and participants
This cross-sectional study was conducted at Zhongshan Hospital, Fudan University, Shanghai, China between November 2024 and May 2025. We used a consecutive sampling method and recruited 341 hospitalized patients with HCC and their spouses through face-to-face questionnaire distribution. The inclusion criteria were as follows: (1) patients and spousal caregivers who were married aged 18 years; (2) patients diagnosed with primary HCC; (3) patients and their spouses fully informed of the diagnosis; (4) spouses who assumed the major caregiving role; (5) patients and their spouses with the ability to hear, speak, and read in Chinese; and (6) patients and their spouses providing informed consent to voluntarily participate. The exclusion criteria were as follows: (1) patients with advanced cancer (stage IV) or metastasized tumors, (2) patients or their spouses with cognitive impairment, or (3) patients in any critical condition. This study was not registered in a public trial registry.

Instruments

Sociodemographic and clinical characteristics
A self-designed questionnaire was administered to collect demographic and clinical information, including gender, age, religious belief, educational level, employment status, duration of the couple relationship, household income (CNY), and number of children. Additional clinical data, such as tumor stage, were retrieved from hospital electronic medical records to ensure data reliability.

Fear of progression Questionnaire-Short Form
The shortened version of the original Fear of Progression Questionnaire (FoP-Q) was employed to assess patients' FoP.3 It consists of 12 items rated on a 5-point Likert scale, with total scores ranging from 12 to 60. Higher scores indicate greater levels of FoP, with 34 points serving as the cutoff for FoP-related psychological dysfunction. The Chinese version, translated and culturally adapted by Wu,19 demonstrated good reliability, and confirmatory factor analysis indicated acceptable model fit indices. The Cronbach's alpha coefficient for the FoP-Q-SF was 0.859.

Fear of progression Questionnaire-Short Form/partner version
This scale was developed based on the FOP-Q-SF to assess the spouse's FoP.20 It has a similar structure to the FoP-Q-SF, with higher scores indicating more fear. The translated and culturally adapted Chinese version demonstrated good reliability.19 Cronbach's alpha coefficient of 0.802.

Dyadic Coping Inventory
The Dyadic Coping Inventory (DCI), developed by Bodenmann, was based on the STM.10 It comprised 37 items measured on a 5-point Likert scale, ranging from 1 (not at all/very rarely) to 5 (very often), across the following 10 dimensions: (1) stress communication by self (SCS) (e.g., I tell partner openly how I feel and appreciate his/her support), (2) stress communication by partner (SCP) (e.g., My partner tells me openly how she/he feels and appreciates my support), (3) supportive dyadic coping by self (SDCS) (e.g., I show empathy and understanding to my partner), (4) supportive dyadic coping by partner (SDCP) (e.g., My partner shows empathy and understanding to me), (5) delegated dyadic coping by self (DDCS) (e.g., I take on things that my partner would normally do in order to help him/her out), (6) delegated dyadic coping by partner (DDCP) (e.g., My partner takes on thing that I normally do in order to help me out), (7) negative dyadic coping by self (NDCS) (e.g., I blame my partner for not coping well enough with stress), (8) negative dyadic coping by partner (NDCP) (e.g., My partner blames me for not coping well enough with stress), (9) CDC (e.g., We try to cope with the problem together and search for ascertained solutions), and (10) coping evaluation, (i.e., assessing respondents’ satisfaction with the use of dyadic coping strategies). Consistent with previous validation studies, these items were not included in the present analyses because they do not capture theoretically defined dyadic coping behaviors, but rather reflect a global evaluation coping.12
Nine dimensions were analyzed, excluding coping evaluation. This design provided a robust foundation for dyadic analysis by demonstrating the interdependence and mutual influence between the dyadic coping processes of patients and their spouses. The Chinese version of the scale, translated and culturally adapted by Xu,12 has been widely used in China and has shown good reliability. In the present study, the Cronbach's alpha coefficient for the DCI was 0.911.

