# Effect of a personality-based psychoeducational booklet aligned with openness-related characteristics on health-related quality of life in pulmonary rehabilitation: A randomized controlled trial

Sébastien Kuss, Nelly Héraud, François Alexandre, Espérance Moine, Benjamin Eichenauer, Lorie Thomas, Laura Brandon, Perrine Sanchez, Brice Canada

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Sébastien Kuss, Nelly Héraud, François Alexandre, Espérance Moine, Benjamin Eichenauer, et al. Effect of a personality-based psychoeducational booklet aligned with openness-related characteristics on health-related quality of life in pulmonary rehabilitation: A randomized controlled trial. Journal of Psychosomatic Research, 2026, 203, pp.112560. 10.1016/j.jpsychores.2026.112560. hal-05492289

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# Effect of a personality-based psychoeducational booklet aligned with openness-related characteristics on health-related quality of life in pulmonary rehabilitation: A randomized controlled trial

Sébastien Kuss<sup>a,b,*</sup>, Nelly Héraud<sup>b</sup>, François Alexandre<sup>b</sup>, Espérance Moine<sup>b</sup>,
Benjamin Eichenauer<sup>c</sup>, Lorie Thomas<sup>c</sup>, Laura Brandon<sup>d</sup>, Perrine Sanchez<sup>d</sup>, Brice Canada<sup>a</sup>

## ARTICLE INFO

### Keywords:

Five-Factor Model

Openness to experience

Single-blind multicenter randomized controlled trial

Psychoeducational booklet

Inpatient pulmonary rehabilitation

## ABSTRACT

**Objectives:** Five-Factor Model personality traits differ in their associations with health outcomes after therapeutic interventions. In the specific context of inpatient pulmonary rehabilitation (PR), higher levels of openness to experience have been associated with greater risk of non-response in terms of health-related quality of life. This study aimed to examine the effect of psychoeducational information aligned with characteristics associated with higher levels of openness on health-related quality of life in inpatient PR.

**Methods:** A single-blind multicenter randomized controlled trial was conducted in the context of inpatient PR with 136 participants diagnosed with chronic respiratory disease. Participants in the intervention group received an openness-based psychoeducational booklet, while the control group received a neutral booklet. Health-related quality of life was measured at baseline and at PR completion using the St George's Respiratory Questionnaire (SGRQ), which includes a total score and three sub-dimensions (i.e., *symptoms, activities, impact*). Mixed ANOVA was conducted to investigate group differences in changes in health-related quality of life.

**Results:** While no significant difference in SGRQ total score was found between the groups, the intervention group exhibited significantly greater improvement in the SGRQ "activities" sub-dimension compared to the control group ($\eta^2_p = 0.04, p < .05$). Exploratory analyses showed that this effect was not moderated by participants' level of openness.

**Conclusions:** This study highlights that an openness-based intervention can improve a sub-dimension of health-related quality of life in inpatient PR and offers valuable insights for the conception of future personality-based interventions in PR.

## 1. Introduction

Pulmonary rehabilitation (PR) is widely regarded as a cornerstone in the management of chronic respiratory disease (CRD) and has demonstrated substantial efficacy in improving health-related quality of life, reducing dyspnea, and enhancing exercise capacity [1,2]. Despite the well-established benefits, 30 to 50% of patients participating in PR show no clinically significant improvement on one or more of the aforementioned outcomes, defined as non-response [3,4]. Beyond clinical factors commonly identified as predictors of PR non-response, such as dyspnea

[5] and forced expiratory volume in 1 s (FEV₁) [6], recent work has also highlighted the role of personality traits, suggesting that personality-based approaches may help optimize intervention efficacy [7].

According to the Five-Factor Model [8,9], personality is defined by five broad traits: neuroticism (i.e., the tendency to be anxious and experience negative emotions), extraversion (i.e., the tendency to be outgoing and experience positive emotions), openness to experience (i. e., the tendency to be curious and seek new experiences), agreeableness (i.e., the tendency to be altruistic and trusting) and conscientiousness (i. e., the tendency to be self-disciplined and responsible). Previous work

<footnote><sup>a</sup> L-ViS, University of Lyon 1, France</footnote>

<footnote><sup>b</sup> Health Research and Innovation Department, Clariane, France</footnote>

<footnote><sup>c</sup> Clinique du Souffle le Pontet, Inicea, France</footnote>

<footnote><sup>d</sup> Clinique du Souffle les Clarines, Inicea, France</footnote>

<footnote>* Corresponding author at: University of Lyon, UFRSTAPS, 27-29 boulevard du 11 novembre 1918, 69622 Villeurbanne, France.</footnote>

