Resilience in Heart Failure Patients Tested by Lebanon’s Overlapping Crises

Heart failure is one of the most demanding chronic conditions a person can live with, requiring daily vigilance over symptoms, strict medication routines, dietary and fluid restrictions, and constant readiness to respond to deterioration. A new cross-sectional study from Lebanon, published in Nursing Open, has now examined how patients with this condition sustain their psychological resilience while living amid one of the most prolonged and compounding sociopolitical crises in the world. The findings offer a rare window into how adversity, self-care behaviour, depression, and coping capacity interact when the healthcare system itself is under strain, and they carry practical implications for nursing practice far beyond the borders of a single country.

The research team, led by investigators affiliated with Beirut Arab University, recruited 299 adults with confirmed heart failure from outpatient clinics and primary healthcare services across all major regions of Lebanon between January 2024 and October 2025. Participants were Arabic-speaking adults aged 30 to 80 years with either reduced ejection fraction of 40 percent or less, or symptomatic preserved ejection fraction confirmed by echocardiography, diagnosed for at least three months according to the Framingham criteria. Of 475 people initially screened, some were excluded because their understanding of the term heart failure was distorted, a striking detail in itself: many patients who had undergone open-heart surgery misinterpreted the diagnosis, underlining how much work remains in patient education. After removing cases with missing data, 299 participants formed the analytical sample.

The burden carried by this group was considerable. More than 90 percent had hypertension, roughly 60 percent had diabetes, and the average Charlson Comorbidity Index was 5.58, indicating substantial multimorbidity. Depression had been formally diagnosed in 35.5 percent of participants. The mean left ventricular ejection fraction was 37.52 percent, nearly half the sample was in New York Heart Association functional class III, and participants had lived with heart failure for an average of 5.3 years. Most were unemployed, nearly half reported a monthly household income between 200 and 500 US dollars, and almost all relied on a family caregiver, most often a spouse or an adult child. These socioeconomic realities matter, because in Lebanon out-of-pocket medication costs and repeated hospital admissions place enormous financial pressure on households already battered by currency collapse and inflation.

To measure the study’s central construct, the researchers used the Connor-Davidson Resilience Scale, a 25-item instrument covering domains such as personal competence, trust in one’s instincts, positive acceptance of change, control, and spiritual influences, scored from 0 to 100. In this Lebanese sample the scale showed exceptional internal consistency, with a Cronbach’s alpha of 0.965. Quality of life was assessed with the Arabic-validated Minnesota Living with Heart Failure Questionnaire, depressive symptoms with the Patient Health Questionnaire-9, and self-care with the Revised Self-Care Heart Failure Index version 7.2, which captures self-care maintenance, symptom monitoring, and self-care management as distinct subscales. All instruments had been previously translated and psychometrically evaluated for the Lebanese population, and reliability coefficients in the current study ranged from 0.86 to 0.965.

The headline result was a picture of a population split almost exactly in two. The mean resilience score was 58.41, just above the developer’s suggested cut-off of 55, and 51.2 percent of participants were classified as resilient while 48.8 percent were not. Depressive symptoms averaged 13.76 on the PHQ-9, corresponding to moderate depression, with more than half of the sample falling into the moderate to severe categories. Self-care maintenance and monitoring scores were low at 62.68 and 64.71, below the conventional adequacy threshold of 70, but self-care management scored 78.24, the only subscale to surpass the cut-off. Quality of life, at 56.07 on the Minnesota questionnaire, reflected moderate impairment. Statistically, resilience correlated negatively with depression and positively with all three self-care subscales, with the strongest correlation, r = 0.540, linking resilience to self-care maintenance.

The multivariable regression model identified four independent predictors of resilience, explaining 36.1 percent of the variance in resilience scores. Higher self-care maintenance and higher self-care management each independently predicted greater resilience, with unstandardized coefficients of 0.248 and 0.282 respectively. Male participants scored higher than female participants after adjustment, a gender difference of just over four points on the CD-RISC. Perhaps most intriguingly, participants taking loop diuretics showed resilience scores more than eight points higher than those not taking this class of medication, a finding that likely reflects the association between being on guideline-directed therapy and being engaged with care rather than a pharmacological effect on psychological coping. Bivariate analyses added further texture: resilient patients were more likely to have received influenza and COVID-19 vaccinations, to be current with medical follow-up, to have higher education, and to be cared for by a spouse rather than a child.

One of the most provocative findings is the negative, though statistically non-significant, correlation between resilience and quality of life, which runs counter to virtually all of the published literature, including studies from Egypt, Iraq, and general populations worldwide. The authors argue that no prior research has examined a population exposed to the compounded burden of simultaneous health, political, social, and economic crises as Lebanon has experienced since 2019, encompassing currency devaluation, hyperinflation, the Beirut Port explosion, and continuing regional instability. In such a context, the usual relationship between adaptation and wellbeing may be distorted: patients who have been forced into self-reliance by a failing system may report functional resilience even as their perceived quality of life erodes. The team also notes that quality-of-life scores among Lebanese heart failure patients nearly doubled between 2018 and 2022 before stabilising, a trajectory that mirrors the country’s crisis timeline.

The self-care management result tells a parallel story. In earlier Lebanese studies, self-care management was consistently the weakest subscale, with mean scores around 47. In the present sample it exceeded 78, suggesting a growing culture of self-reliance in disease management driven by necessity, as patients navigate medication shortages, costly follow-up visits, and disrupted continuity of care. This shift occurred despite previously documented deficiencies in discharge education. For nursing science, the implication is that resilience is not a fixed trait but a modifiable domain that can be assessed, monitored, and supported through education, counselling, family-inclusive care planning, and community-based follow-up, particularly in resource-constrained settings where nurses and advanced practice nurses are often the most accessible point of contact.

The authors are careful to acknowledge the limitations of a cross-sectional design, which cannot establish causal direction between resilience and self-care, along with the possibility of social desirability bias in self-reported questionnaires and the constraints of convenience sampling. Even so, the study stands as the first to document resilience and its predictors among heart failure patients living through sustained national collapse, and its patterns may generalise to Lebanese diaspora communities and to other populations enduring protracted instability. The practical message for clinicians is concrete: screening for low resilience, reinforcing self-care maintenance behaviours, supporting female patients who carry lower resilience scores, ensuring guideline-directed medication including diuretic therapy, leveraging spousal caregivers, and promoting vaccination and regular follow-up may together form the scaffolding that keeps chronically ill patients upright when the systems meant to support them cannot.

Subject of Research: Predictors of psychological resilience among patients living with heart failure during prolonged sociopolitical and economic crises in Lebanon

Article Title: Predictors of Resilience Among Patients Living With Heart Failure Amid Escalating Sociopolitical Challenges: A Cross‐Sectional Approach

Article References: Deek, H., Massouh, A. R., & Shatila, W. (2026). Predictors of Resilience Among Patients Living With Heart Failure Amid Escalating Sociopolitical Challenges: A Cross‐Sectional Approach. Nursing Open, 13(9), Article e70816. https://doi.org/10.1002/nop2.70816

Image Credits: AI Generated

DOI: 10.1002/nop2.70816

Keywords: heart failure, resilience, self-care, Lebanon, depression, quality of life, nursing, cross-sectional study, Connor-Davidson Resilience Scale, chronic illness, sociopolitical crisis, cardiology