Bias
Before analysis, questionnaires were screened for validity. Invalid questionnaires were defined according to the following criteria: (1) missing responses in the scale section; (2) careless responding, operationalized as selecting the same option for more than five consecutive items within a scale; and (3) inconsistent responses, defined as contradictory answers between regular and reverse-coded items. Questionnaires meeting any of these conditions were excluded from the final dataset.
Anonymization was employed to prevent common method bias (CMB) during data collection. Harman's single-factor test with principal component analysis was used to assess common method variance. The first principal component explained 22.24% of the variance, below the 50% threshold, which suggested no dominant common method factor.21 Additionally, the unmeasured latent method construct approach exhibited minimal improvement in the model fit after including a method factor (ΔCFI ​= ​0.066; ΔTLI ​= ​0.056; ΔRMSEA ​= ​−0.007), suggesting limited influence of CMB.22
Multicollinearity was assessed using variance inflation factor (VIF). The VIF values for each dimension of dyadic coping were below the cutoff value of 5. Sensitivity analyses were performed using Sauer's method and verified by the addition of covariates.23

Sample size
As suggested by Ackerman and Kenny,24 a minimum of 264 couples were required to achieve an actor or partner effect of 0.2 and a two-sided type I error of 5% at 90% power. Hence, this study included 305 patients with HCC and their spouses.

Statistical analyses
Data analysis was conducted using IBM SPSS Statistics version 26.0 and R (version 4.4.1). To examine the differences in dyadic coping and FoP between patients with HCC and their spouses, t-tests were performed for paired samples. Due to multiple testing, a significance level of P ​< ​0.005 was projected (after the Bonferroni adjustment).
Before model estimation, univariate and multivariate normality were assessed using the Shapiro–Wilk test, and the data were found to violate the assumption of multivariate normality. Spearman's correlations were computed for all patient and spouse variables to assess dyadic nonindependence.18 The use of traditional maximum likelihood estimation (MLE) under non-normal conditions can inflate chi-square values and increase the likelihood of model rejection. Accordingly, a robust MLE with Yuan–Bentler corrections was applied for comparison.
The analytical strategy was grounded in SEM using APIM. The model parameters were estimated using SEM and a series of models were tested sequentially. The nine dimensions of dyadic coping were specified as exogenous variables and FoP was specified as the endogenous variable. Starting from a saturated model, constraints were placed on the actor and partner effects to simplify the model structure. The competing models were compared to determine the best-fitting and most parsimonious solutions. The model fit indices are presented in Supplementary Table S1.

Results

Participant characteristics
A total of 341 patient–spouse pairs completed questionnaires. After 36 pairs of invalid questionnaires were excluded, 305 pairs of valid questionnaires were included in the final analysis (valid response rate: 89.4%). Table 1 presents the demographic and medical characteristics of the participants. Majority of patients were male (88.5%), which is consistent with the high prevalence of HCC among men. Overall, the patients and their spouses were similar regarding age, educational attainment, and employment status.
The FoP score among patients with HCC and their spouses was 35.03 ​± ​9.00 and 37.78 ​± ​7.75, respectively. Furthermore, 54.1% (n ​= ​165) of patients and 67.2% of spouses (n ​= ​205) was scored ≥ 34 points. Table 2 presents the mean FoP-Q-SF score and each dimension of the DCI.
Patients and their spouses differed significantly regarding FoP, SDCS, DDCS, SDCP, DDCP, and NDCP. The patients experienced significantly less FoP to their spouses. Patients reported significantly more SDCP and DDCP. Furthermore, patients report significantly fewer SDCS, DDCS, and NDCP. Patients and their spouses did not differ significantly in their reported SCS, NDCS, SCP, or CDC (Table 2).

Description of statistics and correlations between relevant variables
We performed correlation analyses of individual variables between the patients and their spouses to evaluate dyadic interdependence. Significant differences between and within dyad correlations suggest nonindependence at the individual level. The matrix of correlation coefficients is presented in Supplementary Table S2. The results revealed that the different dimensions of dyadic coping and FoP were statistically significant between patients and spouses.

