Positive psychological constructs and health behavior adherence in heart failure: A qualitative research study

Abstract

Psychological well-being may play an important role in health behavior adherence and cardiovascular health, but there has been limited study of well-being in patients with heart failure. In this descriptive qualitative research study, we interviewed 30 patients with heart failure to explore their psychological experiences with heart failure and the perceived associations between positive psychological constructs and adherence to physical activity, diet, and medication recommendations. Interviews were transcribed, then coded in NVivo using directed and conventional content analysis, and the Consolidated Criteria for Reporting Qualitative Research checklist was applied to report our findings. Participants spontaneously reported positive psychological constructs both during an acute phase of illness and 3 months later. Participants most commonly experienced gratitude, acceptance, connectedness, and faith in the setting of heart failure. In contrast, pride, determination, and hope were identified most frequently as playing a role in health behavior adherence. Finally, participants reported a reinforcing relationship between positive constructs and health behavior engagement. These findings suggest that interventions to boost positive constructs have the potential to improve well-being and health behavior adherence in patients with heart failure.

1 |. INTRODUCTION

Despite the benefits of health behaviors (e.g. activity, diet) (Arcand et al., 2011; O’Connor et al., 2009; Wu, Moser, Lennie, & Burkhart, 2008), many patients with heart failure (HF) struggle to adhere to these behaviors (Corotto, McCarey, Adams, Khazanie, & Whellan, 2013; Lemon et al., 2010). Positive psychological constructs, such as optimism and positive affect, may play a role both in health behavior adherence and cardiovascular health, as these constructs are associated with engagement in health behaviors (Boehm et al., 2018; Millstein et al., 2016; Trudel-Fitzgerald et al., 2019) and improved survival (Chida & Steptoe, 2008; Kim, Hagan, et al., 2017; Zhang & Han, 2016). While qualitative research studies have examined the negative psychological experiences of living with HF, none have examined the positive psychological constructs experienced by patients with HF and the links between those constructs and adherence to cardiovascular health.

2 |. BACKGROUND

Heart failure (HF) affects nearly 6 million Americans and is associated with poor health-related quality of life (HRQoL), repeated hospitalizations, and high rates of mortality (Aggelopoulou et al., 2017; Benjamin et al., 2019; Chen, Normand, Wang, & Krumholz, 2011). Adherence to health behaviors, such as physical activity, a low sodium diet, and prescribed medications, may improve functioning and cardiovascular outcomes (Arcand et al., 2011; O’Connor et al., 2009; Wu et al., 2008). However, patients with HF often fail to adhere to these health behaviors (Corotto et al., 2013; Lemon et al., 2010).

Psychological health may contribute significantly to health behavior adherence. Among patients with cardiovascular disease, negative psychological constructs, such as depression and anxiety, are linked to impaired health behavior adherence, such as smoking and physical inactivity (Celano, Villegas, Albanese, Gaggin, & Huffman, 2018; Dempe et al., 2013; McGrady, McGinnis, Badenhop, Bentle, & Rajput, 2009). In contrast, measures of psychological well-being, such as optimism and positive affect, are associated with greater intake of fruits and vegetables, more physical activity, smoking cessation, and treatment adherence (Boehm et al., 2018; Millstein et al., 2016; Trudel-Fitzgerald et al., 2019). The associations between positive psychological constructs and health behavior adherence may translate to improved health, as positive constructs have been associated with improved health outcomes in a variety of populations (Chida & Steptoe, 2008; Kim, Hagan, et al., 2017; Zhang & Han, 2016).

