Qualitative study links illness awareness and inner strength in women with heart failure

In a qualitative study of 11 women living with chronic heart failure, researchers found that awareness of the disease’s severity, long-term course, treatment requirements and implications for self-care developed alongside a gradual shift from fear and dependence toward resilience, self-reflection and more deliberate self-care. The women were recruited at a cardiology research hospital in northern Italy between November 2023 and January 2024. Their accounts suggest that understanding heart failure was not simply the accumulation of clinical information: it emerged through illness experience, relationships, reflection and repeated encounters with healthcare professionals, and it appeared closely connected to the development of what the research team calls “inner strength.” Because the study was qualitative and involved no intervention, it cannot establish that awareness caused stronger adaptation or improved clinical outcomes.

The researchers used reflexive thematic analysis, an interpretive approach designed to examine how participants constructed meaning rather than to measure the frequency or distribution of experiences. They conducted face-to-face, semi-structured interviews averaging 37 minutes, with individual sessions lasting between 30 and 45 minutes. An open question about when the women first became aware of heart failure was followed by prompts concerning emotion, identity, relationships, daily life, treatment and coping.

The guide was flexible, allowing interviewers to move between past and present experiences while participants explored what illness meant to them. Field notes captured contextual details, salient nonverbal cues and researchers’ reflexive observations, while all interviews were audio-recorded with consent and transcribed verbatim. Two researchers independently performed inductive, line-by-line coding before comparing codes and jointly developing themes through iterative discussion.

The analysis then moved recursively between extracts, coding, thematic construction and theoretical interpretation. Recruitment continued until the team judged the interviews sufficiently rich, nuanced and conceptually coherent to address the research question; adequacy was assessed through informational depth and interpretive potential rather than statistical saturation or coding redundancy. The team used an audit trail, reflexive journals, researcher triangulation and discussions to strengthen credibility and confirmability.

Four participants were also invited to reflect on the preliminary thematic synthesis, rather than being asked to verify factual details in their transcripts, consistent with the reflexive approach. The participants had a mean age of 79 years, with a standard deviation of 7.4 years, and had lived with heart failure for an average of eight years, with a standard deviation of 4.7 years. All were retired.

Six were classified in New York Heart Association functional class II and five in class III, indicating mild-to-moderate limits on physical activity. Ischemic cardiomyopathy was the cause of heart failure in five participants, hypertensive heart disease in three and valvular heart disease in three. The analysis produced four interconnected themes: confronting vulnerability, reconnecting through others and faith, adapting daily life and learning through awareness and self-care.

The authors interpreted the sequence as a developmental pathway, but the cross-sectional design meant that its progression was reconstructed from retrospective accounts rather than directly observed over time. Diagnosis initially disrupted the women’s sense of safety and continuity. Shortness of breath, profound fatigue and swelling often occurred during acute symptom exacerbations that led to hospitalization, intensifying the impression that the condition was life-threatening and irreversible.

One participant recalled feeling as though she was dying, while another said the diagnosis was “a major blow.” The phrase “heart failure” itself carried a strong association with futility. For some, the severity of the situation was initially overwhelming: one woman said, “It felt like I couldn’t handle it,” and another asked a chaplain for the last rites. These reactions showed that the first stage of adaptation could be dominated by existential fear rather than active management, with the body’s limits unsettling previous expectations about identity, continuity and future life.

Over time, however, bodily symptoms and repeated clinical encounters became reference points for reflection. Some women continued to fear recurrence, but others began to recognize signs of improvement and describe a modest return of control. One participant said that, after following prescribed treatments, she could walk without becoming tired and climb stairs she had previously found difficult.

Another associated her relatively good condition with following the recommendations of her clinicians. The researchers interpreted this progression as movement from distress toward meaning-making, one of the dimensions of the Inner Strength framework, which describes an internal developmental capacity involving distress, connection, commitment, movement and construction of a new normal. This was an interpretive framework applied by the researchers, not a clinical score or an outcome measured in the interviews.

