Background
Chronic heart failure (CHF) is a prevalent condition that imposes a significant burden on both patients and healthcare systems worldwide [1]. Among the various therapeutic interventions, home-based cardiac rehabilitation (HBCR) has emerged as a viable and effective strategy to improve cardiovascular health outcomes [2‐4]. Regular participation in structured exercise programs has been shown to reduce hospital readmissions, improve functional capacity, and enhance quality of life in CHF patients [5‐7]. However, despite these well-documented benefits, adherence to HBCR exercise remains suboptimal among CHF patients, limiting its long-term effectiveness [8].
The challenge of poor adherence raises important questions about the underlying factors influencing patient behavior. Relevant research suggests that exercise motivation may play a critical role in driving adherence [9, 10]. According to Self-Determination Theory (SDT), motivation is shaped by the satisfaction of three fundamental psychological needs: autonomy, competence, and relatedness [11]. As shown in Fig. 1A, SDT emphasizes that when these fundamental psychological needs are met, individuals are more likely to generate and maintain health promoting behaviors either directly or indirectly by continuously internalizing their own motivations [12‐14]. Conversely, when these needs are unmet, motivation diminishes, leading to reduced adherence.
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Fig. 1
Pathway mechanism map of the effects of exercise psychological needs on exercise adherence
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Given the theoretical framework in Fig. 1A, understanding the relationship between psychological needs and exercise adherence could provide valuable insights into the behavioral mechanisms at play in CHF patients undergoing HBCR. In particular, the role of exercise regulatory motivation as a mediator in this relationship warrants further exploration. Regulatory motivation, which reflects the degree to which individuals internalize and integrate external goals and values [11], may serve as a key driver of long-term adherence in this patient population. Based on the above, the study hypothesizes that satisfying the basic psychological needs related to HBCR exercise can directly or indirectly, through the internalization of exercise motivation, promote long-term and consistent adherence to HBCR (Fig. 1B).
The overarching goal of this study is to address the gap by investigating the mediating role of exercise regulatory motivation in the relationship between psychological needs and exercise adherence among CHF patients, and to establish a mechanism model. Specifically, the quantitative component aims to construct and validate the mediation mechanism model based on SDT. The qualitative component aims to explore the specific reasons underlying the mediation mechanisms to refine and supplement the model. Ultimately, the findings are expected to inform the design of more targeted interventions to promote sustained exercise participation in CHF patients.
Methods
Research design
This study employed an explanatory sequential design to explore the driving mechanisms behind exercise adherence in HBCR for patients with CHF from a health psychology perspective. The study consists of two parts. In the first phase, a questionnaire was used to test a theoretically driven mechanism model. To further explore the reasons behind the model’s pathways and the roles of various variables, semi-structured interviews were conducted in the second phase.
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Quantitative study
Participants and sample size
Using convenience sampling, CHF patients receiving care at the CR Center of the First Affiliated Hospital of Jinzhou Medical University were selected as the study population. Inclusion criteria were: (1) diagnosis of CHF; (2) age ≥ 18 years; (3) currently undergoing HBCR; and (4) providing informed consent and willing to participate. Exclusion criteria included: (1) speech communication barriers; and (2) severe comorbid organic diseases. To determine predictors of exercise adherence in HBCR for CHF patients, the study used G*power 3.1.9.7 software with the following parameters: a medium effect size (f²) of 0.15, significance level (α) of 0.05, statistical power (1 - β) of 0.90, and 16 predictor variables. Therefore, the ideal sample size was 204. Considering a 20% rate of invalid questionnaires and the study environment, 250 questionnaires were distributed, with 226 valid responses collected, yielding a valid response rate of 91.20%.
Research instruments
General demographic questionnaire
A general demographic questionnaire was developed after a literature review and group discussions. It includes seven items: age, gender, education level, marital status, duration of illness, monthly income, and place of residence.
Exercise psychological needs scale
The scale, developed by Wilson et al. [15], assesses the fulfillment of basic psychological needs during exercise. Liu et al. [16] applied it in a Chinese community elderly population, showing good reliability and validity. The scale comprises 18 items across three dimensions: autonomy, competence, and relatedness. A Likert 7-point scale was used, ranging from “strongly agree” (7 points) to “strongly disagree” (1 point). Total scores range from 18 to 126, with higher scores indicating greater fulfillment of psychological needs during exercise. In this study, the Cronbach’s α coefficient was 0.724.