<footnote>E-mail address: sebastien.kuss@univ-lyon1.fr (S. Kuss).</footnote>
has shown that personality traits are associated with the efficacy of therapeutic interventions, including medication and rehabilitation [10–13]. However, evidence from non-pharmacological interventions indicates that these associations vary across clinical contexts and study populations. In the specific context of inpatient PR, patients with CRD who scored higher on openness had a higher risk of non-response in terms of health-related quality of life, a multidimensional construct capturing the biopsychosocial consequences of CRD [7]. The authors suggest that the inpatient environment, which is highly supervised and routine in its activities, may not meet the psychological needs that characterize higher levels of openness (e.g., needs for autonomy). This hypothesis is consistent with the person-environment fit framework, which posits that outcomes are reduced when individuals' personal characteristics do not align with the features of their environment [14,15]. Such a misfit may reduce motivation, foster more negative beliefs about PR efficacy, and weaken the therapeutic alliance, which could diminish perceived benefits [16,17]. In addition, it may also influence improvements in psychological mechanisms related to PR efficacy, such as disease-specific fears, illness perceptions, and self-efficacy [18–20].

In light of these findings, higher levels of openness can be viewed as an at-risk trait for PR efficacy, underscoring the relevance of taking this dimension into account [21,22]. Indeed, personality-based interventions have shown greater effects on a range of outcomes, including health outcomes, compared to standard approaches [21,23–25]. Among the different methods available, personality-based information represents a relevant strategy for several reasons. First, short information that is aligned with the characteristics associated with a specific personality trait has been shown to be more effective in improving diverse outcomes than standard information, such as saving behaviors [26], political attitudes and voting intentions [27], and daily steps [28]. Second, personality-based information may help reappraise perceptions of the environment, thereby promoting a better person-environment fit. Third, this information can be feasibly integrated into highly structured and standardized settings without requiring substantial modifications to existing procedures. Building on this evidence, psychoeducational information aligned with the characteristics of higher levels of openness may be a promising approach to optimizing health-related quality of life benefits in people with CRD and higher levels of openness undergoing inpatient PR, who may be at risk of reduced efficacy [7]. To date, as no threshold score has been defined to identify these patients, one strategy is to deliver the same personality-based intervention to all participants, regardless of their level on the trait. This approach has already been implemented and shown to be effective in a previous study [28]. In that study, the intervention group received a short text on the benefits of walking that was aligned with the characteristics of high conscientiousness, irrespective of their level on this trait. Moderation analyses were subsequently conducted to examine whether conscientiousness moderated its efficacy. Such a non-restrictive design helps prevent the exclusion of patients who may not meet an arbitrary threshold but could still benefit from the intervention. Importantly, existing evidence suggests that delivering personality-based content without individual-level matching is unlikely to result in effects worse than those observed in standard information conditions [26,28,29]. On this basis, the balance of potential benefits and risks was judged to favor implementation of this approach, as it maximizes the number of patients who may benefit while limiting the risk of unfavorable effects, even if some individuals may perceive the content as less relevant.

In line with prior results [7], this study aimed to assess the effect on health-related quality of life of psychoeducational information aligned with characteristics linked to higher levels of openness in patients with CRD undergoing inpatient PR. The main hypothesis was that the intervention group (i.e., openness-based information) would show greater improvements in terms of health-related quality of life than the control group (i.e., neutral information). Given the null or limited effect

expected for individuals with lower levels of openness [26,28,29], it can be expected that the benefits observed at the group level are primarily driven by those with higher levels of openness.

## 2. Method

### 2.1. Study design

The present study was a single-blind, multicenter randomized controlled trial in a 1:1 ratio. This study was approved by an independent French ethics committee (CPP Ile de France VI, reference number: 2022-A00155-38, March 28, 2022). Informed consent was obtained from all the participants prior to the experiment. The protocol was pre-registered at clinicaltrials.gov (NCT: NCT05325086). This study was reported according to the Consolidated Standards of Reporting Trials (CONSORT) guidelines [30].

### 2.2. Participants

Inclusion criteria were admission to a four-week inpatient PR, diagnosis of CRD, aged between 18 and 80 years old, and reading and writing skills. Exclusion criteria were inability to participate in exercise training, inability to answer a questionnaire, severe or unstable heart disease, orthopedic, neurologic, or psychiatric (i.e., bipolar and related disorders, schizophrenia spectrum and other psychotic disorders, and personality disorders) comorbidities, recent exacerbation (< four weeks before participation), pregnant or breastfeeding women, protected adults, and participation in another study, except observational studies. Participants were recruited in two clinics between April 2022 and July 2023: Clinique du Souffle Inicea le Pontet (Plateau d'Hauteville, France) and Clinique du Souffle Inicea les Clarines (Riom-ès-Montagnes, France).

