REVIEW ARTICLE

Domains analyzed in the assessment of resilience in individuals with chronic cardiovascular diseases: a scoping review

Josiana Araujo de Oliveira1, Bruna Lins Rocha de Pádua1, Ricardo Gonçalves Cordeiro1, Denilson Campos de Albuquerque1

1 State University of Rio de Janeiro, RJ, Brazil

ABSTRACT

Objective: To map the scientific evidence on the instruments used to assess resilience in adult individuals with chronic cardiovascular disease, and explore their domains.  Method: A scoping review to meet the question: What are the instruments or questionnaires used to assess resilience in adult individuals with chronic cardiovascular disease? The search was conducted in LILACS, Scopus, Web of Science, Pubmed, CINAHL databases and the grey literature. Studies were uploaded to Mendeley and the selection was performed by two independent reviewers (Kappa=0.86).  Results: A total of 164 studies were identified and 14 were included; six instruments were used to assess resilience. The resilience assessment occurred in individuals with ischemic heart disease, myocardial infarction, stroke, and heart failure. Conclusion: The instruments were not adapted for use in individuals with chronic cardiovascular diseases. The development of specific instruments that include individual domains and consider the social context of these individuals is necessary.

Descriptors: Psychological resilience; Surveys and Questionnaires; Cardiovascular Diseases.

INTRODUCTION

Chronic noncommunicable diseases (NCDs) are the leading cause of death and disability worldwide. They include five major disease groups: cardiovascular, chronic respiratory, cancer, diabetes, mental, and neurological conditions, accounting for 63% worldwide. Chronic noncommunicable diseases represent 72% of the causes of death in Brazil, and cardiovascular diseases are the predominant cause(1).

Chronic health conditions are characterized by their irreversibility, residual disability, degenerative aspects and long duration, generating a crisis that disrupts the life of the patient/family, with restrictive daily activities, use of multiple medications, and uncomfortable symptoms, affecting the physical, emotional, economic, and social spheres(2,3).

Facing the stress of a chronic disease, some people manage to positively overcome the diversity of disorders caused by the disease, and remain adherent to treatment. This behavioral process may be related to resilience(4).

Research that addresses resilience can be classified into two generations: the first aims to identify risk and resiliency factors (1970s); the second is more comprehensive, where the emphasis permeates individual, social, and family factors (1990s). From this perspective, resilience is understood as a process and not as a personality feature(3).

Regarding the understanding of the construct of resilience, British and North American individuals understand it as hardiness on stress, while Latin American researchers have a perception of resilience that is seen either as hardiness on stress, or is associated with coping processes(5). The Latin American view has contributed significantly with studies on resilience in the last two decades, identifying the social context as a pillar where the possibilities of response to the problems of individuals facing adversities are created and developed(2,6). This review is based on the Latin American view, as we understand the great influence of the social context on resilient behaviors in patients with chronic cardiovascular diseases (CVD).

Although resilience is a complex construct with many origins and different emphases, there is a consensus around the term: resilience is related to active, dynamic movement in order to break the succession of immobilizing repetitions established by adversities and harms suffered(6).

Resilience is extremely valuable for the establishment of self-care behaviors and the consequent adherence to treatment in patients living with chronic diseases.  Resilience can contribute to dealing with chronic diseases with positive health outcomes(2,6).

Considering the relevance of the theme, the scoping review can contribute to the identification and analysis of instruments and domains used to assess resilience in individuals with chronic CVD, as well as to subsidize the identification of gaps on the subject.  The lack of specific instruments to measure resilience in individuals with chronic CVD limits the progress of scientific research, as they need to contain specific domains and attributes, clearly elucidating the concepts and attributes that characterize resilience in individuals with chronic CVD.

Therefore, the purpose of this study is to map the scientific evidence on the instruments used to assess resilience in adult individuals with chronic CVD, as well as to explore their domains.

METHOD

This was a scoping review based on the Joanna Briggs Institute (JBI) methodology(7). The protocol was registered in the Open Science Framework (OSF) with the link https://osf.io/9r5t8.

Studies conducted with adult individuals with chronic CVD of any type were included. The inclusion criteria for the studies were: primary studies available freely and in their entirety, published or not, with a quantitative or qualitative approach, in Portuguese, English, and Spanish languages, in individuals aged ≥18 years. The search was not filtered for date of publication. Studies in editorial format, letter to the editor, and duplicates were excluded.

To identify the studies, the search was conducted in the following databases from the online portal of Capes (Coordination for the Improvement of Higher Education Personnel), login through CAFe (Federated Academic Community): LILACS, MEDLINE/PubMed, Web of Science, SCOPUS, and CINAHL. In addition to these databases, a search was conducted in a Bank of Theses and Dissertations and in Google Scholar (gray literature). The search for studies in the databases occurred between the months of January and February of 2021. The Periodicals Portal, of the capes is a virtual library that gathers and makes available to Brazilian educational and research institutions the best of international scientific production login through CAFe (Federated Academic Community) allows access to wider range of publications available from the online portal of Capes.