Behavioral regulation in exercise questionnaire-3
The original scale, developed by Mullan et al. [17], measures the regulation of exercise motivation. The Chinese version introduced by Lou et al. [18], is adopted in this study. It consists of 24 items covering six dimensions: amotivation, intrinsic regulation, integrated regulation, identified regulation, introjected regulation, and external regulation, with four items per dimension. Responses were collected using a 5-point Likert scale, ranging from “strongly agree” (4 points) to “strongly disagree” (0 points). Total score = 3×intrinsic regulation + 2×integrated regulation + 1×identified regulation − 1×introjected regulation − 2×external regulation − 3×amotivation. Scores range from − 96 to 96, with higher scores indicating stronger motivation for home-based cardiac rehabilitation exercise. In this study, the Cronbach’s α coefficient was 0.792.
HBCR exercise adherence scale
Developed by the research team, this scale measures adherence to HBCR exercises for heart disease patients [19]. The scale includes 20 items across four dimensions: seeking support, rehabilitation exercises, exercise monitoring, and feedback on information. A 5-point Likert scale was used, ranging from “strongly agree” (5 points) to “strongly disagree” (1 point). Total scores range from 20 to 100, with higher scores indicating better adherence to home-based cardiac rehabilitation exercises in patients with CHF. In this study, the Cronbach’s α coefficient was 0.767.
Data collection
After explaining the purpose, significance, voluntary nature, and anonymity of the survey, 260 chronic heart failure patients were anonymously surveyed during outpatient follow-up, with the assistance of clinical nurses, after signing informed consent. For patients with poor vision or other reasons preventing them from completing the survey independently, the investigator read each question aloud and recorded their verbal responses.
Data analysis
The Henze-Zirkler test was used to examine the multivariate normal distribution of the data. Continuous variables were represented by means and standard deviations, while categorical variables were described using frequencies and percentages. Independent t-tests and one-way ANOVA were employed to analyze the effects of demographic data on home-based cardiac rehabilitation exercise adherence. Pearson correlation analysis was used to explore the relationships between the three variables. Based on previous research findings and theoretical assumptions, relevant demographic data were considered as covariates, and PROCESS macro model 6 was used to test the driving model of exercise adherence in home-based cardiac rehabilitation for chronic heart failure patients [20]. The bootstrap resampling method was applied 5,000 times to estimate and test the indirect effects and their 95% confidence intervals. SPSS 27.0 software was used for data analysis, and a p-value of < 0.05 was considered statistically significant.
Qualitative research
Participants and sample size
The researchers compiled information from CHF patients who agreed to participate in qualitative interviews during the questionnaire survey. Participants were selected using purposive sampling and a maximum variation strategy, with patient adherence to HBCR serving as a key variable to ensure a diverse range of experiences. The inclusion and exclusion criteria were consistent with the quantitative study. The sample size was determined based on the principle of data saturation [21], meaning interviews were conducted until no new information emerged in three consecutive interviews after at least 10 interviews.
Research tools
Semi-structured interview guide
Based on the research objectives and group discussions, a semi-structured interview guide was developed, focusing on four core questions: (1)How do you perceive HBCR exercise? (2)What factors motivated your mental shift from “needing to do” to “wanting to do” the exercise? (3)What factors encouraged you to move from “wanting to do” to “continuing to do” the exercise? (4)Do you have any additional psychological needs or experiences related to HBCR exercise to share?
Research team
In qualitative research, researchers themselves are one of the most crucial tools. This research team consisted of two professors specializing in qualitative research, responsible for quality control and finalizing coding (APW and CQZ), and two Ph.D. candidates skilled in qualitative methods who conducted the interviews and coding (ZY and HH).
Data collection
The researchers, as clinical nurses, built rapport with participants. Two researchers conducted face-to-face interviews with the participants, choosing quiet and comfortable locations based on the participants’ preferences. After explaining the study’s purpose, significance, and obtaining informed consent, the interviews were carried out. One researcher led the interviews neutrally, while the other observed non-verbal cues. Interview durations ranged from 18 to 25 min. Post-interview, both researchers wrote reflective journals to enhance the interaction process and documented the most vivid, emotional thoughts.