### 2.3. Randomization

Participants were randomly assigned to the intervention or control group, with the different randomization steps being performed independently by two methodologists. The randomization sequence was computer-generated and concealed until formal patient enrollment, after consent to participate and before the first assessment. Once the patients were included, the allocation results were sent to the investigator. Participants and PR healthcare professionals were blinded to group allocation.

### 2.4. Procedure

All participants underwent an inpatient PR program in accordance with the recommendations of the American Thoracic and European Respiratory Societies [2]. A complete clinical evaluation (clinical assessment, respiratory function, blood gas test, and body composition) was performed at the start of PR. PR included endurance and resistance training, breathing exercises, and relaxation. Furthermore, after an individual educational diagnosis consisting of a structured assessment of patients' educational needs and personal goals, participants could take part in educational sessions (e.g., understanding lung diseases, physical activity after PR, etc.) and receive nutritional, psychological and nursing support. The program lasted four weeks.

At the start of the inpatient PR, eligible patients were identified by the investigator and invited to participate in the study. After providing informed consent, participants were randomly assigned to one of the two conditions. Baseline assessment was conducted at the start of PR, while follow-up assessment took place at the end of the program.

### 2.5. Intervention

In addition to inpatient PR, all participants received a
psychoeducational booklet at the end of the baseline assessment, regardless of their levels of openness. The booklet content was derived from the clinic's websites and was identical across groups in terms of information scope. Each booklet included a program purpose and the same seven sections: "Program benefits"; "Our program and our Clinic"; "Our team"; "Our activities"; "Exercise training"; "Specific benefits of physical activity", and "Therapeutic education". The booklets were printed as a double-sided A5 color page and standardized in terms of visual. Content was deliberately kept short and simple to facilitate readability and comprehension. To ensure that the booklet was properly read and understood, the investigator met all participants in the middle of the PR for a 30-min interview, during which participants were asked to summarize and review the main information.

The booklet content was experimentally manipulated according to group allocation. Illustrative examples are provided in Table 1, and the full English translations from the original French versions are available in supplementary material.

### 2.5.1. Control group

Participants in the control group received neutral information as described above (Table 1).

### 2.5.2. Intervention group

Participants in the intervention group received the same information content as the control group but this content was framed to be aligned with characteristics associated with higher levels of openness (Table 1). The tailoring relied primarily on empirical evidence linking openness to specific motivational and psychological needs (e.g., beliefs, goals, values), rather than on theoretical conceptualizations of the trait. Previous studies have shown that people with higher levels of openness tend to pursue personal goals related to autonomy and independence, personal growth and learning, and the pursuit of positive affect [31,32]. They are also more inclined to explore a variety of activities [33,34] and show a preference for outdoor exercise [35]. Based on this evidence, openness-based information emphasized how specific features of inpatient PR could meet these psychological needs, thereby promoting a better person-environment fit. These features included the diversity and novelty of activities offered, opportunities for learning development, and elements of the program supporting autonomy and independence. In addition, openness-based information highlighted benefits of PR that are most meaningful for people with higher levels of openness (e.g., independence and autonomy) [31,32], consistent with evidence suggesting that enhancing the perceived benefits in situations of person-environment misfit is important [36].

## 2.6. Measures

Demographic and clinical characteristics, as well as personality traits, were evaluated at the start of PR (T1). Primary and secondary outcomes were measured at T1 and at the end of PR (T2).

### 2.6.1. Demographic, clinical, and psychological characteristics

Sociodemographic variables included age in years, sex coded 0 for men and 1 for women, and educational level in years. Clinical characteristics, including pulmonary function, body mass index (BMI), cognitive function, and depressive symptoms, were assessed. Pulmonary function assessment included FEV₁, its predicted value (FEV₁ % pred), forced vital capacity (FVC) and Tiffeneau index (FEV₁ / FVC). Cognitive function was assessed using the French version of the Montreal Cognitive Assessment 5-min protocol [37,38]. Depressive symptoms were measured using the French version of the Patient Health Questionnaire – 9 items [39,40].

The French version of the Big Five Inventory [41,42] was used to assess the Five-Factor Model personality traits (i.e., neuroticism, extraversion, openness, agreeableness, and conscientiousness). Participants were asked to agree or disagree with 45 descriptive statements using a five-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). A higher score indicates a higher level of the trait. Cronbach's alphas were 0.83 for neuroticism and openness, 0.75 for extraversion, 0.53 for agreeableness, and 0.68 for conscientiousness.