Research regarding the relationships between psychological well-being and health behavior adherence in HF is limited. While studies have examined negative psychological constructs and emotional responses to HF (Celano, Villegas et al., 2018; Jeon, Kraus, Jowsey, & Glasgow, 2010; Yu, Lee, Kwong, Thompson, & Woo, 2008), to our knowledge only one study has examined the association between a positive psychological construct and health behavior adherence in HF (Kessing, Pelle, Kupper, Szabo, & Denollet, 2014). Furthermore, no studies have examined patients’ understanding of how positive psychological constructs are associated with adherence to HF-related health behaviors in qualitative interviews. The identification of relationships between positive psychological constructs and health behavior adherence in HF is particularly relevant, as interventions to boost positive constructs (e.g. positive psychology) are effective at improving well-being (Bolier et al., 2013) and could be incorporated into health behavior interventions for this population. Given the importance of health behavior adherence in HF, such interventions have the potential to improve both HRQoL and HF outcomes (Lainscak et al., 2011; Moser et al., 2012). Finally, no studies have examined differences in HF patients’ psychological experiences during acute (e.g. during hospitalization) and postacute phases of medical illness.

Accordingly, we performed a descriptive qualitative research study (Colorafi & Evans, 2016; Kim, Sefcik, & Bradway, 2017) in 30 patients with HF to (i) explore the positive psychological constructs most commonly experienced; (ii) identify perceived links between positive psychological constructs and health behavior adherence; and (iii) examine the impact of illness acuity on participants’ psychological experiences.

3 |. METHODS

This descriptive qualitative research study (Colorafi & Evans, 2016; Kim, Sefcik, et al., 2017) was the initial step of a treatment development project to develop a positive psychology-based program to improve health behavior adherence in patients with HF. Participants were recruited between May 2015 and May 2016 from medical inpatient units at an urban academic medical center.

3.1 |. Ethics

All participants provided written, informed consent prior to study procedures, and the Partners Healthcare Institutional Review Board approved the research protocol (IRB #2015P000069). We registered the trial at ClinicalTrials.gov (NCT#NCT02737761) and applied the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist to report our findings (see Supplementary File 1) (Tong, Sainsbury, & Craig, 2007).

3.2 |. Participants

Eligible participants were adults 18 or older with a diagnosis of HF (diagnosed at any time) and New York Heart Association (NYHA) (The Criteria Committee of the New York Heart Association, 1994) class II or III HF symptoms (which lead to mild to marked limitation of physical activity) prior to admission who were hospitalized on an inpatient medical unit between May 2015 and May 2016 for management of HF or another medical illness. Sampling was purposive to ensure inclusion of a diverse sample. Inpatient recruitment allowed interviews to be performed around the time of an acute medical illness and a period of stability.

Potential participants had no relationship to study staff prior to being approached about the study. Study team members identified participants through reviews of inpatient unit censuses, focused chart reviews, and as-needed consultation with inpatient team members, using an IRB-approved process. After confirming a participant’s interest in hearing about an optional study, a team member described the study and evaluated the participant for eligibility, including confirming HF diagnosis and NYHA class. NYHA class was determined based on participants’ reporting of symptoms prior to admission to reflect participants’ general burden of HF symptoms; these symptoms may have been worse during hospitalization. We excluded participants due to cognitive or language barriers, medical conditions that precluded participation in interviews, and lack of access to a telephone.

Eligible participants completed informed consent and baseline measures of health. HRQoL was measured using the Medical Outcomes Study Short Form-12 (SF-12; (Ware, Kosinski, & Keller, 1996), a valid scale which has been used in cardiac populations (Thombs et al., 2008). Demographic and medical history information was obtained through chart review. A tentative sample size of 30 participants was chosen to achieve thematic saturation (Hennink, Kaiser, & Marconi, 2017).

3.3 |. Qualitative interviews

Participants underwent semi-structured, hour-long (mean length = 53.1 [SD 10.1] minutes) qualitative interviews in person while hospitalized (n = 20; 67% of interviews) or by telephone within 15 days of discharge (n = 10; 33% of interviews; baseline interviews were considered to occur during an acute phase of illness), then 3 months later (postacute phase) by telephone. In-person interviews were performed in the patient’s hospital room. While a roommate could be present, study staff ensured that the participant was comfortable with the setting prior to the interview. Interview guides were developed based on prior qualitative research in patients with coronary artery disease (Huffman et al., 2015, 2016), in collaboration with a qualitative research expert (E.P.) (see Supplementary File 2). The first author (a male psychiatrist with training in medical psychiatry and experience with qualitative research) conducted all interviews, which examined participants’ emotional experiences in the setting of HF, barriers to health behavior adherence, and opinions about a health behavior intervention. Though both positive and negative psychological experiences were explored in interviews, the interviews more intensely focused on participants’ positive experiences and the links between positive constructs and health behaviors, given that these were largely unexplored areas in the HF literature and that the focus was on the development of a PP-based intervention.