The PCC (Population (or participants)/Concept/Context)) strategy was used to formulate the research question: "Which instruments or questionnaires are used to assess resilience in adult individuals with chronic cardiovascular disease?". After combining uncontrolled terms and descriptors, the search was performed with the search strategy: ((“psychological resilience” OR “resilience”) AND (“cardiovascular diseases”) AND (“surveys and questionnaires” OR “assessment”)).

The decision to use the term "cardiovascular disease" without relating it to the term "chronic" was because it restricted the results when the search was performed. The pre-selection of studies was performed by two independent doctoral students, with expertise in the care of patients with CVD, and disagreements were resolved by a third reviewer, also a doctoral student. The studies found were exported to Mendeley® software. The pre-selection and selection of studies was conducted in a simple blinded process.  

The eligible studies were mapped in a reflective and critical manner. Data were arranged and tabulated in a Microsoft Excel spread sheet. The stages of eligibility, data extraction, critical analysis, discussion, and conclusion were performed from March to June of 2021.

The methodological analysis of the studies was not evaluated, as this step is not required in scoping reviews, which aim to provide a mapping of what evidence has been produced rather than to seek the best available evidence to answer a specific question. However, for data extraction, we used the form recommended by the JBI(7), which was adapted for this study to facilitate the synthesis of information, that includes: authors, year of publication, country of origin, title, objective, sample, methodology (including the resilience measuring instrument used), intervention (if applicable), results, and main conclusions.

RESULTS

A total of 164 studies were found: two in LILACS, 74 in MEDLINE/PubMed, 29 in Web Of Science, 47 in SCOPUS, and seven in CINAHL. A search in theses and dissertations banks and in Google Scholar (gray literature) was performed, and five studies were identified. After reading the titles and abstracts, 17 studies were selected for reading and analysis, and 14 studies were included: 13 scientific articles and one dissertation.

Kappa index was performed between the two evaluators, with agreement of k=0.86 (p <0.0001; agreement of 93%). The selection of studies followed the recommendations of PRISMA-ScR(7) as shown in Figure 1:

Figure 1 - Flowchart of the search and eligibility of studies. Rio de Janeiro, RJ, Brazil, 2021

Source: Adapted from PRISMA-ScR, 2015.

The included studies were published between the years 2015 and 2020 in different countries, including eight (57%) cross-sectional studies. The countries that published the most were the United States and Brazil, with four and three studies, respectively. Not a single study presented as a primary or related subject the context of the pandemic of COVID-19, considering the devastating and lethal effects that occurred during the year 2020 (and until the present year, 2022) that would possibly influence resilience.

The characteristics of the included studies can be seen in Figure 2:

Figure 2 - Characteristics of the included studies. Rio de Janeiro, RJ, Brazil, 2021

Source: Developed by the authors, 2021.

In the studies included in this review, the assessment of resilience was analyzed in individuals with ischemic heart disease, myocardial infarction, stroke, and heart failure, and six resilience assessment instruments were identified, four adapted for use in Brazil: Wagnild & Young, CD-RISC, BRS, and DRS-15. All used self-report scales adopted a Likert-type response model (4-7 points), with variation in the number of questions (6-25). Figure 3 presents the domains and attributes of the instruments identified:

Figure 3 - Instruments used in the included studies. Rio de Janeiro, RJ, Brazil, 2021

Source: Developed by the authors, 2021.

DISCUSSION

Studies on resilience have increased in the last ten years nationally(8) and internationally(9), along with research that assesses resilience in individuals with chronic CVD.

The Strategic Action Plan for Tackling NCDs, proposed for the period of 2021 to 2030, aimed to develop and implement effective, integrated, sustainable, and scientific evidence-based public policies for the prevention and control of NCDs(10). Some studies have shown that psychological variables are potentially influential in the occurrence, maintenance, and recovery from CVD(3,11).

Assuming the concept of resilience (psychological variable), it must be analyzed critically, from the complexity of the phenomenon, comprehending its relationships and insertions, and not under an exclusively individual aspect. In the individualizing perspective, resilience has the status of an "entity", not linked to a process(6,8).

Older resilience assessment measures, such as the scales of Wagnild & Young (1993) and the CD-RISC (2003), instead of assessing resilience as the ability to recover from and adapt to stress, evaluated protective factors or resources that involve personal characteristics and coping styles(9,12). These instruments contain domains that clearly involve individual characteristics.

Two different categories that figure as fundamentally important components in resilience must be reflected on, but should not be confused with the concept of resilience: the risk factors (negative adaptation patterns) and the protective factors (positive adaptation patterns). Among the psychological risk factors for CVD is stress, which can lead to increased adrenaline, hemodynamic, neuroendocrine, and immunological changes. The psychological protective factors include the ability to adapt and resist to stressful situations, revealing resilience as a protective factor(2).

