Background
Chronic heart failure(CHF) is one of the most common heart diseases affecting approximately 23 million people worldwide, and an additional 2 million individuals are added to this population annually [1]. According to the latest report from the World Health Organization (WHO), cardiovascular diseases claim 17.9 million lives annually worldwide, constituting 32% of the total global deaths [2]. In Iran, heart failure may account for 46% of all mortalities and contribute to 20 to 23% of the disease burden [3].
Heart failure leads to a variety of physical symptoms, and these physical challenges can pave the way for various psychosocial difficulties, including a decrease in patients’ resilience and sense of well-being [4, 5]. Well-being, defined as a mental awareness and a general judgment, is categorized into external well-being (stemming from income, work, society and government, values, and religion) and personal well-being (stemming from mental and physical health, family experiences, education, gender, and age) [6]. Having higher levels of well-being can lead to improved psychological resilience, enabling individuals to cope better with life challenges such as illness [7].
For many heart patients, especially those with CHF, initiating behavioral changes and lifestyle modifications can be challenging. These adjustments, although recommended by physicians, are often difficult to maintain. Frequently, such lifestyle changes lead to a decrease in well-being and optimism, which can result in negative outcomes like an increased risk of depression [8, 9].
Reduced levels of well-being can result in increased levels of stress in patients [10]. The results of a study by Howell et al. indicated that patients with cardiovascular diseases who had higher levels of well-being and optimism showed higher levels of improvement and survival compared to other patients and experienced better outcomes following treatment [11]. Given the importance of well-being in patients with heart failure, it is necessary to plan and implement interventions for them.
In this regard, recent research indicates the impact of positive psychology approaches on enhancing psychological health and well-being [12].
Positive psychology is a new movement that emphasizes the need to understand the positive aspects of human experience and the things that give value to their lives. What this approach essentially conveys is that each of us possesses an inner wisdom that guides our lives in the best possible way [13]. Positivity refers to an individual’s tendency to observe life and its experiences from a positive perspective.
This approach aims not only to alleviate disease symptoms but also to improve the quality of patients’ lives [14]. Positive individuals, using problem-focused coping strategies, deal with psychological stresses and tensions more effectively and efficiently, and most of the time, they are happier and healthier [15].
According to previous studies, positive interventions in heart failure patients have been effective in promoting health behaviors, improving psychological well-being [16], resilience, anxiety, depression [17], mental health, and quality of life [18], and adaptive stress coping skills [19]. However, some studies have reported conflicting results in this area [12, 20]. Seligman et al.
(2016) suggested a study in the cardiovascular field to examine the influence of a positive psychology skill enhancement program in clinical settings, considering the prevalence of cardiovascular diseases and their significance for health policies [21]. Despite the emphasis on these issues, few quantitative studies have been conducted focusing on patients with CHF [22], and a study specifically evaluating the impact of a positive psychology skill enhancement program on the sense of happiness in patients with CHF was not found. Given the crucial role of emotions and thoughts in the quality of life, as well as in the continued path of treatment and self-care for chronic and progressive heart failure, it seems essential to pay closer attention to the psychological issues of these patients.
One of the responsibilities of nurses during the hospitalization of patients is to attend to their psychological well-being. Furthermore, compared to other healthcare professionals, nurses have more opportunities for direct patient contact, thus they can utilize psychological techniques to enhance the psychological well-being of patients using scientific evidence [23].
Objectives
This study aimed to evaluate the effect of a positive psychology skill enhancement program on the sense of well-being in patients with CHF.
Methods
Trial design
This study was a randomized controlled trial conducted to evaluate the impact of a positive psychology skill enhancement program on well-being in patients with CHF.
Setting
The trial was conducted at Chamran Medical Center, Isfahan, Iran.
Participants
The research population consisted of all patients admitted to the cardiac care units of Chamran Medical Center in Isfahan, Central Iran, from February 2023 to July 2023.