Data analysis
Using Braun and Clark’s thematic analysis method [22], Nvivo 12.0 software was employed to analyze the textual data. Both researchers familiarized themselves with the data to identify meaningful sentences and generate initial codes. The initial codes were then evaluated and new themes were identified. The researchers reviewed potential themes to ensure alignment with the codes and themes. Further refinement and definition of these themes were made based on theoretical frameworks to present the findings logically. While participants did not directly participate in the data analysis process, the identified themes and corresponding interpretations were returned to the participants for review. This step allowed them to verify that the themes and meaningful sentences accurately captured their experiences and perspectives. Additionally, three professors with extensive qualitative research experience reviewed the codes and themes to enhance the scientific rigor of the analysis.
Rigor
Strict adherence to qualitative research guidelines ensured the study’s rigor [23]. Purposive sampling and the maximum variation strategy ensured the representativeness of participants. The credibility of the findings was reinforced through robust data collection and triangulation of the analysis. The data saturation approach ensured thorough exploration of relevant themes. While neutrality of the interviewers was not formally assessed, the research team made every effort to pose questions neutrally to minimize the chance of participants providing socially desirable responses. Interviewers received training in qualitative methods to reinforce this approach. Additionally, audio recordings were reviewed to ensure consistency and adherence to the interview guide. In-depth descriptions of themes enhanced the study’s transferability and reproducibility.
Ethical consideration
After explaining the purpose, significance, and voluntary nature of the study, patients were invited to complete an informed consent form. All participants provided informed consent. All procedures were conducted in accordance to the Declaration of Helsinki of 1964 and its further modifications. The study protocol was approved by the ethics Review Committee of the First Affiliated Hospital of China Medical University (No. 2023. 66).
Results
Quantitative research
General demographic information
A total of 226 eligible chronic heart failure patients were included in the study, with 101 males and 125 females. The majority (42.9%) were between the ages of 60–70. 47.8% had a primary school education level, 58.4% were married, and 54.4% had been diagnosed with the condition for less than four years. 41.2% had a monthly income below 3000 yuan, and 59.3% lived in rural areas. See Table 1 for details.
Table 1
Univariate analysis of sociodemographic data on exercise adherence
Variable | Frequency (%) | Mean (standard deviation) | t / F value | p-value |
|---|---|---|---|---|
Age | 3.828 | 0.023 | ||
<60 | 50 (22.1) | 54.46 (7.95) | ||
60∼70 | 97 (42.9) | 54.37 (6.21) | ||
>70 | 79 (35.0) | 51.58 (8.09) | ||
Gender | -0.650 | 0.516 | ||
Male | 101 (44.7) | 53.06 (7.93) | ||
Female | 125 (55.3) | 53.70 (6.96) | ||
Education level | 12.557 | <0.001 | ||
Primary education | 108 (47.8) | 51.44 (6.67) | ||
Secondary education | 86 (38.1) | 54.06 (6.31) | ||
Advanced education | 32 (14.2) | 58.38 (9.71) | ||
Marital status | 0.593 | 0.554 | ||
Unmarried | 24 (10.6) | 54.42 (7.89) | ||
Married | 132 (58.4) | 53.61 (7.15) | ||
Divorced/Widowed | 70 (31.0) | 52.70 (7.72) | ||
Diagnosis duration (year) | 3.145 | 0.045 | ||
<4 | 123 (54.4) | 52.83 (7.38) | ||
4∼8 | 78 (34.5) | 53.24 (7.20) | ||
>8 | 25 (11.1) | 56.84 (7.46) | ||
Monthly income (rmb) | 1.606 | 0.203 | ||
<3000 | 93 (41.2) | 53.92 (6.68) | ||
3000∼6000 | 81 (35.8) | 53.86 (7.73) | ||
>6000 | 52 (23.0) | 51.81 (7.98) | ||
Location | 0.645 | 0.520 | ||
Village | 134 (59.3) | 53.68 (7.29) | ||
City | 92 (40.7) | 53.03 (7.58) |
Univariate analysis of exercise adherence by baseline
In this study, the variables of exercise psychological needs (statistic = 0.732, p = 0.203), exercise regulatory motivation (statistic = 0.930, p = 0.219), and exercise adherence behavior (statistic = 0.554, p = 0.148) followed a multivariate normal distribution. The overall adherence score for exercise adherence among CHF patients was (53.42 ± 7.40). The scores for different dimensions were as follows: support-seeking (12.43 ± 2.95), rehabilitation exercise (14.27 ± 3.52), exercise monitoring (13.29 ± 3.52), and information feedback (13.42 ± 3.04). Univariate analysis showed that adherence scores differed significantly by age (F = 3.828, P = 0.023), education level (F = 12.557, P<0.001), and disease duration (F = 3.145, P = 0.045) among CHF patients, as detailed in Table 1.
