What influences physical activity in people with heart failure? A qualitative study

doi:10.1016/j.ijnurstu.2011.03.003

International Journal of Nursing Studies

Volume 48, Issue 10, October 2011, Pages 1234-1243

https://doi.org/10.1016/j.ijnurstu.2011.03.003 Get rights and content

Abstract

Background

Research has highlighted the benefits of physical activity for people with stable heart failure in improving morbidity and quality of life. However, adherence to exercise among this patient group is low. Barriers and enablers to sustained physical activity for individuals with heart failure have been little investigated.

Objectives

To explore reasons why people with heart failure do and do not engage in regular physical activity.

Design

A qualitative, interview-based investigation.

Settings

Three heart failure clinics held at hospitals in the UK.

Participants

Purposive sampling was adopted to provide maximum variation in terms of gender, age, heart failure duration and severity, and current activity levels. Twenty two patients (7 = female) were interviewed, aged between 53 and 82 years.

Methods

Semi-structured interviews were conducted via telephone. These were recorded and transcribed verbatim. Framework analysis was applied to collected data.

Results

Interviewees’ narratives suggested that adopting positive health behaviours was complex, affected by internal and external factors. This was reflected in the four themes identified during analysis: fluctuating health; mental outlook; others’ expectations; environmental influences. Failure to exercise arose because of symptoms, co-morbidities, poor sense of self as active and/or lack of perceived benefit. Likewise, encouragement from others and inclement weather affected exercising.

Conclusions

Areas identified during interviews as influencing activity levels relate to those commonly found in behavioural change theories, namely perceived costs and benefits, self-efficacy and social support. These are concepts that practitioners may consider when devising interventions to assist patients with heart failure in undertaking and maintaining regular exercise patterns.

Section snippets

Background

Heart failure is a chronic syndrome that can result from multiple cardiovascular diseases and conditions. Its prevalence and incidence is on the rise due to an ageing population and increased survival from ischaemic and other heart diseases (Dickstein et al., 2008). Despite improvements in treatment, heart failure is a frequent cause of hospitalisation, as reported in a range of international studies (Ham et al., 2003, Teng et al., 2010), with admissions contributing substantially to the cost

Aims

The study set out to explore reasons why people with heart failure do and do not engage in regular physical activity by investigating patients’ views of exercise or keeping active as part of their condition's self-management. Specific objectives included: (1) understanding patients’ beliefs about exercise or keeping active and how these relate to beliefs about their condition; (2) investigating preferences among those with heart failure in relation to exercise or keeping active for management

Methods

Design: Qualitative research was undertaken to address the aims listed above. This type of investigation strives “to understand and represent the experiences and actions of people as they encounter, engage, and live through situations” (Elliot et al., 1999, p. 216). Qualitative research is inductive, rather than testing pre-determined hypotheses (Allender et al., 2006), allowing for an in-depth understanding of the experiences and meanings individuals attach to a phenomenon (Sim and Wright, 2000

Results

Between January and April 2010, 22 interviews were conducted. They lasted for approximately 45 min each (range 35–65 min). All interviewees self-defined as White British. Most (n = 19) had retired when data were collected, due to age or ill health. Seven had an implantable cardioverter defibrillator. Other background details, from medical records, are listed in Table 2.

No one factor explained patients’ willingness to undertake exercise; cognitive and emotional responses played a role, as did

Discussion

This study is the first using a qualitative design that has centred on the views of patients with heart failure about adherence to physical activity, which should form part of self-management. Internal and external factors shaped interviewees’ perceptions of and approach to exercise (see Diagram 1), and acted as barriers or enablers to this behaviour. Information outlined above, relating to the themes identified during analysis, is summarised in Table 3, which highlights areas to be considered

Implications for practice

Several interviewees described receiving information on exercise when first diagnosed, but this may not be the optimum moment to prompt such behaviour because individuals will have to take on board their changed status as someone with heart failure. In contrast, broaching the topic of exercise post-diagnosis, at regular intervals with patients, may help raise the profile of this component of self-care, highlighting its role alongside rather than as a subsidiary to medication. It should be noted