At both time points, the interviewer queried participants in an open-ended fashion about the thoughts and emotions they experience in the setting of HF and when engaging in health behaviors. Based on their responses, the interviewer asked more targeted questions and provided prompts about specific psychological constructs or relationships. Both spontaneous and prompted responses were coded. All interviews were audio-recorded and transcribed by trained research coordinators or using a professional transcription service. Trustworthiness of the data was enhanced through repeated interviews, field notes, and team data analysis (Korstjens & Moser, 2018). Transcripts and findings were not discussed with participants.

3.4 |. Analysis

Through iterative review of transcripts and discussions with the qualitative research expert, the study team developed a coding framework using directed content analysis (i.e. codes are derived from prior research) (Hsieh & Shannon, 2005) informed by interview guides and prior qualitative work in patients following acute coronary syndrome (references removed for blinding). Major coding categories included (i) health behavior engagement; (ii) health behavior goals; (iii) HF symptoms and their impact; (iv) emotional experiences; and (v) links between emotions and adherence. This framework was modified using conventional content analysis (i.e. codes are derived from the current data) (Hsieh & Shannon, 2005) based on early interviews to ensure it captured the experiences of patients with HF. This manuscript focuses specifically on the analyses related to positive psychological constructs, health behavior adherence, and the links between positive constructs and adherence. Qualitative interviews were coded in their entirety using NVivo 10 (QSR International, Melbourne, Australia). Coders included a physician, social worker, and bachelor’s level research coordinator, with 61% of transcripts coded by at least two coders. Coding was reviewed for consistency throughout the coding process, with ongoing adjudication of differences, and agreement between coders was high (kappa = 0.96).

Sociodemographic and medical characteristics were summarized using means and standard deviations for continuous variables and frequencies for categorical variables. Change in SF-12 scores from baseline to follow-up were assessed with paired t-tests, and unpaired t-tests were used to examine whether changes in SF-12 scores were associated with the likelihood of expressing positive emotions at follow-up. Significance was defined as P < 0.05, and all analyses were performed using Stata 15 (StataCorp, College Station, TX).

4 |. RESULTS

See Figure 1 for a diagram of study flow. Of 100 potentially eligible participants, 38 were found to be ineligible due to lack of NYHA class II or III symptoms or for meeting other exclusion criteria, and two were discharged prior to full evaluation. Of the remaining 60 individuals, 28 declined to participate, and 32 (53%) enrolled. Thirty participants completed the acute phase interview, and 25 completed the postacute phase interview at 3 months (one withdrew, three could not be reached, and one died). All information from completed interviews was included in our analyses.

FIGURE 1.

Enrollment

Baseline demographic, medical, and psychological characteristics of participants who completed the baseline interview are listed in Table 1, and individual participant descriptions are listed in Supplementary File 3. Participants were 67 (SD 13.1) years old on average, 77% (n = 23) were women, and 70% (n = 21) were white. At enrollment, 23 of 30 (77%) participants were experiencing an exacerbation of HF symptoms. Most (70%) participants had NYHA class III HF, and scores on the SF-12 suggested low physical HRQoL. Both physical and mental HRQoL trended towards improvements from the baseline to follow-up interviews (physical: 28.8 [baseline] vs 32.2 [3 months], t = 1.92, P = 0.07; mental: 47.8 [baseline] vs 51.3 [3 months], t = 1.57, P = 0.13)

TABLE 1.

