Multiple chronic conditions (MCCs) are defined as two or more chronic conditions coexisting in the same person.1 MCCs are becoming increasingly prevalent, and have emerged as crucial public-health concerns worldwide.2 Globally, on average, one in three adults is suffering from MCCs, due to highly heterogeneous reports with methodological differences, different data sources suggest that the prevalence of MCCs ranges from 54% in the United Kingdom, 26% in the United States, 20% in Australia, and 9.4% in urban settings in South Asia.3, 4, 5, 6 Compared to the general population, a systematic review indicated that the prevalence of MCCs varies between 55%–98% for adults older than 60 years,6 with prevalence rates of 45% in China, 48% in Ghana, and 71% in Russia for adults over 50 years of age.7

MCCs not only affect older patients but also their families due to their complex, dynamic, cyclic and multidimensional characteristics. MCCs can impact the entire family in several aspects, especially the overall wellbeing and quality of life of family members, including their physical, psychological, social, spiritual, and financial states.8, 9, 10 For couples, the influence of chronic illness takes place in an interpersonal context, and the illness affects not only the individual who has the illness, but also that individual's spouse or romantic partner.7,11 Chronic illness is no longer conceptualized as an individual phenomenon but considered to be a dyadic stressor.12 To prevent/control illness progression and minimize the side-effects of illness and disturbances to daily living, couples must cope with chronic illness.13, 14, 15 How couples cope with stressors together, such as daily problems or chronic illnesses, has been the focus of research on ‘dyadic coping’ since the early-1990s.13 In general, dyadic coping refers to how partners communicate about stress, support each other in times of stress, and deal with stressors together.16 Among couples, dyadic coping represents a dynamic transactional process in which one partner's coping is dependent upon the other partner's coping.13

Research focused on coping with chronic illnesses has begun to shift from an individual approach (patients or caregivers) to a patient–caregiver dyadic approach in which they function as one unit in coping with chronic illnesses.12,17 An increasing number of studies have investigated individual patients’ coping in the context of MCCs. Löffler et al. found that older patients still held positive attitudes toward life while coping with MCCs at the social, emotional, and practical levels.18 A recent integrative review synthesized patients’ perceptions of MCCs involving negative moods and physical limitations and assessed strategies of coping with MCCs, including problem- and emotion-focused strategies.19 Most studies analyzing dyadic coping with respect to chronic illness have focused on couples dealing with life-threatening diseases such as cancer,20,21 or just a single type of chronic illness.14,22,23 A recent systematic review summarized the research evidence available from 1990–2020 on dyadic coping in couples with chronic physical illnesses, summarized dyadic coping was associated with beneficial outcomes in physical health, well-being, and relationship satisfaction.13 Some studies have included patients and caregivers in the context of coping with MCCs. One study from the United States found that older patient–caregiver dyads demonstrated various preferences and attitudes toward the receipt and provision of caregiving assistance for MCCs management.24 Another study conducted in the United Kingdom revealed the perspectives of patients and their caregivers on factors influencing the healthcare system.25 Quantitative studies have also included patient-caregiver dyads in the context of MCCs, for example, Iovino et al. investigated patient self-care and care partner contributions to self-care, and reported higher levels of self-care monitoring than self-care maintenance and management behaviors for both members of the dyads.26 Another recent study examined the distribution of dyadic care types and found that the most frequent dyadic care type is the collaborative-oriented one (63%).27 These studies confirm the need for further research on couples coping with MCCs as a whole. However, current studies have only focused on individual or the patient-caregiver dyads, which may different from actual couple dyads coping with MCCs. In addition, few studies have focused on older couples with MCCs, who may be overwhelmed by the many challenges associated with their chronic conditions. Notably, these challenges can be triggers for significant stress, and these individuals may be simultaneously affected by stressors encountered in other areas of their daily lives.10

Other studies have examined the experience of coping with MCCs from the perspectives of patients, family caregivers, and healthcare providers, with the main focus being on the perceived value of informal support and formal support,28 the care needs of older adults and the delivery of healthcare,29 and care goals across the triad of the patient, caregiver, and physician to determine alignment.30 However, these studies adopted a tripartite perspective on how older adults cope with MCCs instead of looking at dyadic coping from real couples’ perspectives. Given the high prevalence of MCCs among older couples worldwide, knowledge on dyadic coping in the context of MCCs is lacking and needs to be described.31 Understanding how older adults cope with MCCs as a dyad can provide valuable insights on what can be done to help couples maintain a positive living status.8

Additionally, a study showed that culture influences factors that dominate the ways of coping present among people with MCCs.19 Cultural differences can influence older couples’ perceptions of illness and their way of coping with MCCs in the context of family. According to the recent seventh national census by the Chinese National Bureau of Statistics, people more than 60 years of age account for 18.7% of the total population, and more than 180 million older adults in China suffered from chronic diseases in 2020. The Chinese government recently published a number of policies aimed at promoting positive coping given the rapid and deepened social aging in China. Especially, as the first generation of single-child parents gradually entered old age and small, core, and empty-nester families developed, the new social problem of elderly empty-nester couples has emerged. Empty-nester elderly are older people with no children or whose children have already left home. It was estimated that the proportion of empty nesters in China is expected to reach 90% by 2030, which means that there will be more than 200 million empty nesters.32 Therefore, further exploration and understanding of the views of Chinese older couples on coping with MCCs that are rooted in Chinese culture are valuable for supporting older couples coping with MCCs. Reporting findings from an Eastern country such as China will also expand the current literature on coping from an Asian perspective and inform further cross-culture research on this topic. Qualitative research is an appropriate method to provide a combined understanding on the opinions, thoughts, and perspectives of coping, and results can contribute to common understanding of a focused whole.33 A qualitative study with a dyadic approach is necessary to understand the experiences of older couples coping with MCCs. Therefore, we aimed to gain a deeper understanding of how Chinese older couples cope with MCCs as a dyad, including their perceptions of MCCs and their experiences in dyadic adjustment to MCCs. Our findings may help healthcare professionals to design couple-based interventions to support older couples with MCCs.