Eligibility criteria
Inclusion criteria for the study involved being between 35 and 70 years of age(this age range typically encompasses adults who are at increased risk for CHF while also likely to benefit from psychological interventions aimed at improving well-being), Diagnosed with CHF for at least one year, Ability to read, write, and speak in Persian, No prior participation in similar educational or therapeutic programs, absence of severe stressors (e.g., recent divorce or loss of a loved one) within the last six months, no diagnosed mental or cognitive impairments that could impact learning and participation in the program and Willingness to participate in the study. Exclusion Criteria involved development of severe physical or psychological complications during the study period, Experience of significant new stressful events after study enrollment, absence from two or more educational sessions and Withdrawal of consent to continue participation.
Sample size
Sample size calculation based on the formula
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, and with reference to Asareh Zadegan [24],\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\:\:{\boldsymbol{Z}}_{1-\frac{\boldsymbol{\alpha\:}}{2}}:1.96$$\end{document},\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\:\:{\boldsymbol{Z}}_{1-\boldsymbol{\beta\:}}:.84$$\end{document}, S1:6.50, S2:4.50 and d:3.74 with 95% confidence and 80% power, resulted in a required sample size of 35 individuals per each group.
Randomization
The samples were selected through convenient sampling from among the patients admitted to the inpatient wards of Chamran Hospital who met the study criteria. Subsequently, The randomization list was generated by an independent statistician who was not involved in any other part of the study. This list was created using a computer-generated random number sequence to ensure unbiased allocation.
To maintain allocation concealment, the randomization sequence was placed in sealed, opaque envelopes, each labeled with only the participant number. These envelopes were sequentially opened by a research assistant, who assigned participants to either the intervention or control group based on the predetermined sequence. The research assistant was not involved in delivering the intervention or in data collection, thereby minimizing the risk of bias.
Outcomes
The primary outcome was the sense of well-being, measured using the Oxford Happiness Inventory(OHI) at three time points: baseline, immediately post-intervention, and one month later.The OHI was developed by Argyle et al., incorporating 21 items from the Beck Depression Inventory, reversed and added with eleven questions to cover other aspects of mental health, covering satisfaction, positive mood, well-being, efficiency, and self-esteem aspects. Scoring of this questionnaire is based on a 4-point Likert scale (not at all: score 0, a little: score 1, much: score 2, very much: score 3), with scores ranging from 0 to 87, where higher scores indicate greater levels of happiness [25]. Arayeigl et al., confirmed the reliability of this questionnaire with a Cronbach’s alpha coefficient of 0.90 and 0.87 using Fahrenheit and Breen’s methods, respectively [26, 27].
Alipour and Noorbala conducted a formal validity and reliability assessment of this questionnaire in Iran, reporting a Cronbach’s alpha coefficient of 0.93 [28].
Ethical approval
For the study was obtained from the Ethics Committee of Isfahan University of Medical Sciences, with the study registered under code IRCT20180601039934N2. The study objectives and procedures were communicated to Chamran Medical Center, and institutional cooperation was secured prior to patient recruitment. After providing necessary explanations about the goals and stages of this study and obtaining written informed consent from the patients, they were randomly assigned to the control and intervention groups.
Then, patients in both groups completed a demographic information form and the OHI in a self-report manner.
Interventions
The intervention was a positive psychology skill enhancement program delivered over six sessions, each lasting 45 to 60 min. Sessions were conducted by a trained psychiatric nurse with expertise in positive psychology. The sessions were arranged consecutively, with one session per day, allowing participants to engage in the program without significant delays between lessons.
The positive psychology skills covered in each session included introduction to positivity, cognitive restructuring and managing negative thoughts, gratitude practices, building hope and optimism, enhancing enjoyable experiences and social connections, review and integration (Table 1).