Actor–partner interdependence model
Each dimension of dyadic coping was independently modeled using, standardized estimates. The effects of dyadic coping on couples’ FoP are summarized in Table 3 and Fig. 1. The additional model parameters are presented in Supplementary Table S2.
Patients' FoP was negatively associated with all dimensions of positive dyadic coping and positively associated with negative dyadic coping, demonstrating significant actor effects (P-values were all less than 0.01). Patients’ FoP was negatively associated with SDCS (b ​= ​−0.152, P ​= ​0.005), SDCP (b ​= ​−0.104, P ​= ​0.007), and DDCP (b ​= ​−0.073, P ​= ​0.021), and positively associated with NDCS (b ​= ​0.118, P ​< ​0.001), and NDCP (b ​= ​0.089, P ​= ​0.013), demonstrating significant partner effects.
Spouses' FoP was negatively associated with SDCS (b ​= ​−0.123, P ​= ​0.002) and SDCP (b ​= ​−0.107, P ​= ​0.02) and positively associated with NDCS (b ​= ​0.133, P ​= ​0.01) and NDCP (b ​= ​0.134, P ​= ​0.006), demonstrating a significant actor effect. Spouses’ FoP was negatively associated with SDCP (b ​= ​−0.104, P ​= ​0.007) and DDCP (b ​= ​−0.073, P ​= ​0.021) and positively associated with NDCS (b ​= ​0.118, P ​< ​0.001) and NDCP (b ​= ​0.089, P ​= ​0.013), demonstrating significant partner effects.
The results for NDCS, SDCP, and NDCP confirmed hypothesis H1. In addition, DDCP showed significant partner effects for both patients and spouses, while its actor effect on spouses' FoP was not significant (b ​= ​−0.032, P ​= ​0.435). Furthermore, the findings supported the hypothesis that negative dyadic coping is positively associated with FoP (H2b). By contrast, there was insufficient evidence to support the hypothesis that positive dyadic coping is negatively associated with FoP in both patients and spouses (H2a). Within the APIM, several associations between positive dyadic coping and FoP were not significant: the partner effect of SCS on patients' FoP and the actor effect of SCS on spouses' FoP; the partner effect of SDCS on spouses' FoP; the actor effect of DDCP on spouses' FoP; and the partner effects of DDCS, SCP, and CDC on patients' FoP, as well as the actor and partner effects on spouses’ FoP.

Sensitivity analyses
Variables that had an impact on dyadic coping and FoP—namely gender, cancer stage, relationship duration and economic status—were selected as covariates to be introduced into the model for sensitivity analysis. The results are presented in Supplementary Table S3; they confirm that the introduction of covariates into the model did not significantly affect the model results.