Participant characteristics

Characteristic	Baselinea (N = 30)	Follow-upa (N = 25)
Demographic characteristics
Age in years; mean ± SD	67.0 ± 13.1	NA
Female gender	23 (77)	NA
White, non-Hispanic	21 (70)	NA
Lives alone	6(20)	NA
Medical characteristics
Hypertension	25 (83)	NA
Type 2 diabetes	8(27)	NA
Hyperlipidemia	16 (53)	NA
NYHA class
Class II	9(30)	NA
Class III	21 (70)	NA
Age-adjusted Charlson Comorbidity score; mean ±SD	6.5 ± 3.1	NA
Left ventricular ejection fraction (%); mean ± SD	47.1 ± 17.1	NA
Medical self-report data (mean ± SD; range 0–100)
Physical health-related quality of life (SF-12 PCS)	29.0 ± 7.6	32.2 ± 8.7
Mental health-related quality of life (SF-12 MCS)	47.4 ± 8.2	51.3 ± 11.1

^aAll values are N (%) unless otherwise specified.

HF, heart failure; NYHA, New York Heart Association; SD, standard deviation; SF-12 MCS, Medical Outcomes Study Short Form-12, mental component score; SF-12 PCS, Medical Outcomes Study Short Form-12, physical component score.

In qualitative interviews, several key themes emerged related to positive emotional experiences and their links to health behaviors (see Table 2). These included the identification of psychological constructs most frequently experienced by participants, as well as the positively reinforcing relationship between these constructs and engagement in health behaviors.

TABLE 2.

Main themes in qualitative analysis

Positive emotions/constructs experienced by participants
Construct	Representative quote
Gratitude/appreciation	“I had my moments where I would look at the sky and the trees and stuff like that and just like can’t imagine myself being in this world…You grow to appreciate the things that you see and you grow to appreciate...your days that you wake up (ID 16).”
Acceptance	“[I have] acceptance and [am] determined to beat this…people have lived a long time…with this situation (ID 16).”
Connectedness	“My life now is about my children and my grandkids. They’re the most important things in my life. I live, I breathe every day for them (ID 16).”
Faith	“Everybody who’s really had a connection with religion has always said that [God’s] not going to give it to you if you can’t deal with it, and it seems like if you believe and have hope and faith and you work at trying to get healthier, it may work for you (ID 27).”
Positive constructs leading to health behaviors
Construct	Representative quote
Positive affect	“I think if my mood is better, I am more apt, even through pain and fatigue, to get up and…clean the kitchen or go outside (ID 5).”
Hope/optimism	“[Hope] will help me feel like there’s this goal to get to and that I have this hope and that I’ll lose the weight and I’ll get more fit (ID 19).”
Determination	“I’m definitely not one of these people that, ’Oh, I love exercising, and I’m going to feel wonderful about it.’ It’s more like, ’Okay, I have a goal, I’m going to accomplish it (ID 26).’”
Connectedness	“[Family members] give you that extra strength, that extra determination to stay on that lifestyle, wanting to be with your family more years, more days, all those things really. They motivate you to want to stay on that diet to be around good, loving people (ID 7).”
Health behaviors leading to positive constructs
Construct	Representative quote
Positive feelings	“The physical activity definitely makes you feel better and more - opens up your mind… I think once I start getting physical activity it makes my mind a little sharper and clearer and not just kind of neutral (ID 10).”
Pride/accomplishment	“It makes me feel great that I’m trying to eat right…[I am] proud of myself when I stick to my diet (ID 16).”
Reinforcing relationship between positive constructs and health behaviors
Relationship	Representative quote
Bidirectional	“I think it’s like a cycle. I think it’s synergy. You start off feeling happy, and then you’re going to do the right thing [related to a health behavior], and you just know that cycle’s going to continue, and you train yourself actually (ID 31).”

4.1 |. Positive psychological constructs noted by participants

Participants identified several positive psychological constructs at both interview time points. The most commonly identified constructs were gratitude or appreciation for their health and the care provided by others, acceptance of a diagnosis of HF, and connectedness with other people in their lives. A subset of participants also noted faith as a particularly powerful comfort and motivator for them.