### 2.6.2. Primary outcome

The primary outcome of this study was health-related quality of life, assessed using the French version of the St George's Respiratory Questionnaire (SGRQ) [43,44]. This questionnaire contains 50 items and provides four scores: a total score and three sub-dimension scores (i.e., symptoms, impact, and activities). The "symptoms" sub-dimension includes the severity and frequency of respiratory symptoms. The "activities" sub-dimension focuses specifically on activities that cause or are limited by dyspnea. The "impact" sub-dimension assesses the social and psychological consequences of airway diseases. Higher scores represent poorer health-related quality of life. Responders were patients achieving a ≥ 4-point reduction in total score, according to the minimal clinically important difference (MCID) [45]. Cronbach's alphas were 0.91 and 0.90 for total scores at T1 and T2, respectively. For sub-dimensions, they ranged from 0.67 to 0.87.

### 2.6.3. Secondary outcomes

Dyspnea was assessed using the French version of the Dyspnea-12 (D-12) [46,47]. It includes 12 items and evaluates the physical and affective dimensions of dyspnea. Each participant responds using a four-point Likert scale ranging from 0 (none) to 3 (severe). All items are summed,

<table><caption>**Table 1**
Examples of the personality-based and neutral information.</caption><thead><tr><th>Section</th><th>Group</th><th>Examples</th><th>Targeted characteristics</th></tr></thead><tbody><tr><td rowspan="2">Program purpose</td><td>Intervention</td><td>Regain some autonomy in my daily life</td><td>Needs for autonomy [32]</td></tr><tr><td>Control</td><td>Reduce my dyspnea</td><td></td></tr><tr><td rowspan="2">Program benefits</td><td>Intervention</td><td>You will be able to do new things when you return home</td><td>Needs for new activities [33,34]</td></tr><tr><td>Control</td><td>You will be able to improve your quality of life</td><td></td></tr><tr><td rowspan="2">Our program and our Clinic</td><td>Intervention</td><td>Enjoy this new environment</td><td>Needs for novelty [33]</td></tr><tr><td>Control</td><td>The environment is particularly suitable</td><td></td></tr><tr><td rowspan="2">Our team</td><td>Intervention</td><td>Here to support you in achieving your goals</td><td>Needs for more confidence [31]</td></tr><tr><td>Control</td><td>At your disposal</td><td></td></tr><tr><td rowspan="2">Our activities</td><td>Intervention</td><td>Discover new methods, such as relaxation</td><td>Needs for new activities [33,34]</td></tr><tr><td>Control</td><td>A range of activities is offered</td><td></td></tr><tr><td rowspan="2">Exercise training</td><td>Intervention</td><td>Some activities are conducted outdoors</td><td>Preferences for outdoor exercise [35]</td></tr><tr><td>Control</td><td>The program includes the following activities</td><td></td></tr><tr><td rowspan="2">Specific benefits of physical activity</td><td>Intervention</td><td>Promotes positive feelings</td><td>Needs for positive affect [31]</td></tr><tr><td>Control</td><td>Improves exercise capacity</td><td></td></tr><tr><td rowspan="2">Therapeutic education</td><td>Intervention</td><td>Acquire new knowledge and develop new skills</td><td>Needs for new knowledge [31]</td></tr><tr><td>Control</td><td>Better understand your disease</td><td></td></tr></tbody></table>
with higher scores indicating greater dyspnea. According to the MCID, patients with a reduction of ≥2.83 points in total score were classified as responders [48]. Cronbach's alphas were 0.94 at T1 and T2.

Exercise capacity was measured with a 6-min walking test (6MWT). In compliance with the guidelines of the American Thoracic and the European Respiratory Societies [2], patients were asked to walk as far as possible in six minutes, in a 30-m hallway. The distance was recorded in meters. Responders were those achieving a ≥ 30 m improvement according to the MCID [49].

## 2.7. Sample size

G*Power software version 3.1.9.6 [50] was used to perform an a priori power analysis for mixed analyses of variance (ANOVAs) with an interaction between time (within) and group (between). Based on a previous study examining the effect of psychoeducational booklets on health-related quality of life in schizophrenia [51], the expected effect size was $f = 0.133$. Considering this, the sample size calculation parameters were set as follows: $f = 0.133$; $\alpha = 0.05$; power = 0.80; number of groups = 2; number of measurements = 2; and correlation among repeated measures = 0.5. The sample size calculation indicates 114 participants. To compensate for the expected dropout, 20% extra patients were added. The final sample size was 136 participants.