Table 1The content of the sessions based on the positive psychology skillenhancement programSessionContent HomeworkAssignment1Welcoming, introduction, and acquaintance with the program and the researcherIntroduction to the group and the regulations governing itFamiliarity with the concept of CHFIntroduction to the concept of positivity Conduct a pre-testTake note of at least two of your thoughts (positive or negative) during the day2Review of the previous session and assignmentsFamiliarity with the formation of thoughts and emotionsFamiliarity with negative and irrational thoughts and ways to moderate themTeaching positivity by challenging negative thoughtsEliminating negative thoughts from lifePositive thinking and its effect on people’s health and longevityRecord one instance of your cognitive distortions and then replace it with a more balanced thought3Review of the previous session and assignmentsFamiliarity with the concept of gratitudeEmphasis on good memories and appreciationWrite down three good things you are grateful for and share with someoneFind something to appreciate or admire during the day and share it with your favorite person, then write it down4Review of the previous session and assignmentsFamiliarity with the concept of hopeFamiliarity with the concept of optimismShare at least one of your successes with others5Review of the previous session and assignmentsEnjoyable lifeSharing enjoyable experiences with othersCreating memoriesCongratulations to yourselfWrite about a pleasurable activity in your life that you shared with someone this week6Review of the previous session and assignmentsSummary of the topics discussed in previous sessionsConduct a post-test AppreciationPresentation of gifts to the participants
The educational content included a formal curriculum based on Seligman et al. [29] and approved by five faculty members in the Department of Psychiatry at the Isfahan School of Nursing. This content was integrated into the intervention to help participants understand the theoretical basis of positive psychology skills, enhancing their engagement and application of these techniques. The intervention primarily focused on enhancing psychological skills, including cognitive restructuring, gratitude, and optimism exercises, without incorporating additional disease-specific self-management education.
Blinding
The intervener was aware of group allocation as they were responsible for delivering the intervention. However, to reduce bias, the outcome assessors -those collecting data and administering assessments- were blinded to group allocation. Additionally, all statistical analyses were conducted by a separate statistician who did not participate in the intervention or data collection.
If a patient was discharged within less than 6 days, they were given access to the session content via virtual space, and if the patient did not have access to virtual space, a time was arranged to conduct the training with the patient. Immediately after the completion of the intervention and one month later, patients from both groups completed the OHI. To ensure the ethical conduct of the research, after the study was completed, an educational booklet containing all the training given to the intervention group was provided to the control group patients as well.
Statistical methods
Data analysis was performed using SPSS22 (SPSS Inc., Chicago, IL, USA). To analyze the variables, initially, the normality of the data between the intervention and control groups was assessed using the Kolmogorov-Smirnov test, and then evaluated by the independent t-test and Fisher’s exact test. Additionally, statistical tests, including repeated measures ANOVA and one-way ANOVA, were used to compare changes in the mean happiness scores between and within groups, with a significance level of p < 0.05 interpreted as a significant difference.
Results
Participant flow
A total of 96 patients were assessed for eligibility, with 78 randomized (39 intervention, 39 control). Flow details are illustrated in the CONSORT flow diagram (Fig. 1).
Fig. 1CONSORT Flow Diagram
Baseline characteristics
Baseline characteristics were comparable between groups (Table 2). The results showed that the mean and standard deviation of the patients’ age in the control and intervention groups were 93.8 ± 56.58 and 02.12 ± 86.53 years, respectively. There was no statistically significant difference in the demographic information between the two groups (p > 0.05).