4.1.1 |. Gratitude

Many participants noted experiencing gratitude or appreciation for their health, those activities they were still able to perform, and people who helped them when they were experiencing HF symptoms. Most commonly, participants noted a significant and newfound appreciation for small things in their lives that they did not notice or attend to in the past. For example, one participant noted, “I had my moments where I would look at the sky and the trees and stuff like that and just like can’t imagine myself being in this world…You grow to appreciate the things that you see and you grow to appreciate…your days that you wake up (ID 16).” Participants also experienced gratitude for the things that they are still able to do: “[I’m grateful] that I still…get up in the morning, go to work, laugh with people at work, [and] enjoy what I’m doing (ID 26).” Finally, participants expressed appreciation for the assistance that friends, family members, and medical team members provided for them: “It raises your awareness of how wonderful people are to you when you need them…people that now fill the spaces that I can’t fill anymore or the things that I can’t do (ID 30).”

4.1.2 |. Acceptance

Participants expressed a variety of opinions related to acceptance. Many participants expressed some degree of acknowledgment and acceptance of HF as a diagnosis. However, of those who accepted the diagnosis, some were more optimistic about managing it moving forward than others. For example, one participant noted feeling determined about managing HF: “[I have] acceptance and [am] determined to beat this…people have lived a long time…with this situation (ID 16).” In contrast, another participant felt that the diagnosis of HF required an acceptance of getting older and eventually dying: “Getting the heart failure was just another step on the [way] one gradually backs off on life (ID 28).”

4.1.3 |. Connectedness

Participants identified connectedness, or relationships with other people, as important. Some participants noted the significant support that family members and friends provided them. For example, one participant noted: “I think that my husband has been really good in being supportive and realizing that I can’t do as much. So all those feelings [of appreciation and gratitude] are there (ID 15).” As seen in this example, feelings of connectedness related to social support were frequently associated with gratitude. However, in addition to social support, participants also noted that relationships with family members and friends could provide a sense of purpose and allow them to focus on others: “My life now is about my children and my grandkids. They’re the most important things in my life. I live, I breathe every day for them (ID 16).”

4.1.4 |. Faith

Faith affected participants in different ways. Some participants noted that their faith played a role in coping with HF and provided hope for improving: “Everybody who’s really had a connection with religion has always said that [God’s] not going to give it to you if you can’t deal with it, and it seems like if you believe and have hope and faith and you work at trying to get healthier, it may work for you (ID 27).” Another mentioned that HF caused her to re-evaluate her purpose in life: “God gave me a second chance at life, so my life, I take it a different way…I give my life value now (ID 4).”

4.2 |. Differences in positive psychological constructs during acute and postacute phases of illness

There were notable differences between the psychological constructs reported during an acute phase of illness compared to 3 months later (postacute phase). In the acute phase interviews, participants reported relatively few positive psychological constructs, with only 54% (17/30) spontaneously reporting any positive constructs related to HF. At that time, the most commonly reported constructs were acceptance of their HF symptoms (N = 11) and appreciation/gratitude for the positive aspects of their lives (N = 7). In the postacute phase interviews, participants more frequently expressed positive constructs spontaneously (72%; 18/25). The constructs expressed spontaneously at this time point were less specific and tended to focus on generalized positive affect since discharge from the hospital, with participants reporting feeling “very positive (ID 31),” “pretty upbeat (ID 15),” “excellent (ID 7),” and “wonderful (ID 30).”

Improvements in positive emotional experiences were mirrored by improvements in mental HRQoL. Individuals who spontaneously expressed positive emotions in postacute phase interviews experienced non-significantly greater improvements from baseline in mental HRQoL (change: 6.0 vs −3.0, t = 1.91, P = 0.07), but not physical HRQoL (change: 3.3 vs 3.7, t = 0.08, P = 0.94) – than those who did not.