Relationships and faith supplied resources during this process. Family members, friends and neighbors offered both practical assistance and companionship. One woman said her children left work to help her, while another described being cared for by her sisters and daughters.

A participant living in a supportive building said she could always find someone to accompany her to the hospital. Some women also drew serenity and patience from inner dialogue or explicitly religious beliefs. “I take things with patience, and the Lord watches over me from above,” one participant said. Support was not unambiguously comforting, however: receiving help could also evoke guilt, dependence or a sense of being a burden.

The findings therefore portray connection as a negotiated resource capable of both stabilizing and complicating everyday life. Some mourned a life in which they could move independently and pursue activities without planning around fatigue. “I used to take long trips, visit exhibitions… but now I can’t anymore,” one woman said. Another said, “Now I can’t do anything, I feel almost useless.” Gradually, some participants began to define a new normal around medication schedules, short walks, quiet periods at home and assistance with daily tasks.

The authors described this as a movement from resistance toward adaptation, but the accounts also preserve the grief accompanying lost roles and independence rather than presenting resilience as a simple or complete reversal of disability. For several women, accepting help also required renegotiating family roles and expectations that had previously been organized around independence. Illness awareness emerged as a fragile and uneven learning process.

Although every participant had lived with chronic heart failure for years, several still did not fully understand its severity or progression. One said she did not “fully realize the severity of the situation,” while another described hearing about the disease “as if it didn’t concern me.” Some followed medication without understanding its purpose. These accounts illustrate a gap between knowledge and action, but the study did not test a causal relationship between awareness, adherence and clinical outcomes.

The final theme described a movement from passive compliance toward conscious engagement with self-care. Repeated hospitalizations, conversations with clinicians and reflection on bodily changes helped some women interpret the relationship between everyday behavior and well-being. “Now I follow everything they prescribe and recommend,” one participant said, while another described continuing to “keep going” in terms that shifted from endurance toward persistence and hope. The study therefore portrays awareness as both an educational and a therapeutic process within the participants’ accounts, although it did not test whether such a process improves resilience, reduces hospitalization or prolongs survival.

The authors proposed that structured educational and psychosocial support may help women connect clinical information with reflection, relationships and daily self-management, but that prospect requires evaluation in intervention studies. The findings come from a small, purposively selected sample at one hospital, so they are not intended to represent all women with heart failure or establish population-wide prevalence. Participants were selected for their ability to provide articulate, reflective accounts, and all were fluent in Italian.

Educational level, socioeconomic status and living arrangements were not systematically collected. ACC/AHA heart-failure staging was not routinely recorded, limiting the researchers’ ability to contextualize progression further. Because the interviews captured one point in time, the study could not directly observe how awareness and inner strength evolved; the developmental sequence was reconstructed from retrospective accounts.

The researchers’ backgrounds in nursing, cardiovascular care and education may also have shaped the interpretive lens. Within those limits, the study identifies a clinically relevant tension: information alone did not necessarily produce informed action, whereas awareness embedded in emotional, social and spiritual experience appeared more closely associated with resilient adaptation. The results point toward person-centred education for further testing, not proof of a new treatment.

Subject of Research: How illness awareness and inner strength developed among 11 women living with chronic heart failure in northern Italy

Article Title: Awareness as a path to inner strength: a qualitative study on women living with heart failure

Article References: Dellafiore, F., Cazzato, S., Primosa, F., Gotri, L., Diamanti, O., Modena, G., & Artioli, G. (2026). Awareness as a path to inner strength: a qualitative study on women living with heart failure. Frontiers in Cardiovascular Medicine, 13, Article 1744193. https://doi.org/10.3389/fcvm.2026.1744193

Image Credits: AI Generated

DOI: 10.3389/fcvm.2026.1744193

Keywords: heart failure, women's health, illness awareness, inner strength, qualitative research, self-care, resilience, patient education, reflexive thematic analysis, cardiovascular nursing, Awareness, path