Table 2Comparison of participants’ demographic characteristics in two groupsVariable under studyControl groupIntervention groupThe results of the intergroup comparisonMean ± SDMean ± SDAge(years)58.56 ± 8.9353.86 ± 12.02*p=0.58Variable under studyNumber (percent)Number (percent)The results of the intergroup comparisonGenderFemale13 (36.1) 14(38.9)**p=0.808Male23 (63.9)22 (61.6) Marital statusMarried30 (83.3) 26(72.7) **p= 0.576Single3 (8.3))5 (13.9)Divorced0 (0)2 (5.56)widow3 (8.3)3 (8.3)OccupationEmployee10 (27.8) 5 (13.9)**p=0.374Unemployed5(13.9)3 (8.3)Retired7 (19.4)12 (33.3)housewife13(36.1)13 (36.1)Laid off(2.8)3 (8.3)Education levelBelow diploma26(72.2)18 (50)**p=0.133 Diploma5 (13.9)11 (30.6)University5(13.9)7 (19.4)Income statusLess than living expenses29(82.9)32 (88.9) *p=0.602Equal to living expenses5(14.3)4(11.1)More than living expenses1(2.8)0(0)Place of residenceCity28(77.8)29(80.6)**p=0.772 Village8 (22.2)7 (19.4)Care at homespouse25(69.4)25(69.4)**p=0.9240 Son2 (5.6)1(2.8)Daughter5(3.9)5(3.9)Sister1(2.8)0(0)Mother2 (5.6)4(11.1)No one1(2.8)1(2.8)*T-test **Fisher’s test
Outcomes
As seen in Table 3, the mean score of happiness between the intervention and control groups before the intervention did not show a statistically significant difference (intervention: 51.8 ± 68.30 and control: 02.10 ± 41.31). The mean score of happiness in the intervention group immediately and one month after the intervention was 31.5 ± 06.53 and 80.6 ± 35.44, respectively. In the control group, the mean score of happiness immediately after the intervention was 91.8 ± 21.31 and one month after the intervention was 99.8 ± 30.30.
The results indicated a significant increase in the mean score of happiness among the patients in the intervention group from before to one month after the intervention, while no significant increase was observed in the mean score of happiness from before to one month after the intervention in the control group. Furthermore, the results regarding the dimensions of happiness also showed a significant improvement in the mean score in all dimensions (p < 0.001) except for the self-efficacy dimension (p = 0.168) in the periods from before to one month after the intervention.
Table 3Comparison of the mean score of the happiness dimensions across two groups before, immediately, and 1 month after the interventionDimensions of happinessGroupBefore the interventionAfter the interventionOne month after the interventionResult of the effect of time in each of the groups *Result of the simultaneous effect of the treatment group and timeMean ± SDMean ± SDMean ± SDLife satisfactionControl2.94 ± 8.752.74 ±8.33 2.85 ± 8.47 < 0.001< 0.001Intervention2.80 ± 8.421.48 ± 14.83 1.66 ± 12.53Result of group comparisons at independent times< 0.001< 0.001< 0.001EnjoymentControl3.08 ± 8.532.67 ± 8.75 2.20 ± 6.69< 0.001< 0.001Intervention 2.48 ± 8.531.83 ± 15.422.06 ± 10.86Result of group comparisons at independent times< 0.001< 0.001< 0.001Self-confidenceControl2.00 ± 5.641.73 ± 5.531.78 ± 5.39< 0.001< 0.001Intervention1.57 ± 5.611.09 ± 8.721.08 ± 7.58Result of group comparisons at independent times< 0.001< 0.001< 0.001CalmnessControl1.81 ± 3.611.44 ± 3.83 1.34 ± 3.50< 0.001< 0.001Intervention1.79 ± 3.921.40 ± 5.25 1.41 ± 4.72Result of group comparisons at independent times0.0040.0040.004ControlControl2.05 ± 3.601.80 ± 3.51 1.77 ± 3.23< 0.001< 0.001Intervention1.77 ± 3.631.27 ± 7.51 1.46 ± 5.74Result of group comparisons at independent times< 0.001< 0.001< 0.001Self-efficacyControl0.71 ± 0.89 0.65 ± 0.970.64 ± 0.86< 0.001< 0.001Intervention0.60 ± 0.77 0.61 ± 1.43 0.51 ± 1.09Result of group comparisons at independent times0.1680.1680.168Total happiness sensation scoreControl10.02 ± 31.41 8.91 ± 31.21 8.99 ± 30.30< 0.001< 0.001Intervention8.51 ± 30.68 5.31 ± 53.06 6.80 ± 44.35Result of group comparisons at independent times0.128< 0.001< 0.001Analysis of variance test with repeated measurements
According to Table 4, it can be seen that there is a significant difference between the control and test groups in happiness (p < 0.05). The results of analysis of variance with repeated measurements show that the average score of happiness in 3 times before, immediately after and One month after the intervention has a significant difference (p < 0.05). Also the significance level of the effect of group membership in time is less than 0.05.