Correlation analysis between exercise adherence and variables
As shown in Fig. 2, exercise psychological need (r = 0.701, p < 0.05) and exercise regulation motivation (r = 0.583, p < 0.05) were both significantly positively correlated with exercise adherence. Additionally, exercise regulation motivation was also significantly positively correlated with exercise adherence (r = 0.555, p < 0.05).
Fig. 2
Results of correlation analysis among various variables
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Multivariate regression analysis of mediation effect
The results indicated that exercise psychological needs positively predicted exercise regulation motivation (β = 0.504, p < 0.001), and exercise regulation motivation positively predicted exercise adherence (β = 0.269, p < 0.001). Exercise psychological needs also positively predicted exercise adherence (β = 0.530, p < 0.001). Moreover, education level was a significant predictor of exercise adherence (β = 0.530, p = 0.029), as detailed in Table 2.
Table 2
Regression analysis of mediation effect
Outcome Variable | Predictor Variable | β | 95% CI | t-value | p-value | |
Lower | Upper | |||||
Exercise Regulation Motivation a | Exercise Psychological Needs | 0.504 | 0.301 | 0.484 | 8.458 | <0.001 |
Age | -0.068 | -1.830 | 0.458 | -1.182 | 0.239 | |
Education | 0.130 | 0.187 | 2.567 | 2.281 | 0.024 | |
Diagnosis duration | -0.272 | -1.370 | 1.038 | -0.272 | 0.786 | |
Exercise Adherence b | Exercise Psychological Needs | 0.530 | 0.322 | 0.489 | 9.590 | <0.001 |
Exercise Regulation Motivation | 0.268 | 0.159 | 0.369 | 4.950 | <0.001 | |
Age | 0.041 | -0.507 | 1.311 | 0.871 | 0.385 | |
Education | 0.103 | 0.110 | 2.017 | 2.198 | 0.029 | |
Diagnosis duration | 0.082 | -0.063 | 1.844 | 1.841 | 0.067 | |
Mediation effect test
To further explore the mechanism through which exercise psychological need influences exercise adherence, the non-parametric percentile Bootstrap method (interval estimation) was applied to test the mediating effect of exercise regulation motivation between exercise psychological need and exercise adherence. As shown in Table 3; Fig. 1C, both the direct and indirect effects’ Bootstrap 95% confidence intervals did not include 0, indicating a significant partial mediation effect, accounting for 20.24% of the total effect (0.103/0.509).
Table 3
The comparison of the results of the mediation effect
Effects | Path | Point estimate | SE | 95%CI | Proportion of indirect effect | |
|---|---|---|---|---|---|---|
Lower | Upper | |||||
Total effect | — | 0.509 | 0.387 | 0.433 | 0.585 | 1.000 |
Direct effect | X—Y | 0.406 | 0.423 | 0.322 | 0.489 | 0.780 |
Indirect effect | X—M—Y | 0.103 | 0.027 | 0.052 | 0.158 | 0.202 |
Qualitative research
Demographic characteristics of participants
A total of 18 eligible CHF patients were selected using purposive sampling, maximum variation sampling, and data saturation principles. The group consisted of 9 males and 9 females, aged between 52 and 72 years, with an average age of (61.72 ± 6.32) years. The duration of illness ranged from 1 to 8 years, with an average of (4.28 ± 1.82) years. See Appendix 1 for details.
Thematic results
In this section, five subthemes emerged from the text data. Based on the research objectives and thematic meaning, these subthemes were deductively assigned to two main themes: “Specific Functions of Pathway Variables” and “Reasons for Mediation Path Significance.” The detailed results of the thematic analysis are presented in Fig. 3.
Fig. 3
The coded result plots in qualitative study
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Theme 1: Specific functions of pathway variables
Subtheme 1: Exercise Psychological Needs—Trigger and Activation.
Exercise psychological needs play a role in “triggering and activating” exercise regulatory motivation and adherence behavior. Patients indicated that consistently meeting basic psychological needs in HBCR activates their motivation for exercise regulation and triggers their initial adherence to HBCR exercises.
P13
Meeting my psychological needs, such as making me feel that cardiac rehabilitation isn’t too difficult and that I can do it easily, makes me more inclined to do it (Male, 61 years old, primary school education, disease duration: 4 years).