4.3 |. Relationships between positive psychological constructs and health behaviors

Participants consistently expressed that positive psychological constructs were associated with the performance of health behaviors and noted a bidirectional relationship between positive constructs and health behavior completion. In contrast to those positive constructs most commonly reported in relation to HF in general (e.g. acceptance, gratitude), the constructs most commonly associated with health behavior completion were determination, pride, and hope.

4.3.1 |. Positive constructs leading to health behaviors

Several positive constructs were identified as helpful for engaging in healthy behaviors. Positive affect increased participants’ willingness to engage in health behaviors, even when facing potential challenges: “I think if my mood is better, I am more apt, even through pain and fatigue, to get up and…clean the kitchen or go outside (ID 5).” Participants also believed that optimism may lead to a quicker improvement in their health. When discussing how optimism motivated her to go to the gym more frequently, one participant noted: “I find that if you keep the positive point of view on things, or look at things from a positive standpoint, it’s going to help you. It’s going to help me get better quicker physically, emotionally (ID 18).”

Participants identified hope and optimism that their efforts will lead to results as an important factor necessary for the performance of health behaviors. For example, one participant identified weight loss as a goal for health behavior performance: “[Hope] will help me feel like there’s this goal to get to and that I have this hope and that I’ll lose the weight and I’ll get more fit (ID 19).” Another emphasized hope that physical activity would lead to improved physical health. When discussing motivators for physical activity, one participant stated: “Hope that when I’m able to do exercise, and get around, and do my normal chores, then I’m hoping that it will improve my physical condition (ID 23).”

Determination was also identified by many participants as a key factor that would enable them to engage in health behaviors. Some participants described feeling determined to attain their prior level of functioning. When discussing her motivation to reduce sodium intake, one participant noted, “I’m determined to want to do the things I used to do without being fatigued (ID 13).” Determination seemed particularly important for individuals who did not derive significant pleasure from health behaviors: “I’m definitely not one of these people that, ‘Oh, I love exercising, and I’m going to feel wonderful about it.’ It’s more like, ‘Okay, I have a goal, I’m going to accomplish it.’ But it’s not out of any sort of pleasure (ID 26).”

Finally, participants identified connectedness as a factor associated with health behaviors. Some felt that social support helped them to engage in health behaviors. When discussing successful weight loss, one participant noted: “Particularly when I did the [diet], I felt like I had support, a lot of support from friends…(ID 24).” Others identified a desire to spend time with family members as a motivator for adherence: “[Family members] give you that extra strength, that extra determination to stay on that lifestyle, wanting to be with your family more years, more days, all those things really. They motivate you to want to stay on that diet to be around good, loving people (ID 7).”

4.3.2 |. Health behaviors leading to positive constructs

Conversely, engaging in health behaviors led to a number of positive experiences. This was most apparent when discussing physical activity, which many participants identified as leading to positive feelings. For example, one participant noted: “I used to jog a lot, and just how much better you feel after you’ve jogged. It’s the same way if you get up and go walking too, so I know I’m looking forward to feeling that way, and I will if I get more activity (ID 15).” Another expressed feeling more alert when exercising: “The physical activity definitely makes you feel better and more – opens up your mind…I think once I start getting physical activity it makes my mind a little sharper and clearer and not just kind of neutral (ID 10).”

Participants also experienced pride and accomplishment when adhering to a physical activity or dietary regimen. When recounting his experience going to the gym, one participant remarked, “When I started going to the gym with my older nephew, seeing results, that gave me a sense of accomplishment (ID 27).” Regarding adherence to a low sodium diet, another stated, “It makes me feel great that I’m trying to eat right…[I am] proud of myself when I stick to my diet (ID 16).”