This means that the treatment plan has a significant difference on the average happiness score in the three times of before, after and One month after the intervention group (p < 0.05).
Table 4Analysis of variance with repeated measures on happinessSourceSum of squaresDegrees of freedomMean squareFP-valueEtaStatistical powerwithin grouptime4196.7451.5712671.168295.392< 0.0010.8171.00time*group4497.5691.5712862.638616.566< 0.0010.8271.00error937.686103.69443.9Between groupgroup7117.7700.17117.77037.551< 0.0010.3631.00error12510.16766.001989.548Analysis of variance test
The repeated measures ANOVA showed a statistically significant interaction between time and group membership (F = 616.57, p < 0.001, η² = 0.827), indicating that changes in well-being scores differed between the intervention and control groups over the three time points. In the intervention group, the mean well-being score increased significantly from baseline (M = 30.68, SD = 8.51) to immediately after the intervention (M = 53.06, SD = 5.31) and was sustained one month later (M = 44.35, SD = 6.80). In contrast, the control group did not exhibit significant changes in mean well-being scores across the same time points (baseline: M = 31.41, SD = 10.02; immediately after: M = 31.21, SD = 8.91; one month later: M = 30.30, SD = 8.99).
The Bonferroni post-hoc test further confirmed that the differences in well-being scores within the intervention group were statistically significant at all three time points (p < 0.001). However, no significant differences were observed within the control group across the same periods. Additionally, the between-group comparisons at each time point revealed significant differences in well-being scores immediately after the intervention and one month later (p < 0.001 for both), confirming the effectiveness of the positive psychology skill enhancement program (Table 5).
Table 5Bonferroni ‘s follow-up test for the comparison of the treatment on happiness in the three stages of the testScaleStage AStage BMean differenceABStandard errorStatistical powerhappinessBefore the interventionAfter the intervention-088.110.5600.000One month after the intervention-6.1470.4300.000After the interventionOne month after the intervention-4.9410.3590.000Bonferroni ‘s follow-up test
Discussion
The present study aimed to determine the impact of a positive psychology skill enhancement program on the sense of happiness in patients suffering from CHF. The results of the present study indicated a significant increase in the mean score of happiness and its dimensions (life satisfaction, pleasure, self-esteem, calmness, control) except for the dimension of self-efficacy in the intervention group compared to the control group immediately and one month after the intervention. Therefore, it seems that the positive psychology skill enhancement program can have effective in enhancing and improving the level of happiness and its dimensions in patients with CHF.
Since the goal of the positive psychology skill enhancement program is to help improve emotional (the sense of feeling happy), social (related to the individual’s joyful relationships and their ability to utilize social support), cognitive (mental health, life satisfaction) [30], and emotional (balancing the pleasant and unpleasant feelings) [31] components in some individuals, it seems that the positive psychology skill enhancement program in the present study was able to play an effective role in improving happiness and its various dimensions.
The limited impact of the positive psychology skill enhancement program on self-efficacy may be due to the high physical and psychological burdens faced by CHF patients. Since this intervention focused on psychological skills without specific disease management education, it was less likely to influence self-efficacy, which is often tied to physical self-management skills. Similarly, Mollazem et al. found that while positive psychology increased happiness in heart surgery patients, the addition of self-care education was crucial for impacting self-efficacy [32].