P6
Exercising with friends makes me feel that I’m not alone, which gives me strength and motivates me to continue with cardiac rehabilitation (Male, 58 years old, senior middle school education, disease duration: 3 years).
P9
I overcame my fear of exercise in home-based cardiac rehabilitation and realized I could control the pace and goals, which shifted me from needing to do it to wanting to do it (Female, 72 years old, primary school education, disease duration: 8 years).
Subtheme 2: Exercise Regulatory Motivation—Direction and Internalization.
As a key mediating factor, exercise regulatory motivation plays a role in “direction and internalization” within the patient’s exercise adherence behavior. Patients shared that as their basic psychological needs are consistently met, their motivation for exercise regulation becomes internalized, helping them establish clear goals in HBCR.
P11
The more my psychological needs are met, the stronger my desire to do home-based cardiac rehabilitation, as I know it’s good for my health (Female, 57 years old, bachelor education, disease duration: 2 years).
P7
I’ve come to realize this is beneficial, and I’m more motivated to do it. I’m now working with my doctor to set rehabilitation exercise goals and plans (Female, 48 years old, master education, disease duration: 1 years).
P1
I exercise with my companions every day, no matter the weather. We all genuinely want to do it, striving towards a common goal (Male, 65 years old, junior high school education, disease duration: 4 years).
Subtheme 3: Exercise Adherence Behavior—Maintenance and Adjustment.
Exercise adherence behavior functions to “maintain and adjust” HBCR for patients. With growing self-efficacy based on meeting psychological needs and regulatory motivation, patients consistently and regularly maintain their HBCR exercises. The exercise prescription is dynamic, adjusting to patients’ functional status and preferences.
P5
I feel confident in completing my HBCR exercise prescription. I’ve consistently followed it for more than six months (Male, 70 years old, primary school education, disease duration: 7 years).
P12
As my heart function improves based on test results, the doctor continuously adjusts my CR exercise prescription, and I follow along (Male, 59 years old, primary school education, disease duration: 6 years).
P9
After overcoming my fear, I wanted to start home-based cardiac rehabilitation and found that my heart function improved significantly, and I’ve had few interruptions over the past year (Female, 72 years old, primary school education, disease duration: 8 years).
Theme 2: Reasons for mediation path significance
Subtheme 1: Path A (Exercise Psychological Needs—Exercise Regulatory Motivation): Control, Competence, and Belonging.
Patients shared that continuously meeting their psychological needs during HBCR makes them feel a sense of control and competence over their rehabilitation goals. It also strengthens their connection with peers, fostering a sense of belonging, which in turn activates and internalizes their exercise regulatory motivation.
P3
Meeting my psychological needs helps me feel in control of the HBCR process, allowing me to set goals and plans with my doctor (Female, 59 years old, senior middle school education, disease duration: 6 years).
P14
The doctor’s case studies made me realize I’m capable of completing the exercise prescription, and over time, I genuinely wanted to do it (Female, 65 years old, senior middle school education, disease duration: 3 years).
P10
I joined a CR group early on, and my peers gave me a sense of strength and warmth, which made me feel motivated to do rehabilitation (Female, 68 years old, junior high school education, disease duration: 6 years).
Subtheme 2: Path B (Exercise Regulatory Motivation—Exercise Adherence Behavior): Enjoyment, Efficacy, and Satisfaction.
As their exercise regulatory motivation becomes internalized, patients report increased exercise efficacy and an enjoyable and comfortable experience during HBCR, further boosting their satisfaction and long-term adherence to the exercise routine.
P4
After a few attempts, I feel confident in completing the CR exercise prescription, which has kept me consistent with home-based cardiac rehabilitation (Male, 61 years old, junior high school education, disease duration: 5 years).
P15
P15: As my motivation to exercise grows, my actions are in sync with my inner rhythm, my condition improves, and I feel highly satisfied, which motivates me to keep going (Female, 53 years old, master education, disease duration: 2 years).
P8
P8: I want to do cardiac rehabilitation, and my doctor says I’m doing well, which makes me feel happy and keeps me going (Male, 64 years old, primary school education, disease duration: 5 years).