## 2.8. Statistical methods

Statistical analyses were performed using R software version 4.4.3 (2025.02.28), with *lme4*, *lmerTest*, and *emmeans* packages. The analysis scripts can be accessed in an OSF repository (https://osf.io/rbuhz/).

First, confirmatory analyses examined the effect of the intervention on the primary outcome (SGRQ total score and its three sub-dimensions) and secondary outcomes (D-12 and 6MWT). Mixed ANOVAs were conducted for each outcome, with the interaction of within (time effect) and between factors (group effect). Second, exploratory analyses tested whether openness moderated the efficacy of the intervention. Analyses of covariance (ANCOVAs) were conducted including the interaction between group and openness, with post-intervention outcome adjusted for baseline value. A sensitivity power analysis was performed to quantify the magnitude of interaction effects detectable with the current

sample size, operationalized as the incremental variance by the interaction term ($\Delta R^2$). With the current sample, the study had 80% power to detect an interaction effect of approximately $\Delta R^2 = 0.03$ ($r \approx 0.17$), corresponding to a small-to moderate effect size based on contemporary recommendations [52]. Lastly, chi-square tests were used to compare responder and non-responder rates between groups (for the results, see Table S1).

# 3. Results

## 3.1. Participant characteristics

One hundred and thirty-six participants provided informed consent and were randomly assigned to the intervention group ($n = 68$) or the control group ($n = 68$; Fig. 1). Table 2 shows the baseline characteristics of participants, with no statistically significant differences observed between the two conditions. In terms of response to inpatient PR, 72% of the participants were classified as responders for the SGRQ total score, 58% for the D-12 score and 65% for the 6MWT distance.

## 3.2. Effect of intervention on health-related quality of life

Confirmatory analyses revealed no significant interaction effect between time and group for SGRQ total score (Table 3). A time effect was observed, indicating that participants in both groups demonstrated significant improvements in SGRQ total score between T1 and T2 (Table 3).

For sub-dimensions of the SGRQ, an interaction effect between time and group for “activities” sub-dimension of the SGRQ was found ($\eta^2_p = 0.04$; see Table 3). Tukey post-hoc analysis revealed that the intervention group demonstrated a significant improvement on this sub-dimension ($M = -9.79, p < .001$), while the control group showed no improvement ($M = -4.26, p = .111$; see Fig. 2). There was no significant interaction effect for the “symptoms” and “impact” sub-dimensions of the SGRQ, whereas a significant effect of time was found for both sub-dimensions (Table 3).

The exploratory ANCOVAs revealed no significant interaction between group and openness on SGRQ total score ($F(1,111) = 0.54, p = .464$), “activities” sub-dimension ($F(1, 111) = 0.30, p = .584$),