4.3.3 |. Reinforcing relationship between positive constructs and health behaviors

Some participants expressed that positive psychological constructs and health behaviors reinforce each other. Several participants noted that the anticipation of feeling better can serve as a motivator for engaging in healthy behaviors. For example, one participant noted, “When I started really going to the gym, seeing the progress, seeing how I was feeling, seeing how my body was changing was a big purpose…it drove a lot of me going to the gym (ID 6).” When speaking about exercise and diet, another stated, “I think that I consider not doing the exercise or not eating the right foods, and then I think how much better I’ll feel afterward (ID 7).” Finally, one participant noted the significant cyclical relationship between positive constructs and health behaviors: “I think it’s like a cycle. I think it’s synergy. You start off feeling happy, and then you’re going to do the right thing [related to a health behavior], and you just know that cycle’s going to continue, and you train yourself actually (ID 31).”

5 |. DISCUSSION

In this qualitative research study of 30 patients with HF, several key themes emerged related to positive emotional experiences and the links between positive psychological constructs and health behaviors. Most participants reported positive psychological experiences, including acceptance of their medical condition, gratitude for those that care for them, connectedness to others, and faith. While participants most commonly reported acceptance, gratitude, connectedness, and faith when discussing their experience of having HF, they focused on other positive constructs, such as pride, determination, and hope, that played a role in health behavior adherence. Furthermore, participants noted a reinforcing relationship between positive constructs and health behaviors.

Our findings regarding the specific positive constructs experienced in the setting of HF is consistent with and extends prior qualitative research studies. In prior qualitative work, acceptance was a commonly reported construct (Buetow, Goodyear-Smith, & Coster, 2001; Mahoney, 2001; Martensson, Karlsson, & Fridlund, 1997, 1998) that played a significant role in allowing individuals to both acknowledge symptoms of HF but then shift their focus to other things in their lives, without placing too much importance on the symptoms (Ekman, Ehnfors, & Norberg, 2000). Gratitude for specific HF treatments (e.g. left ventricular assist devices) and a greater appreciation for life experiences and current life circumstances also have been reported (Martensson et al., 1998; Overgaard, Grufstedt Kjeldgaard, & Egerod, 2012). Finally, patients with HF have reported the importance of feeling supported by family members or friends who care about them (Martensson et al., 1997, 1998). In this study, participants similarly experienced acceptance of their illness, appreciation of the positive aspects of their lives, and the importance of social support. However, this study extends the findings of prior work in several ways. First, the gratitude noted by participants in this study focused not only on specific treatment modalities, but also on providers, family members, and friends who provide assistance regularly. Second, beyond simply endorsing the importance of social supports in their lives, participants in the present study also noted that their friends and family could provide them with a sense of purpose and meaning. Finally, participants in this study expressed the importance of faith as both a comfort and motivating factor; this has been less consistently observed in the literature.

The current study also provides important information about the relationship between positive psychological constructs and health behaviors. Specifically, participants described a bidirectional, reinforcing relationship between positive constructs and health behaviors, with pride, determination, and hope being the most prominent constructs involved. This relationship between positive constructs and health behaviors has not been identified in HF (Tierney et al., 2011) but is consistent with both qualitative and quantitative evidence in other populations. In quantitative studies, positive psychological constructs, such as optimism, are associated with physical activity, a healthy diet, and medication adherence (Boehm et al., 2018; Millstein et al., 2016; Trudel-Fitzgerald et al., 2019). Furthermore, in a qualitative research study of patients who had experienced an acute coronary syndrome, a similar reinforcing relationship between positive psychological constructs and engagement in health behaviors was observed (Huffman et al., 2016). This study extends these findings by identifying several specific positive psychological constructs – namely, optimism/hope, determination, accomplishment, and connectedness – that participants identified as being linked to health behavior adherence and by doing so in a new and important patient population.

The reinforcing relationship between positive psychological constructs and health behaviors is consistent with the broaden-and-build theory of positive emotions and upward spiral theory of lifestyle change (Fredrickson, 2004; Van Cappellen, Rice, Catalino, & Fredrickson, 2018). The broaden-and-build theory suggests that positive emotions (i) broaden one’s “thought-action repertoire”, which can increase one’s ability to adapt to challenges to health behaviors; and (ii) allow for the creation of resources to help achieve health behavior goals (Fredrickson, 2004). The upward spiral theory extends the broaden-and-build theory by noting that positive emotions experienced during health behavior performance can cause individuals to be unconsciously motivated to continue those health behaviors (Van Cappellen et al., 2018). In this study, some participants expressed positive feelings related to physical activity in particular, which could have served as a motivator to continuing to perform physical activity. Furthermore, consistent with the broaden-and-build theory, participants who noted that connectedness was associated with health behaviors may have found their family members or friends to be resources that helped them accomplish their goals.