A systematic review(8) that aimed to understand how national researchers have evaluated resilience identified that 90% of the 31 studies included assessed constructs associated with, and/or underlying characteristics of resilience, and not the construct itself.

The DRS scale was developed in an attempt to measure dispositional resilience (resistance), that is, resilience as a personality trait(s). However, the authors themselves indicate a potential limitation of the scale by relating resilience to some personality traits, not understanding it as a dynamic process that is developed over a lifetime(13). Some criticisms involve the observation that scales that propose to evaluate resilience as a personality trait are not effective(9).

The BRS seems to have a singular place in behavioral medicine research, as it appears to be the only measure that specifically assesses resilience at its original: recovering from stress. When studying people who are already ill, assessing the specific ability to recover may be more important than assessing the capacity to resist illness, and in turn have a more direct relationship to positive health outcomes(12,14). In this review, three of the 14 included studies used the BRS; none of them were performed in Brazil(15-17).

The BRS adopts an outcome-oriented approach that defines resilience in terms of how well someone recovers from stress and is a six-question instrument that is quick to be answered(16). However, the BRS should contain questions considering support networks and not focused only on the individual, as can be seen in the questions that compose it: “Do I have a tendency to recover quickly after difficult times? Do I have difficulty coping with stressful events? Do I take a long time to recover from a stressful event? Is it difficult for me to react when something bad happens?  Do I usually go through difficult times with very few problems? Do I usually take a long time to overcome setbacks in my life?".

Recent studies are interested in individuals or groups that transcend the scope of coping with a stressful situation and are able to evolve and develop from it, in a movement of positive learning from the traumatic or adverse experience to which they are exposed(2,18). When dealing with a chronic disease, resilience can contribute to mitigating the negative impact of the physical, social, emotional, and economic consequences experienced. What do you want to use it for? Which group do you want to assess?(4)

A study evaluating markers of vulnerability in health of patients with heart failure (HF), showed three dimensions to which these individuals are exposed: Human person, Co-presences, and Care. The "Human Person" dimension includes: socioeconomic and demographic status, clinical profile, learning, health behaviors, and mental health. The "Co-presences" dimension includes social support and family bonds. The "care" dimension includes health technologies, costs, and health services(19). Such studies are essential to identifying variables that may influence treatment adherence and quality of life.

The constitutive and operational definitions of the "Co-Presence" markers regarding social support must include the instrumental, emotional, informational, and autonomy support needs of the patient. And, when reflecting on family support, the family relationships, monitoring, and family functioning must be accounted for. In addition, mental health variables such as disease acceptance, beliefs about treatment, and dispositional optimism are fundamental markers for treatment evaluation(19).

Recent studies indicate that married patients with HF present a better emotional state when facing the disease(20,21), while earlier studies(22,23), state that the sources of support can be people living close to the HF patient, whether or not they live with him.

Many times, patients with HF need care for activities of daily living, and it is essential to have someone close to them most of the time, in this case the spouse. This care is related to physical impairment (fatigue, dyspnea), resulting in the loss of self-care and self-esteem, producing uncomfortable feelings such as embarrassment, feelings of worthlessness, and sadness. The level of resilience can be affected depending on the existing support network.

This review showed that most studies assessing resilience in individuals with CVD are recent, but still consider instruments with domains that do not corroborate the currently accepted concept of resilience(2, 24-33).

A methodological review study of resilience scales reviewed 15 measurement instruments. Among the instruments used, the Wagnild & Young, CD-RISC, and BRS scales received better psychometric evaluations, however, the conceptual and theoretical adequacy was questionable. The findings showed that no current "gold standard" exists for resilience measures(34).  

As resilience is a construct under development, both nationally and internationally, few instruments that assess resilience related specifically to chronic diseases are available.

CONCLUSION

Six resilience assessment instruments were identified in this review, four of them validated for use in Brazil, none of them specific for assessment of resilience in chronic diseases. These instruments have varied domains and attributes, however, there is no doubt that all of them address issues about coping with stressful situations via individual characteristics.  

Measurement instruments that assess the construct itself, with good psychometric analysis, and that consider the vulnerabilities to which patients with CVD are exposed, their social context, and how they cope with stressful situations, seems to be a promising approach for assessment of resilience in an expanded and specific manner for positive health outcomes.

We believe that these findings will contribute to the scientific community that provides care to individuals with chronic CVD, by assessing and considering this variable of great importance for coping with the disease. This study will support the development of a specific instrument to assess resilience in individuals with HF, a chronic CVD that is the final pathway for most of these diseases.

ACKNOWLEDGMENTS

We thank Dr. Ricardo Mourilhe for his collaboration on the conceptual basis of this study.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

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Submission: 08/12/2021

Approved: 02/15/2022