Discussion

Differences in dyadic coping and fear of cancer progression between patients and spouses
Patients with HCC and their spouses experienced high levels of FoP; more than half scored 34 or higher, which is similar to that observed in patients with breast cancer and myeloma.6,25 This is probably because HCC often progresses insidiously and a considerable proportion of patients are diagnosed at a high degree of malignancy. Additionally, HCC is more common in middle-aged men who bear important family responsibilities and have a huge impact on the entire family after they fall ill. In the Chinese cultural context, middle-aged men are often regarded as the “pillar” of the family and, as the “sandwich generation,” are expected to be the primary breadwinners who financially support both their children and aging parents. Once diagnosed, the cancer may impair their physical strength and work capacity, raising concerns about job performance and income loss. The fear of losing the earning capacity, along with the emergence of illness-related stigma and the added economic burden on the family.26 Therefore, patients are particularly afraid of cancer progression. The findings predominantly capture the experiences of male patients and their spouses, and caution should be exercised in generalizing the results to female patients.
Spouses experienced significantly higher FoP than patients, which was consistent with a study with predominantly female patients.7 This may be related to the fact that, spouses perceived lower levels of social support than patients did.27 Generally, families and society tend to provide more support to patients, whereas support for spouses is relatively limited. In the Chinese cultural context, the responsibility of caring for other family members, such as children and elderly parents, is typically assumed by female spouses. As a result, spouses often take on more responsibilities than patients as primary caregivers, which can lead to a decline in their quality of life and may, in turn, contribute to higher levels of FoP.28 Differences and imbalances in the patients and spouses’ coping measures may contribute to spouses experiencing more severe FoP than the patients.
Patients reported higher levels of SDCP and DDCPs than by their spouses, as well as lower levels of NDCPs. Similar to previous findings, due to the illness, patients receive more support within the dyadic relationship, as spouses often assume a caregiving role.27 Consistent with patient reports, spouses reported higher levels of SDCS and DDCS. Subjectively, spouses also provide more support to patients in dyadic relationships. It is consistent with previous studies, which revealed that spouses often take on a more active role in caregiving or support following the patient's diagnosis.15 Concurrently, spouses tend to perform some of the household responsibilities that were previously handled by the patient. They are also expected to provide psychological support and comfort, and sometimes engage in protective buffering—that is, they conceal their own worries or distress in order to shield the patient from additional stress, further increasing their FoP.29 Moreover, spouses experienced higher levels of NDCP, which may be related to their excessive concern for the patient following diagnosis. In addition, the spouses' perceptions of negative behaviors from patients may leave them feeling misunderstood and disappointed. The higher level of NDCPs might also be a contributing factor to the higher FoP observed in spouses than in patients.