<figure><img src="image_2.png" /><figcaption>**Fig. 1.** Consolidated Standards of Reporting Trials (CONSORT) diagram.</figcaption></figure>
<table><caption>**Table 2**
Baseline characteristics of sample.</caption><thead><tr><th rowspan="2">Variables</th><th colspan="3">Mean | % (SD)</th></tr><tr><th>Full sample (N = 116)</th><th>Intervention group (N = 58)</th><th>Control group (N = 58)</th></tr></thead><tbody><tr><td><strong>Demographic</strong></td><td></td><td></td><td></td></tr><tr><td>Age</td><td>65.05 (8.26)</td><td>65.36 (8.80)</td><td>64.74 (7.74)</td></tr><tr><td>Sex (% of women)</td><td>53%</td><td>50%</td><td>55%</td></tr><tr><td>Education (in years)</td><td>12.09 (4.11)</td><td>12.48 (4.30)</td><td>11.69 (3.91)</td></tr><tr><td>BMI</td><td>29.08 (6.88)</td><td>28.51 (6.26)</td><td>29.66 (7.47)</td></tr><tr><td><strong>Clinical variables</strong></td><td></td><td></td><td></td></tr><tr><td>Diagnosis at PR<br>admission</td><td>• COPD: 62%<br>• Asthma: 24%<br>• Other: 14%</td><td>• COPD: 62%<br>• Asthma: 24%<br>• Other: 14%</td><td>• COPD: 62%<br>• Asthma: 28%<br>• Other: 10%</td></tr><tr><td>FEV<sub>1</sub> (L)</td><td>1.72 (0.80)</td><td>1.75 (0.82)</td><td>1.67 (0.79)</td></tr><tr><td>FEV<sub>1</sub> (% pred)</td><td>65.46 (28.04)</td><td>66.12 (27.15)</td><td>64.79 (29.15)</td></tr><tr><td>FEV<sub>1</sub>/FVC (%)</td><td>60.48 (16.14)</td><td>61.42 (15.57)</td><td>59.51 (16.78)</td></tr><tr><td>BMI</td><td>29.08 (6.88)</td><td>28.51 (6.26)</td><td>29.66 (7.47)</td></tr><tr><td>PHQ-9</td><td>7.96 (6.12)</td><td>8.31 (6.48)</td><td>7.60 (5.76)</td></tr><tr><td>MoCA</td><td>28.32 (2.00)</td><td>27.97 (2.29)</td><td>28.67 (1.60)</td></tr><tr><td><strong>PR outcomes</strong></td><td></td><td></td><td></td></tr><tr><td>SGRQ total score</td><td>43.87 (16.80)</td><td>44.21 (16.26)</td><td>43.54 (17.47)</td></tr><tr><td>Dyspnea-12</td><td>13.91 (9.42)</td><td>13.33 (9.37)</td><td>14.48 (9.52)</td></tr><tr><td>6MWT</td><td>440 (114)</td><td>434 (125)</td><td>446 (103)</td></tr><tr><td><strong>Personality traits</strong></td><td></td><td></td><td></td></tr><tr><td>Neuroticism</td><td>2.67 (0.84)</td><td>2.61 (0.91)</td><td>2.72 (0.78)</td></tr><tr><td>Extraversion</td><td>3.27 (0.72)</td><td>3.25 (0.69)</td><td>3.29 (0.74)</td></tr><tr><td>Openness</td><td>3.49 (0.74)</td><td>3.52 (0.74)</td><td>3.46 (0.75)</td></tr><tr><td>Agreeableness</td><td>4.25 (0.40)</td><td>4.28 (0.37)</td><td>4.22 (0.42)</td></tr><tr><td>Conscientiousness</td><td>3.99 (0.54)</td><td>4.02 (0.55)</td><td>3.96 (0.52)</td></tr></tbody><tfoot><tr><td colspan="4"><strong>Note.</strong> P values are based on independent-samples t-tests or chi-square tests, as appropriate, to compare baseline characteristics between groups.</td></tr><tr><td colspan="4"><strong>BMI:</strong> body mass index; <strong>FEV<sub>1</sub>:</strong> forced expiratory volume in 1 s; <strong>FVC:</strong> forced vital capacity; <strong>PHQ-9:</strong> Patient Health questionnaire; <strong>MoCA:</strong> Montreal Cognitive Assessment; <strong>SGRQ:</strong> St George's Respiratory Questionnaire; <strong>6MWT:</strong> six minutes walking test.</td></tr></tfoot></table>

"symptoms" sub-dimension ($F(1, 111) = 0.15, p = .701$), and "impact" sub-dimension ($F(1, 111) = 0.43, p = .514$).

### 3.3. Effect of intervention on dyspnea and exercise capacity

No significant interaction effect between time and group was observed for changes in D-12 and 6MWT between T1 and T2 (Table 3). However, the time effect was significant, indicating that all participants had significant improvements in D-12 and 6MWT during inpatient PR.

In the exploratory ANCOVAs, the interaction between group and openness was not significant for D-12 ($F(1, 111) = 0.621, p = .650$) and 6MWT ($F(1, 111) = 0.09, p = .769$).

## 4. Discussion

To the best of our knowledge, this study was the first to investigate the effect of a personality-based psychoeducational booklet aligned with characteristics related to higher levels of openness on health-related quality of life in patients with CRD undergoing inpatient PR. The findings revealed that the intervention did not improve global health-related quality of life. Although the main hypothesis was not supported, the intervention group showed a greater improvement in the "activities" sub-dimension of health-related quality of life than the control group,

suggesting that an openness-based psychoeducational booklet may specifically influence the "activities" sub-dimension during inpatient PR. In addition, the exploratory analyses suggest that the intervention did not yield greater benefits for patients with higher levels of openness.

First of all, inpatient PR was effective on average across the sample, yielding significant improvements in health-related quality of life, dyspnea, and exercise capacity, alongside a substantial proportion of participants classified as responders. Both findings are consistent with previous studies [1,4,53], supporting the validity of the PR context for interpreting the effects of the personality-based intervention.