Strengths and weaknesses

The study was explorative and largely descriptive but gives an insight into the topic from patients’ perspective. Results do not allow for inferential generalisability, given the small sample size. However, it should be noted that qualitative research is concerned with information richness and on exploring ideas arising from data rather than establishing their prevalence and in that sense can be seen as idiographic (seeking to report on a small group of cases) in its aim to provide meaningful

Conclusion

A range of emotional and cognitive responses to physical activity were clear in interviews, but participants’ exercise behaviours could also be influenced by external forces, such as the weather and social support. Encouragement from healthcare professionals, whereby activity levels are discussed as a matter of course during heart failure appointments, could prove beneficial in promoting exercise as part of self-care. This may help with increasing self-efficacy, developing a sense of self as

Acknowledgements

The authors would like to thank the following practitioners who assisted with recruitment: Susie Bowell, Kath Coezy, Dr Anne Cooper, Teresa Coppinger, Jennifer Gow and Carolyn Waywell.

Conflict of interest: None declared.

Funding: This project was funded by the Greater Manchester Collaborative Leadership in Applied Health Research and Care (CLAHRC) flexibility and sustainability funding. The work was supported by the Manchester Academic Health Sciences Centre, and the NIHR Manchester Biomedical

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Patients with chronic heart failure often experience symptoms during physical activity, such as shortness of breath and tachycardia, which may result in fear of physical activity (FoPA). This study tested whether interoception (i.e., the perception of body sensations) and symptom distress (i.e., negative appraisal of symptoms) are associated with FoPA in outpatients with chronic heart failure.
FoPA was assessed with the Fear of Activities in Situations (FActS) in patients with diagnosed heart failure and healthy controls. A heartbeat tracking task and self-reports were used to assess interoceptive accuracy and interoceptive attention in patients and controls. Heart failure-related distress was assessed using ratings of symptom and treatment burden in patients. Multiple regression models were calculated to determine associations with continuous FoPA scores.
Patients with low FoPA perceived their heartbeats more accurately than patients with high FoPA and healthy controls. Interoceptive accuracy and symptom distress explained almost half of the variance in FoPA, after adjustments for sex and disease severity, in patients with heart failure.
In patients inaccurate interoception and symptom distress were associated with high FoPA, independent of heart failure severity. The perception and appraisal of cardiac arousal and symptoms during physical activity deserve further attention to develop interventions to reduce FoPA in patients with heart failure.
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A sedentary lifestyle is prevalent among patients with heart failure (HF) and is associated with poor prognosis and survival, possibly owing to the displacement of health-enhancing behaviors, such as physical activity (PA). However, there is limited evidence examining the displacement effects of reducing duration of sedentary time (ST) on clinical outcomes in patients with HF. The current study examined the theoretical effects of relocating ST with PA on all-cause and cardiovascular disease (CVD)-specific mortality risks in patients with HF. We analyzed 265 patients with HF who participated in the National Health and Nutrition Examination Survey from 2003 to 2006. Cox proportional hazards regression model was fitted to estimate mortality risks based on objectively measured ST well as time spent in light-intensity PA (LPA) and moderate- and vigorous-intensity PA (MVPA). The theoretical changes in the hazard ratio (HR) by replacing ST with LPA or MVPA were examined using isotemporal substitutional modeling. On average, patients with HF spent 70% of waking hours per day in ST (9.01 hours), followed by LPA (29%; 3.75 hours) and MVPA (1%; 0.13 hours). Ten-minute substitution of ST with LPA was associated with significantly lower all-cause and CVD-specific mortality risks (hazard ratio [HR]=0.93 for both). The mortality risks progressively decreased as more ST was relocated to LPA. The relocation effects of ST with MVPA were not statistically significant, possibly because of limited MVPA accrued in this clinical population. The current study provides empirical evidence about the potential health benefits of replacing a modest amount of ST with LPA among patients with HF.
Dynamic factor analysis of seasonal variation in daily physical activity in individuals with heart failure and implanted cardiac devices
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The purpose of the present study was to determine the presence and magnitude of seasonal variation in daily physical activity (PA) in those with heart failure (HF).
Retrospective study and dynamic factor analysis (DFA) of Patient Activity data from Medtronic implanted cardioverter defibrillator and cardiac resynchronization devices (ICD/CRTs).
In a data set of 435 patients, distinct states/trends were identified by DFA including a classic, sinusoidal pattern of seasonal variation and a pattern of decline over the course of 12 months, which were associated with specific clinical characteristics. Overall, model fitting was good.
Those with low comorbidities, better NYHA Class, higher BMI, no hospitalization, and male sex demonstrated greater seasonal variation of at least 40 min per day between winter (lowest PA) and spring/summer (highest PA). Those with female sex and hospitalization demonstrated overall downward trajectories of approximately 40 and 80 min, respectively, over the course of the year.
Modulation of startle and heart rate responses by fear of physical activity in patients with heart failure and in healthy adults
2020, Physiology and Behavior
Citation Excerpt :