Interdependent effects of dyadic coping dimensions on patients' and their spouses’ fear of cancer progression
Our findings underscore the relevance of the APIM in understanding how dyadic coping influences FoP. The results indicated that SDCS, NDCS, SDCP, DDCP, and NDCP had significant actor and partner effects on FoP in both patients and their spouses, confirming our hypothesis on the interdependent association between dyadic coping and FoP. This pattern reflected the interdependent nature of couples' coping processes, as conceptualized in APIM, where both partners' dyadic coping behaviors influenced not only their own but also each other's FoP.
Contrastingly, SCS, DDCS, SCP, and CDC were negatively associated with patients' FoP and demonstrated significant actor effects only in patients. The partner effect of SDCS on the spouses' FoP was not significant, indicating that the patients' SDCS did not alleviate the spouses' FoP. Similarly, the actor effect of DDCP on spouses' FoP was not significant, suggesting that spouses’ perception of DDCP did not alleviate their own FoP.
Positive dyadic coping (stress communication, SDC, DDC, and CDC) were found to reduce patients' FoP, suggesting that patients' active engagement with positive dyadic coping and perceived support from their spouses may facilitate better personal adjustment. Contrastingly, spouses benefited less from dyadic coping. Associated studies on colon cancer similarly reported the limitations of dyadic coping in reducing spouses' psychological burden.30 The higher FoP observed among spouses may be related to an imbalance in the dyadic coping process. Spouses tend to provide more support to patients as primary caregivers, whereas patients limited by illness-related factors might not adequately engage in dyadic coping to support their spouse's stress adaptation.
Stress communication was a protective factor for patients' FoP; however, it was not effective in reducing spouses' FoP. While numerous studies on couples with one of them having cancer suggested that stress communication helped maintain psychological well-being and acceptance of illness,15,31, 32, 33, 34 its effects differed when viewed from a dyadic perspective. In this study, among the various dimensions of stress communication, only patient-reported self-reported stress communication and partner stress communication indicated significant actor effects on lower FoP levels. This suggests that patients' expression of stress and feedback received from their spouses may effectively facilitate their adaptation to FoP. However, stress communication did not contribute to spouses' stress adaptation, which may be attributed to protective buffering; spouses may have concealed their worries and fears in an attempt to reduce the patient's stress burden. However, a study on patients with hematological cancers revealed that patient-reported SCP was negatively associated with their depression, whereas spouse-reported SCP was positively associated with patients' depression and anxiety.27 Possibly, the content of stress communication has a higher impact on patients and their spouses than the act of communication. For example, if communication involves negative content, it may exacerbate one's or another's FoP.
Although patient-reported SDCS did not significantly affect spouses' FoP, spouse-reported SDCS and SDCPs were significantly associated with both spouse’ and patient’ FoP. Spouses' supportive behaviors toward patients are indicative of their adaptive psychological functioning, while perceiving support from the patient helps alleviate their spouse's FoP. A systematic review found that SDC improved psychological well-being in couples.35 SDC, characterized by mutual emotional support and joint problem-solving may alleviate FoP in patients with HCC and their spouses by helping them effectively manage daily stress. Prior research has revealed that higher levels of supportive coping driven by relationship commitment enhance couples' resilience and protect their psychological well-being under stress.36
DDC refers to one partner actively assuming responsibilities that would typically belong to the other. In our study, patient-reported DDCS were not significantly associated with spouses' FoP, whereas DDCP were negatively associated with spouses' FoP. However, patient-reported DDCPs reduced patients' FoP and was negatively associated with spouses' FoP. Spouse-reported DDCS was not significantly associated with their FoP. However, a previous study reported that DDC helped both patients and spouses adjust to the stress and changes brought about by illness.37 The discrepancy in our study may be explained by the caregiving context: DDC may increase spouses' responsibilities due to the patient's illness, adding to their burden and negatively impacting their quality of life. A literature review noted that although DDC reduced depressive symptoms in spouses, it lowered their quality of life and worsened patients' depression.15 When patients engage in DDC, it often reflects a positive and adaptive response to their illness. Conversely, higher levels of DDC among spouses may indicate that the patient is experiencing more severe physical or psychological difficulties and requires more support.15
CDC exhibited a significant actor effect only on patients' FoP. However, this association was less robust than that suggested by earlier studies that examined psychological outcomes more broadly. For example, research on couples coping with breast cancer reported that higher levels of CDC were linked to lower psychological distress.38 From the patient's perspective, the spouse's presence may signify a shared illness experience—viewing the disease as “ours” rather than “yours”—which can help alleviate the patient's psychological burden; however, without it, stress and risk of FoP may increase.39 From the spouse's perspective, CDC was not significantly associated with either their or the patients' FoP. Some spouses perceived their coping efforts as fulfilling their expected marital role. We suggest that viewing the illness as “our disease” may also be a burden for the spouses.
Consistent with our hypothesis, negative dyadic coping emerged as a risk factor for FoP. Negative dyadic coping showed significant actor and partner effects on FoP in both patients and spouses, indicating that one's use of negative dyadic coping, as well as that of the other couples, contributed to an elevated FoP. Literature reviews have indicated that negative dyadic coping is associated with more psychological distress in both patients and their spouses.15 Negative dyadic coping behaviors may stem from negative emotions, which may intensify FoP. By comparing the negative dyadic coping behaviors of patients with HCC and their spouses (i.e., hostile, ambivalent, superficial, and avoidance behaviors), we found that their manifestations of negative dyadic coping were consistent and showed no significant differences. Nevertheless, such maladaptive patterns share similar detrimental effects by undermining emotional closeness, fostering misunderstanding, and intensifying distress within the dyad. Negative dyadic coping has also been associated with poorer relationship quality,40 leaving one partner feeling isolated and disappointed in the intimacy, while couples may worry about the disruption and alteration of their relationship due to cancer—concerns that may exacerbate FoP.
In contrast to relationship-focused coping models that have proposed, additional forms of negative coping, such as protective buffering, blocked the interactive process of stress adaptation, and reduced communication behavior was a risk factor for poorer psychological outcomes.41 Studies on negative dyadic focused on protective buffering, such as avoiding illness-related communication, to reduce fear. This approach can increase psychological problems for both couples and may be associated with higher FoP, although well-intentioned.29