The present study was designed to examine whether a psycho-educational booklet aligned with openness-related characteristics could enhance the benefits of inpatient PR. Drawing on evidence-based characteristics associated with higher levels of openness [31–35], the booklet was designed to complement standard rehabilitation care. Overall, the intervention failed to improve global health-related quality of life but led to a greater improvement in the "activities" sub-dimension. Several factors may explain these findings. First, differences in study populations may have played a role. Previous work linking openness to non-response in terms of health-related quality of life was conducted in a small sample of patients with severe CRD [7], whereas this study included patients with less severe disease. Openness may therefore play a different role in shaping PR responses, which could partly explain why

<table><caption>**Table 3**
Comparison of primary and secondary outcomes at the beginning and the end of PR.</caption><thead><tr><th rowspan="2">Variables</th><th colspan="4">Intervention group (N = 58)</th><th colspan="3">Control group (N = 58)</th><th colspan="3">Mixed ANOVA</th></tr><tr><th colspan="2">T1</th><th colspan="2">T2</th><th colspan="2">T1</th><th>T2</th><th colspan="2">Group</th><th>Time</th><th>Time x Group</th></tr></thead><tbody><tr><td>SGRQ total</td><td>M</td><td>SD</td><td>M</td><td>SD</td><td>M</td><td>SD</td><td>M</td><td>SD</td><td>F</td><td>F</td><td>F</td></tr><tr><td>SGRQ total</td><td>44.21</td><td>16.26</td><td>33.13</td><td>16.10</td><td>43.54</td><td>17.47</td><td>34.71</td><td>15.09</td><td>0.05</td><td>83.12***</td><td>1.06</td></tr><tr><td>SGRQ total</td><td>46.86</td><td>22.67</td><td>27.47</td><td>19.56</td><td>43.20</td><td>22.93</td><td>25.02</td><td>14.49</td><td>0.95</td><td>113.94***</td><td>0.12</td></tr><tr><td>SGRQ Activities</td><td>62.64</td><td>62.64</td><td>52.85</td><td>23.65</td><td>62.23</td><td>23.16</td><td>57.97</td><td>21.25</td><td>0.01</td><td>27.99***</td><td>4.33*</td></tr><tr><td>SGRQ Impact</td><td>32.86</td><td>17.46</td><td>23.64</td><td>15.21</td><td>32.97</td><td>17.03</td><td>24.46</td><td>16.08</td><td>0.00</td><td>50.61***</td><td>0.08</td></tr><tr><td>Dyspnea-12</td><td>13.33</td><td>9.37</td><td>8.78</td><td>8.05</td><td>14.48</td><td>9.52</td><td>9.72</td><td>8.80</td><td>0.48</td><td>54.16***</td><td>0.03</td></tr><tr><td>6MWT (in meters)</td><td>435</td><td>125</td><td>480</td><td>120</td><td>446</td><td>103</td><td>491</td><td>111</td><td>0.29</td><td>123.84***</td><td>0.12</td></tr></tbody></table>

Note. *** $p < .001$, ** $p < .01$, * $p < .05$. SGRQ: Saint-George's Respiratory Questionnaire; 6MWT: 6 min walking test.
<figure><img src="image_3.png" /><figcaption>**Fig. 2.** Line graph showing the results of the mixed ANOVA with 95% confidence intervals for the “activities” sub-dimension of the SGRQ. A lower score on the “activities” sub-dimension indicates a better health-related quality of life.</figcaption></figure>

the intervention did not improve global health-related quality of life. Second, in the inpatient rehabilitation setting, where patients are already exposed to a wide range of information [54], the added value of a personality-based booklet may have been diluted. The choice of this modality over more resource-intensive approaches (e.g., personality-based activities) was aligned with one of the aims of this study: to prioritize future implementation and generalizability. This aim addresses a key challenge in clinical research—the translation of evidence into clinical practice [55]. Third, the booklet was delivered regardless of participants' level of openness due to the absence of empirically validated threshold scores. Exploratory analyses showed that openness did not moderate the intervention effect. This suggests that the openness-based booklet did not confer differential benefits according to baseline levels of openness, or that any such differential effects were overshadowed by the broader PR environment. However, small moderation effects cannot be ruled out. Power considerations indicate that detecting a small interaction effect (ΔR² = 0.01, r ≈ 0.10) would have required a substantially larger sample (N = 351). Notably, interaction effects reported in the literature are typically smaller than 1% of explained variance [56], indicating that the present exploratory analyses were likely underpowered to detect effects of the magnitude commonly observed. Accordingly, the absence of a significant moderation effect should be interpreted with caution.

