Resilience profiles and functional independence in adults with cardiovascular diseases: An exploratory study

Theoretical framework

The present study is based on the four-factor structure of resilience validated in the Persian version of the Connor–Davidson Resilience Scale (CD–RISC; Khoshouei, 2009). This structure conceptualizes resilience as a multidimensional construct comprising four domains: achievement motivation, self-confidence, tenacity, and adaptability. Achievement motivation reflects goal-directed effort despite obstacles. Self-confidence represents perceived competence in managing challenges. Tenacity captures persistence in the face of adversity. Adaptability encompasses meaning-based beliefs and behavioral flexibility in response to change.

Each domain can be conceptually linked to occupational performance processes. Self-confidence may influence perceived competence in self-care and mobility tasks; achievement motivation and tenacity may support sustained effort during daily task completion; and adaptability may facilitate adjustment to environmental or bodily changes affecting performance. The Persian four-factor structure is a culturally validated adaptation of the original Connor–Davidson conceptualization (Connor and Davidson, 2003), which identified five domains: personal competence and tenacity; trust in one’s instincts and stress tolerance; acceptance of change and secure relationships; perceived control; and spiritual influences.

This framework facilitates the examination of resilience both as a global adaptive orientation (reflected in the total CD–RISC score) and as distinct but related domains. The present study employs this domain-specific framework to investigate which resilience domains are most strongly associated with functional independence in ADL among adults with non-neurological CVD.

Aims

ADL performance is a core domain of occupational therapy practice and a central functional outcome in cardiovascular rehabilitation (Schmucker et al., 2019). Accordingly, functional independence in ADL was selected as the primary outcome for examining resilience as an occupationally expressed construct. Using the Persian four-factor structure of the CD–RISC, the study pursued three specific aims:

Although the study was exploratory and not designed to support confirmatory hypothesis testing, the following directional expectations guided the inferential analyses:

No a priori hypothesis was specified for Aim 3, as the item-level analyses were exploratory and intended to provide descriptive context.

Design

This study employed a cross-sectional, exploratory design to examine resilience and its domain-specific expressions in adults with CVD. A cross-sectional approach was chosen to provide an initial characterization of resilience profiles and their associations with functional independence. This design is appropriate for a clinical population with limited empirical evidence and aligns with the study’s focus on describing patterns rather than testing causal relationships.

Study setting

The study was conducted in Shiraz, Iran, a major metropolitan area with specialized cardiovascular care services. Participants were recruited from a single cardiovascular care center affiliated with Shiraz University of Medical Sciences, which serves as a regional referral facility for adults with cardiovascular conditions. Recruitment from this center ensured diagnostic consistency and provided access to individuals receiving standardized cardiovascular care and follow-up services.

Participants

The study sample consisted of 39 adults with a documented history of CVD, including myocardial infarction and coronary artery disease, who were receiving outpatient cardiac care. Eligibility criteria included: (1) age 18 years or older, (2) confirmed medical diagnosis of CVD documented in clinical records, (3) medical stability at the time of assessment, and (4) ability to provide informed consent. The inclusion of a broad adult age range was intentional, as CVD affects individuals throughout midlife and older adulthood. Although functional independence and resilience may vary across the lifespan, age was not the primary explanatory variable in this study and was treated as a demographic characteristic of the clinical population. Therefore, participants were analyzed as a single adult cohort.

To minimize confounding factors affecting functional independence, individuals with diagnosed neurological disorders (e.g. stroke and neurodegenerative diseases), severe cognitive or communication impairments that precluded valid self-reporting, acute medical instability at the time of assessment, or psychiatric conditions likely to interfere with questionnaire completion were excluded. These criteria were applied to ensure that variations in ADL performance more accurately reflected cardiovascular status rather than comorbid neurological, psychiatric, or acute medical conditions.

Instruments

Participants were asked to complete two standardized questionnaires in Persian: CD–RISC and the Barthel Index. In addition, they completed a demographic checklist, which provided self-reported information on factors such as age, gender, marital status, educational attainment, and living arrangement. These demographic variables were included because prior research suggests they may influence resilience.

Procedure

This research was approved by the Research Ethics Committees of Shiraz University of Medical Sciences, Shiraz, Iran. Participants were recruited using a consecutive sampling approach over a 1-month period, during which all eligible patients presenting within the data collection timeframe were invited to participate. This strategy was chosen to enhance feasibility within the clinical context, reduce selection bias, and improve the representativeness of the accessible outpatient CVD population. Eligible individuals were approached by two trained research assistants who provided standardized verbal and written explanations of the study objectives and procedures. Written informed consent was obtained from all participants prior to data collection. Although 51 individuals initially participated, 12 were excluded from the final analysis due to incomplete or insufficient questionnaire data, resulting in a final analytical sample of 39 participants.