The pathophysiological syndrome is defined by reduced cardiac output or elevated intra-cardiac pressure, and characterized by symptoms such as breathlessness on exertion, reduced exercise tolerance, and increased time to recover after exercise [3]. Although heart failure treatment guidelines strongly recommend regular exercise to improve exercise capacity in terms of peak oxygen consumption and cardiac output [3], there is a lack of interventions that focus on psychological barriers to physical activity in those patients who show low adherence to exercise regimens due to symptom burden [4,5]. Differences between patients’ strategies to emotionally cope with heart failure might contribute to either low or high levels of physical activity, as suggested by interview data [6]: Patients who reported to be physically active used disavowal of emotional strain as a coping strategy, whereas patients who showed low adherence to treatments used avoidance of unfavorable situations as a maladaptive coping strategy to reduce affective arousal due to anxiety.
Fear of physical activity (FoPA) has been suggested as a barrier to physical activity in patients with heart failure and might be associated with low adherence to exercise regimen despite medical guideline recommendations. The present study examined physiological indicators of FoPA by assessing startle modulation (via EMG at the orbicularis oculi muscle) and heart rate responses (derived from ECG) after affective priming with lexical stimuli of positive, neutral, and negative valence, as well as words related to physical activity as potentially phobic cues. After screening for FoPA in patients with heart failure and healthy adults, twenty participants each were assigned to one of three subsamples: a healthy control group and two cardiac patient groups scoring either low or high on FoPA. The high-FoPA group showed startle potentiation and more pronounced heart rate acceleration (than did controls) in the phobic prime condition, indicating defensive response mobilization. Among the patients, higher FoPA accounted for 30% of the startle potentiation by phobic priming, whereas general anxiety, depression, and disease severity were no significant predictors of startle modulation. These findings suggest that FoPA in patients with heart failure is associated with defensive responses on a physiological level that might be indicative of avoidance behavior, thereby contributing to low adherence to exercise regimen. Thus, FoPA presents a significant target for psychological interventions to foster physical activity in cardiac patients.
Decline in physical activity in the weeks preceding sustained ventricular arrhythmia in women
2020, Heart Rhythm O2
Heightened risk of cardiac arrest following physical exertion has been reported. Among patients with an implantable defibrillator, an appropriate shock for sustained ventricular arrhythmia was preceded by a retrospective self-report of engaging in mild-to-moderate physical activity. Previous studies evaluating the relationship between activity and sudden cardiac arrest lacked an objective measure of physical activity and women were often underrepresented.
To determine the relationship between physical activity, recorded by accelerometer in a wearable cardioverter-defibrillator (WCD), and sustained ventricular arrhythmia among female patients.
A dataset of female adult patients prescribed a WCD for a diagnosis of myocardial infarction or dilated cardiomyopathy was compiled from a commercial database. Curve estimation, to include linear and nonlinear interpolation, was applied to physical activity as a function of time (days before arrhythmia).
Among women who received an appropriate WCD shock for sustained ventricular arrhythmia (N = 120), a quadratic relationship between time and activity was present prior to shock. Physical activity increased starting at the beginning of the 30-day period up until day -16 (16 days before the ventricular arrhythmia) when activity begins to decline.
For patients who received treatment for sustained ventricular arrhythmia, a decline in physical activity was found during the 2 weeks preceding the arrhythmic event. Device monitoring for a sustained decline in physical activity may be useful to identify patients at near-term risk of a cardiac arrest.
The effects of physical activity and sedentary behavior in the associations between cardiovascular diseases and depression: A four-way decomposition
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Negative effects of cardiovascular diseases (CVDs) on depression have been reported, but the relative contribution of physical activity (PA) and sedentary behavior (SB) to such effects remains unclear. Our objective was to precisely quantify the effects modified or mediated by PA and SB using the recently developed four-way effect decomposition.
Our analysis included 22,117 adults (aged≥20 years) participating in the 2007–2016 National Health and Nutrition Examination Survey (NHANES). Depression was assessed by the Patient Health Questionnaire-9. Moderate recreational activity (MRA), moderate work activity (MWA), and walk or bicycle for transportation, were measured by the Global Physical Activity Questionnaire (GPAQ). A four-way decomposition was applied with PA and SB as mediator to decompose the total effects of CVDs on depression into four components: controlled direct effect (CDE), pure indirect effect (PIE), reference interaction (INT_ref), and mediated interaction effect (INT_med).
There were statistically significant associations between CVDs, MRA, and depression, with the adjusted odds ratios (95% confidence intervals) of being 1.73 (1.42~2.30), 1.81 (1.42~2.30), respectively. With MRA as a mediator, there were interaction and mediation effects in the associations between CVDs and depression, and the proportions attributable of INT_ref, INT_med, and PIE were 94.08% (P<0.001), 3.92% (P = 0.007), and 1.68% (P = 0.006), respectively. Furthermore, the mediation effect was statistically significant in females rather than males.
MRA strongly modified and mediated the effects of CVDs on depression, especially in females. Our results suggested that sufficient MRA (at least 150 min per week) was considered as requirement for preventing depression in CVDs patients in females.