Implications for nursing practice and research
Nursing staff can play a pivotal role in assessing the dyadic coping patterns and FoP of patients with HCC and their spouses, thereby identifying couples who exhibit maladaptive coping strategies or experience high levels of FoP. By providing information on the benefits of positive dyadic coping and the detrimental consequences of negative coping, nurses may enhance couples' communication skills, facilitate their adaptation to illness-related stress, and strengthen confidence in treatment. Building on this foundation, dyadic interventions that prioritize the reduction of negative coping behaviors, supplemented by psychotherapeutic approaches addressing FoP, may be particularly suitable for couples experiencing severe FoP. Such programs should be delivered by multidisciplinary teams and tailored to patients’ clinical conditions, treatment plans, and the dyadic coping and FoP status of both partners. The intervention program could be integrated into each follow-up visit after HCC treatment, including face-to-face sessions of emotion-focused therapy or mindfulness-based stress reduction to address FoP, supplemented by cognitive-behavioral couple therapy targeting maladaptive cognitions and negative interaction patterns to foster more positive dyadic coping. Subsequent interventions may be conducted through online modalities such as telephone or video consultations. Interventions addressing both dyadic coping and FoP may help mitigate the negative psychological impact of FoP on patients and spouses, enhance the beneficial effects of positive dyadic coping in reducing distress, and strengthen relational functioning and psychological well-being within couples facing HCC.

Limitations
First, owing to its cross-sectional design, causal relationships between dyadic coping and FoP could not be established. Longitudinal studies are required to investigate the directionality and temporal dynamics of these associations. Second, as the majority of patients in this study were male (88.5%), the findings may predominantly reflect the experiences of male patients and their female spouses. Given the potential influence of gender on both dyadic coping and FoP, the results may not be fully generalizable to female patients with HCC and their spouses. Lastly, data were collected from a single hospital, which may limit the generalizability of the findings compared to a multicenter study.

Conclusions
This study employed the APIM to examine the associations and mutual influences between specific dyadic coping behaviors and FoP among patients with HCC and their spouses. By adopting a dyadic perspective, this study addressed the limitations of previous studies that mainly focused on patients or their primary caregivers alone. The findings indicate that most positive dyadic coping behaviors were associated with reduced FoP in patients, while only some dimensions showed similar benefits for spouses. In contrast, negative dyadic coping significantly increased FoP for both patients and their partners, exerting adverse effects on both actor and partner levels. These findings highlight the clinical importance of identifying patients with HCC and their spouses who exhibit high levels of FoP and negative dyadic coping. For couples experiencing severe FoP, timely psychological interventions are warranted, supplemented by strategies aimed at reducing negative coping behaviors and fostering supportive interactions. Leveraging the positive role of dyadic coping in alleviating illness-related stress and enhancing relational harmony may contribute to improving FoP in couples facing HCC.

CRediT authorship contributions statement
Rukang Hu: Investigation, Formal analysis, Writing–Original Draft. Huijuan Lu: Conceptualization, Methodology, Supervision, Writing–Review & Editing, Funding Acquisition. Jingxian Yu: Project administration, Resources. Zheng Zhu: Methodology. All authors have read and approved the final manuscript. All participants provided written informed consent.

Ethics statement
This study was approved by the Ethics Committee of Zhongshan Hospital (No. B2024-595R) and was conducted in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All participants provided written informed consent.

Data availability statement
The data support the findings of this study are available from the corresponding author, HL, upon reasonable request.

Declaration of generative AI and AI-assisted technologies in the writing process
No AI tools/services were used during the preparation of this work.

Funding
This study was funded by the Nursing Research Fund of the School of Nursing, 10.13039/501100003347Fudan University (Grant No. FNSF202401). The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.

Declaration of competing interest
The authors declare no conflict of interest.