In contrast, the study by Nikrahan et al. demonstrated that positive psychology interventions improved optimism and psychological well-being in heart disease patients by reducing negative emotions [33], which aligns with the current study’s findings on increased happiness and optimism. Since positive psychology interventions are effective in reducing negative emotions and cognitive distortions in patients during the educational process, both of which have a positive impact on improving positive relationships and their lives [34], they also lead to increased feelings of happiness and optimism in patients with heart disease, as observed in the present study and the study by Nikrahan et al. Other studies, such as Caterin et al. [35] and Sanjuán et al. [36], support the effectiveness of positive psychology interventions in enhancing positive emotions across chronic illnesses.
This cumulative evidence suggests that, regardless of disease type, positive psychology can improve well-being and reduce negative psychological symptoms, underscoring the need to consider these interventions in future cardiac care research.
The results of the present study are not consistent with the findings of Hoffman et al., which indicated that positive psychology-based interventions did not have an impact on increasing feelings of optimism among cardiac patients one month after the intervention [37]. One of the reasons for the inconsistency between the results of the present study and Hoffman et al.‘s study is the difference in the content and number of educational sessions provided to patients in the present study compared to the study mentioned, as well as the difference in the variable under investigation, namely feelings of happiness and optimism.
The positive psychology skill enhancement program included techniques such as cognitive restructuring, gratitude practice, and fostering optimism, each aiming to shift focus from negative to positive thoughts and build resilience against stress. Cognitive restructuring, for instance, helps patients reframe negative thoughts, which may lead to increased happiness and well-being by reducing the mental burden of chronic illness. Gratitude practice and optimism-building activities further promote emotional resilience, which may help improve mood and overall life satisfaction, as observed in the study results.
Therefore, attention to the content of positive psychology-based interventions to enhance feelings of happiness and optimism among cardiac patients should be considered by researchers. The results of the present study are also inconsistent with those of Cohen et al., which reported that positive psychology interventions did not bring about a change in feelings of happiness and optimism in patients with type 2 diabetes immediately after the intervention [38]. One of the reasons for the inconsistency between the results of the present study and Cohen et al.‘s study is the difference in the type of chronic disease among the patients studied in the present research compared to Cohen et al.‘s study (patients with CHF and patients with type 2 diabetes, respectively).
Patients with chronic diseases have different physical, psychological, and social needs that affect their feelings of happiness and optimism according to their illness, its consequences, and outcomes, which require positive psychology-based programs to be designed and implemented based on these factors. Since in the present study, unlike Cohen et al.‘s study, the enhancement program based on positive psychology skills was effective in enhancing feelings of happiness among patients with CHF one month after the intervention, it can be said that the intervention program used in the present study was able to meet the needs related to improving feelings of happiness among the patients studied. The present study is the first in the country to examine the impact of an enhancement program based on positive psychology skills on feelings of happiness and its dimensions in patients with CHF, which can be used as a research-based study in future similar studies.
This study had several limitations that should be considered when interpreting the results. First, there is a lack of previous research specifically on positive psychology interventions for patients with CHF, limiting direct comparisons with existing studies. Second, the psychological conditions of the participants may have influenced their responses to self-report questionnaires, which introduces a possibility of response bias.
Additionally, while the study included a follow-up period of one month post-intervention, future studies with longer follow-up durations would help assess the sustained impact of the intervention. Given that this study involved a relatively small sample size from a single treatment center, further research with larger, more diverse samples and improved blinding methods would enhance the generalizability and robustness of the findings.
Conclusions
This study provides preliminary evidence that a positive psychology skill enhancement program may improve well-being in patients with chronic heart failure. The intervention was associated with significant increases in well-being scores in the intervention group compared to the control group, with effects persisting one month post-intervention.
However, these findings should be interpreted with caution due to the study’s limitations, including the short follow-up period, single-center design, and reliance on self-reported measures. Further research is needed to confirm these results in larger, more diverse populations and to evaluate the long-term sustainability of the intervention’s effects.
While the intervention shows promise as a potential approach to enhance well-being in this patient population, additional evidence from rigorously designed studies is necessary before recommending its widespread implementation in healthcare settings.