Second, the content of the openness-based psychoeducational booklet could explain why the intervention was effective in improving the “activities” sub-dimension of quality of life, while not significantly affecting the other sub-dimensions. This sub-dimension is particularly critical as it is the strongest predictor of physical activity and mortality among patients with chronic obstructive pulmonary disease, compared to the other two sub-dimensions [57–59]. Some of the information aligned with the characteristics of higher levels of openness specifically addressed aspects related to the “activities” sub-dimension. First, it emphasized the beneficial effects of PR in overcoming limitations in daily activities, highlighting its potential to restore autonomy and independence. Second, it focused on the enjoyable nature of physical activities performed during PR and the benefits of regular physical activity. This openness-based information could improve patients' perceptions of tolerating activities that cause dyspnea, such as physical activity. Furthermore, they could enhance their confidence in overcoming their limitations in dyspnea-inducing activities [60]. In contrast, the psychoeducational booklets did not address the “symptoms” and “impact” sub-dimensions, which may elucidate why only the “activities” sub-dimension was affected by the intervention. Also, exploratory analyses showed that openness level did not significantly moderate the intervention effect on the “activities” sub-dimension. One possible interpretation is that the booklet may have exerted a stronger influence among patients with higher openness, for instance by enhancing their

perception of person-environment fit, but the effect was too small to be detected statistically. Alternatively, the booklet may have included a more general effective component, benefiting patients regardless of their openness level. In particular, emphasizing aspects related to the “activities” sub-dimension, initially framed to align with higher openness, may positively shape beliefs about PR and dyspnea and reinforce engagement in rehabilitation, which could contribute to greater benefits. Given the deleterious impact of a deficient “activities” sub-dimension in CRD patients, the efficacy of this resource-efficient intervention highlights its potential for promising cost-effectiveness. Further research is needed to assess the effect of an updated booklet with information about “symptoms” and “impact” sub-dimensions.

Strengths of the current study include a single-blind multicenter randomized design and a population with a large panel of CRD. Several limitations should be considered when interpreting the present findings. The sample size limited statistical power to detect subtle moderation effects between openness and the openness-based intervention. The small effect size observed further underscores the necessity to corroborate these findings through diverse personality-based interventions in PR. This magnitude may partly reflect the absence of tailoring, as the intervention was offered to everyone regardless of their openness to experience score, due to the lack of validated threshold scores. While this approach reduced the risk of excluding patients who did not meet an arbitrary threshold but could still benefit from the intervention, it also raises the possibility that the content was less relevant for some individuals. In such cases, a mismatch between openness level and intervention content may have attenuated overall effects and, in some instances, been associated with slightly unfavorable outcomes. This highlights the importance of evaluating potential unintended effects of mismatched personality-based interventions.

Beyond these limitations, the present findings invite broader reflection regarding the design of personality-based interventions. Identifying proximal mechanisms underlying the efficacy of standard interventions (e.g., inpatient PR), such as self-efficacy or beliefs about dyspnea and physical activity, may be a critical step toward developing more effective personality-based interventions. From this perspective, personality traits serve as optimizers that increase the relevance of core intervention components known to be effective [21]. Building on this framework, future studies may consider more intensive personality-based approaches, such as increasing the amount of information provided [26] or implementing activities and educational workshops informed by personality-related characteristics [24,25]. In addition, explicitly tailored approaches based on individuals' personality trait levels may further enhance the impact of such interventions.

In conclusion, the present study highlights that personality-based intervention through an openness-based psychoeducational booklet in inpatient PR does not improve global health-related quality of life.
However, it has a positive effect on a specific sub-dimension of this outcome, called "activities" in people with CRD, with no evidence of moderation by participants' level of openness. Our study provides new insights for the development of future personality-based interventions in PR.

## CRediT authorship contribution statement

**Sébastien Kuss:** Writing – review & editing, Writing – original draft, Visualization, Methodology, Investigation, Formal analysis, Conceptualization. **Nelly Héraud:** Writing – review & editing, Visualization, Supervision, Methodology, Conceptualization. **François Alexandre:** Writing – review & editing, Methodology, Conceptualization. **Espérance Moine:** Writing – review & editing, Methodology, Conceptualization. **Benjamin Eichenauer:** Writing – review & editing, Investigation. **Lorie Thomas:** Writing – review & editing, Investigation. **Laura Brandon:** Writing – review & editing, Investigation. **Perrine Sanchez:** Writing – review & editing, Investigation. **Brice Canada:** Writing – review & editing, Visualization, Supervision, Methodology, Formal analysis, Conceptualization.

## Funding

The project was financially supported by the French Agency for Research and Technology [ANRT, CIFRE 2022/0900]. The sponsor had no influence on the conduct of this study, the analysis of the data, or the writing of this report.

## Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

## Acknowledgments

The authors thank the experts of the Clariane research committee for their critical analyses of the protocol and the results. Moreover, the authors thank all the participants. Finally, we also gratefully acknowledge the different clinical teams of the Clinique du Souffle le Pontet and les Clarines for facilitating the implementation and the organization of this study.

## Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.jpsychores.2026.112560.

## 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 ethical restrictions.

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