Data collection was conducted in a designated assessment room within the specialized cardiovascular care center to ensure privacy and minimize distractions. Participants completed a demographic questionnaire, the Persian version of the CD–RISC, and the Barthel Index. The total time required to complete all study measures was approximately 45 minutes, with short rest breaks offered as needed to reduce fatigue. All questionnaires were administered in Persian, and participants were encouraged to seek clarification if any item was unclear.

Data analysis

All statistical analyses were performed using IBM SPSS Version 27 (IBM Corp., Armonk, NY, USA), with a two-tailed significance level set at p < 0.05. Prior to inferential testing, data were screened to assess distributional assumptions. Because CD–RISC scores were not normally distributed and group sizes were unequal, nonparametric methods were employed.

In addition to analyses aligned with the primary study aims, exploratory comparisons were conducted to characterize the distribution of overall resilience across demographic variables. Mann–Whitney U tests were employed to examine differences in total CD–RISC scores across dichotomized demographic categories, including age group, gender, marital status, living arrangement, and educational attainment. These analyses aimed to contextualize resilience patterns within the sample and were not intended to establish causal or predictive relationships. The analyses addressing the primary aims were structured as follows:

Differences in overall resilience by functional independence

Total resilience scores differed significantly between functional independence groups (see Table 1). Participants classified as independent (Barthel Index >90) demonstrated higher mean resilience ranks compared to those classified as dependent or relatively dependent (Barthel Index ⩽90), with a moderate effect size (r = 0.323). These findings indicate that greater resilience was observed among functionally independent participants.

Domain-level differences by functional independence

Subscale analyses revealed variability in domain-specific group differences (see Table 2). Among the four resilience domains, only self-confidence showed a statistically significant difference between functional independence groups, with a moderate effect size (r = 0.333). Achievement motivation and tenacity exhibited nonsignificant but directionally consistent differences favoring independent participants, accompanied by small to moderate effect sizes. Adaptability demonstrated the smallest effect size and did not differ significantly between groups. These findings suggest differential domain-level relevance to functional independence in ADL.

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Table 2.

Subscale-level differences in resilience by functional independence in activities of daily living.

Variables	Mean rank a	p Value	Effect size (r)
Achievement motivation
Barthel Index ⩽90 (dependent/relatively dependent)	14.91	0.080	0.280
Barthel Index >90 (independent)	22.00
Self-confidence
Barthel Index ⩽90 (dependent/relatively dependent)	13.95	0.037	0.333
Barthel Index >90 (independent)	22.38
Tenacity
Barthel Index ⩽90 (dependent/relatively dependent)	15.05	0.087	0.274
Barthel Index >90 (independent)	21.95
Adaptability
Barthel Index ⩽90 (dependent/relatively dependent)	16.05	0.172	0.218
Barthel Index >90 (independent)	21.55

a

Mann–Whitney U test. Mean rank values are reported due to the use of nonparametric tests.

Item-level resilience patterns

Item-level descriptive statistics were examined to contextualize the domain-level findings (see Table 3). The highest mean scores corresponded to belief-based coping, persistence, and confidence-related attributes. In contrast, items reflecting behavioral and cognitive flexibility under stress were less frequently endorsed. This distribution aligns with the subscale-level findings, particularly the stronger differentiation observed for self-confidence and the comparatively weaker functional differentiation of adaptability.

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Table 3.

Item-level descriptive statistics for the Persian CD–RISC, ordered by mean score.

Factors	Items	Brief content label	Mean (SD)
Adaptability	CD–RISC 8	Belief that events happen for a reason	3.23 (1.180)
Adaptability	CD–RISC 11	Spiritual or fate-based coping	3.13 (1.056)
Tenacity	CD–RISC 4	Commitment to effort regardless of outcome	3.08 (0.900)
Self-confidence	CD–RISC 3	Pride in personal achievements	3.05 (1.075)
Achievement motivation	CD–RISC 25	Preference for self-directed problem-solving	3.05 (1.099)
Self-confidence	CD–RISC 5	Perceived control over one’s life	2.90 (0.940)
Achievement motivation	CD–RISC 19	Perseverance toward goals despite barriers	2.90 (1.095)
Self-confidence	CD–RISC 22	Ability to recover after illness or adversity	2.87 (0.833)
Adaptability	CD–RISC 2	Having close and secure relationships	2.85 (1.204)
Tenacity	CD–RISC 6	Sense of meaning in life	2.79 (1.105)
Self-confidence	CD–RISC 20	Belief in achieving goals despite obstacles	2.79 (1.151)
Self-confidence	CD–RISC 12	Ability to deal with whatever arises	2.72 (1.099)
Self-confidence	CD–RISC 17	Perceived personal competence in facing challenges	2.69 (1.080)
Adaptability	CD–RISC 1	Ability to adapt to change	2.67 (0.955)
Achievement motivation	CD–RISC 13	Confidence gained from past successes	2.67 (1.060)
Tenacity	CD–RISC 21	Persistence after failure	2.46 (1.166)
Self-confidence	CD–RISC 23	Knowing where to seek help in times of crisis	2.44 (1.119)
Tenacity	CD–RISC 18	Resistance to hopelessness in difficult situations	2.44 (1.231)
Self-confidence	CD–RISC 16	Ability to make difficult or unpopular decisions	2.31 (1.030)
Adaptability	CD–RISC 24	Maintaining focus and clear thinking under pressure	2.21 (1.852)
Achievement motivation	CD–RISC 14	Becoming stronger through stress	2.15 (1.309)
Self-confidence	CD–RISC 10	Regulation of negative emotions	2.08 (1.265)
Adaptability	CD–RISC 7	Seeing humor in stressful situations	1.97 (1.203)
Achievement motivation	CD–RISC 15	Positive orientation toward challenges	1.90 (1.294)
Adaptability	CD–RISC 9	Acting under uncertainty	1.72 (1.050)