These findings may have clinical implications for patients with HF. They suggest that enhancing positive constructs might help individuals with HF to engage in health behaviors, especially since many participants were experiencing a dearth of positive emotions in the context of their illness. An intervention that promotes engagement in health behaviors may have positive downstream effects, as adherence is associated with improved health outcomes in patients with HF (Arcand et al., 2011; O’Connor et al., 2009; Wu et al., 2008). One such approach to promoting positive constructs in HF patients could be through the use of positive psychology interventions, which aim to promote positive thoughts and feelings through systematic exercises, such as writing a gratitude letter (Seligman, Rashid, & Parks, 2006; Seligman, Steen, Park, & Peterson, 2005). Positive psychology interventions consistently reduce depression and improve well-being (Bolier et al., 2013), and a recent single-arm, proof-of-concept study found a positive psychology-based health behavior intervention to be feasible, acceptable, and associated with improvements in optimism, anxiety, and health behavior adherence in patients with HF (Celano, Freedman, Beale, Gomez-Bernal, & Huffman, 2018). Though controlled trials are needed, these results suggest that such interventions could be considered for use in patients with HF.

This study has several strengths. It is the first qualitative research study to focus on the positive emotional experiences of patients with HF and the links between positive constructs and health behavior adherence. The inclusion of interviews during acute and postacute phases of illness allowed us to examine participants’ emotional experiences when having different levels of clinical symptoms. Furthermore, the development of the qualitative interview guides and coding scheme with a qualitative research expert and the ongoing adjudication of differences in coding led to a high level of internal consistency. Finally, the relatively large sample size (N = 30) for a qualitative research study and repeated interviews allowed us to reach thematic saturation.

Despite these strengths, several limitations are notable as well. First, all patients were enrolled from inpatient medical or cardiac units in an academic medical center, a relatively high percentage of participants were White (73%) and female (77%), and the mean LVEF of the sample was high; these factors may limit generalizability. Furthermore, most participants had moderate to severe HF symptoms (70% with NYHA class III symptoms); it is possible that patients with milder HF symptoms may have a different experience. Third, this manuscript does not report on HF patients’ negative emotional experiences, which were substantial; however, these experiences – and their links to health behaviors – have been examined in detail in prior qualitative studies (Jeon et al., 2010; Yu et al., 2008). Fourth, the initial interview could be performed in person or by phone, which may have influenced topics about which participants were comfortable discussing. Additionally, only 61% of interviews were independently coded by two or more study staff, which could have increased the risk of bias. Finally, though we discussed both positive and negative psychological constructs in interviews, our interview guide’s prompts for positive psychological constructs may have increased the likelihood of finding connections between these constructs and health behaviors.

6 |. CONCLUSION

In sum, this study suggests that despite the limitations imposed by HF, many patients with significant HF symptoms experience gratitude, acceptance, and connectedness on a regular basis. Furthermore, some report a bidirectional, reinforcing relationship between positive psychological constructs and health behaviors. These findings suggest that developing interventions to promote both positive psychological constructs and health behaviors may have promise to improve mental health, adherence, and potentially prognosis in this population at high risk for poor psychological and cardiovascular outcomes.

7 |. RELEVANCE TO CLINICAL PRACTICE

Among patients with HF, positive psychological constructs are commonly experienced both during and after hospitalization, and many patients report a reinforcing relationship between these constructs and health behavior adherence. Healthcare providers should be sensitive to the presence of these constructs and work with patients to cultivate feelings of pride, determination, and hope. This has the potential to help patients engage in health behaviors and feel better both physically and emotionally.