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View full text

What influences physical activity in people with heart failure? A qualitative study

Abstract

Background

Objectives

Design

Settings

Participants

Methods

Results

Conclusions

Section snippets

Background

Aims

Methods

Results

Discussion

Implications for practice

Strengths and weaknesses

Conclusion

Acknowledgements

Ten tips for reflexive bracketing

Qualitative Health Research

Tools for physical activity counseling in medical practice

Obesity Research

Understanding participation in sport and physical activity among children and adults: a review of qualitative studies

Health Education Research: Theory and Practice

Self-Efficacy: The Exercise of Control

Beliefs about medication and dietary compliance in people with heart failure: an instrument development study

Heart and Lung

An Everyday Guide to Living with Heart Failure

A realist study of the mechanisms of cardiac rehabilitation

Journal of Advanced Nursing

Effects of a home-walking exercise program on functional status and symptoms in heart failure

American Heart Journal

Physical activity programs and behavior counseling in older adult populations

Medicine and Science in Sports and Exercise

Exercise based rehabilitation for heart failure

Cochrane Database of Systematic Reviews

ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008

European Heart Journal

Evolving guidelines for publication of qualitative research studies in psychology and related fields

British Journal of Clinical Psychology

Experience from controlled trials of physical training in chronic heart failure: protocol and patient factors in effectiveness in the improvement in exercise tolerance

European Heart Journal

Metacognition in action: the importance of implementation intentions

Personality and Social Psychology Review

Implementation intentions and goal achievement: a meta-analysis of effects and processes

Advances in Experimental Social Psychology

Hospital bed utilisation in the NHS, Kaiser Permanente and the US Medicare programme: Analysis of routine data

British Medical Journal

Gender differences in social cognitive determinants of exercise adoption

Psychology and Health

A story of maladies, misconceptions and mishaps: effective management of heart failure

Social Science and Medicine

A dose–response analysis of patients with heart failure enrolled in A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION)

Clinical role of exercise training in the management of patients with chronic heart failure

Journal of Cardiopulmonary Rehabilitation and Prevention

Self-efficacy and the stages of exercise behavior change

Research Quarterly for Exercise and Sport

Combining motivational and volitional interventions to promote exercise participation: protection motivation theory and implementation intentions

British Journal of Health Psychology

Chronic Heart Failure: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care

Factors influencing knowledge of and adherence to self-care among patients with heart failure

Archives of Internal Medicine

Participants’ perspective on maintaining behaviour change: a qualitative study within the European Diabetes Prevention Study

BMC: Public Health

Correlates of exercise among coronary heart disease patients: review, implications and future directions

Journal of Cardiovascular Prevention and Rehabilitation

Cardiac rehabilitation in heart failure: a brief review and recommendations

Current Cardiology Reports