CD–RISC: Connor–Davidson Resilience Scale; SD: standard deviation.

Limitations

Several limitations should be considered when interpreting these findings. First, the sample was recruited using a consecutive, single-center outpatient sampling approach, which may introduce selection bias. Individuals receiving outpatient follow-up care are more likely to be medically stable and functionally higher-performing than those in acute or inpatient settings. This recruitment context may have contributed to the predominance of functionally independent participants and limits the generalizability of the findings to more functionally impaired or hospitalized CVD populations.

Second, although including a broad adult age range enhanced the clinical representativeness of the sample, it also introduced heterogeneity. Functional independence and resilience are constructs that may vary across the adult lifespan. The modest sample size and unequal distribution across age categories limited the ability to conduct age-stratified analyses or to examine potential interaction effects between age and functional status. Although no statistically significant age differences in overall resilience were observed in the present sample, the study was not specifically powered to detect developmental effects.

Third, the cross-sectional design precludes causal inferences about the relationship between resilience and functional independence. The observed associations represent concurrent relationships and do not establish a directional influence.

Fourth, resilience was assessed using a self-report measure, which is susceptible to response bias and may not fully capture behavioral or contextually enacted expressions of resilience in everyday activities. Although the Persian version of the CD–RISC demonstrates strong psychometric properties, it was originally validated in a nonclinical student population, which may not fully represent resilience as expressed in adults with CVD.

Finally, functional independence was measured using the Barthel Index, which focuses on basic ADL performance. Instrumental ADL, participation-level outcomes, and broader occupational engagement were not directly assessed, potentially limiting the interpretation of resilience domains—particularly adaptability—that may be more evident at higher levels of functional complexity.

Implications for practice

The significant association between self-confidence and functional independence observed in this study suggests that occupational therapy interventions should explicitly target confidence through graded ADL challenges and mastery experiences (e.g. progressive mobility or self-care tasks with gradually reduced assistance). Furthermore, the four-factor structure of the CD–RISC (achievement motivation, self-confidence, tenacity, and adaptability) can guide domain-specific clinical reasoning. Rather than treating resilience as a unitary construct, therapists may use domain profiles to tailor interventions: goal-setting for low motivation, activity pacing for low tenacity, or problem-solving training for low adaptability. Given that occupational therapy remains underutilized in cardiac care (Lindsey, 2025) and evidence for its effectiveness on ADL outcomes in adults with CVD remains inconclusive (Takeda et al., 2025), resilience-informed strategies represent an occupationally grounded approach consistent with perspectives that view resilience as embedded in engagement in everyday activities (Turner et al., 2025).

Future research

Given the exploratory and cross-sectional nature of this study, future research should utilize longitudinal designs to clarify the directionality of the resilience–function relationship and to examine how resilience domains evolve in tandem with functional recovery or decline following CVD.

Larger, multisite studies would enhance statistical power and improve representativeness across diverse clinical settings, including inpatient populations and individuals with more severe functional impairments. Utilizing sampling strategies that intentionally recruit participants across a wider range of functional limitations would allow for a more precise analysis of domain-specific resilience effects.

Future studies should incorporate age-stratified or lifespan-informed analyses to clarify potential developmental influences on the relationships between resilience and function. Investigating whether specific resilience domains (e.g. self-confidence vs adaptability) differentially predict functional outcomes in midlife compared to older adulthood would enhance both theoretical and clinical understanding.

In addition, incorporating measures of instrumental ADL, social participation, and occupational engagement may provide a more comprehensive understanding of how resilience is enacted in everyday life. Mixed-method or behavioral assessment approaches could further elucidate how resilience processes are expressed beyond self-report measures.

Finally, intervention-based studies are needed to determine whether resilience-informed approaches can improve functional independence and participation outcomes in adults living with CVD.