Result integration
The integration of quantitative and qualitative findings was conducted to develop a comprehensive model for the driving mechanisms underlying HBCR exercise adherence behavior in chronic heart failure patients. Quantitative results established the relationships between psychological needs, regulatory motivation, and exercise adherence, validating the hypothesized pathways. Qualitative insights provided a deeper understanding of the specific reasons and experiences supporting these pathways, particularly how psychological needs satisfaction and regulatory motivation influenced behavior. By merging these findings, the model was refined to reflect both statistical associations and patient-reported mechanisms. The integration was guided by SDT, ensuring the model aligned with theoretical constructs. The final model is presented in Fig. 4.
Fig. 4
The mechanism model for adherence to home-based cardiac rehabilitation exercise
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Discussion
The factors influencing adherence to HBCR exercise among patients with CHF and the related mechanisms have not been fully explored. Using an explanatory sequential mixed-methods design, the quantitative phase developed and tested a hypothesized model of HBCR exercise adherence based on SDT, while the qualitative phase explored the specific reasons behind the mediation pathways through semi-structured interviews. Meeting patients’ psychological needs for exercise can directly influence their adherence or indirectly affect it through the internalization of exercise regulatory motivation. When these needs are fulfilled, patients experience greater control, competence, and a sense of belonging in HBCR, which activates their motivation for exercise and triggers adherence behavior. As the regulatory motivation becomes more internalized, patients set clear exercise goals and experience enhanced enjoyment, efficacy, and satisfaction, fostering long-term adherence to HBCR. By building and validating this model, we can better understand the drivers of exercise adherence among CHF patients and identify potential intervention targets to improve HBCR management strategies.
Overall adherence to HBCR exercise among CHF patients is low across different dimensions. Stigma is a key factor that hinders patients from seeking support [24]. Those with higher stigma are less likely to ask for help in their HBCR exercise. Additionally, CHF patients often experience persistent physical and psychological symptoms, and fear of exercise may diminish their courage and confidence in completing HBCR [25, 26]. Although smart devices can help monitor exercise safety and efficacy, they rely on patients’ knowledge and skills. Patients with limited knowledge may not recognize the importance of monitoring and thus fail to engage in effective exercise monitoring or data interpretation [27]. Furthermore, CHF patients are required to provide feedback during outpatient follow-ups on their HBCR progress. However, economic constraints and transportation difficulties may reduce their motivation to attend follow-ups [28, 29]. Healthcare professionals can implement tailored, short nudging strategies (such as framing choices) to improve patients’ HBCR exercise adherence based on their different levels of engagement.
The study results show that CHF patients with higher educational levels have better adherence to HBCR exercise. According to the Knowledge-Attitude-Practice (KAP) theory, knowledge forms the basis for beliefs, and beliefs drive behavior [30]. Highly educated patients are more likely to acquire HBCR knowledge from various internal and external sources [31]. This accumulation of knowledge helps patients recognize the importance of HBCR, leading to the discovery of benefits that trigger positive beliefs and, in turn, encourage and sustain HBCR exercise behavior [32]. Therefore, during outpatient follow-ups, healthcare professionals should focus on patients with lower educational levels, using cognitive education and belief reinforcement to improve HBCR exercise adherence effectively.
The results also demonstrate that fulfilling patients’ psychological needs for exercise can directly influence exercise adherence. Meeting these needs helps initiate HBCR exercise, and incorporating shared decision-making in the exercise prescription can significantly match patients’ preferences, making them more willing to participate and adhere long-term [33]. Once HBCR exercise is initiated, patients gradually realize their capability to complete prescribed exercises, boosting their self-efficacy and encouraging active adherence [26]. Furthermore, external factors such as family support and social connections can enhance patients’ sense of belonging, making it easier for them to engage in HBCR, thus improving their exercise motivation [34, 35]. Therefore, meeting psychological needs is key to improving adherence. Healthcare teams should focus on satisfying these needs and enhancing positive emotional experiences by offering personalized support and guidance, promoting long-term and regular participation in HBCR and improved rehabilitation outcomes.
Moreover, the study finds that psychological needs influence exercise adherence indirectly through regulatory motivation. Meeting these needs activates regulatory motivation, which further strengthens patients’ enthusiasm and persistence in HBCR. First, fulfilling these needs enhances the sense of control. When patients can choose exercise modes and intensities based on their preferences and condition, they feel a greater sense of control over the rehabilitation process, which increases their positive attitude and intrinsic motivation [33]. Second, fulfilling psychological needs boosts competence. When patients receive appropriate guidance and feedback during HBCR and see their abilities improve, their exercise self-efficacy grows, further stimulating stronger regulatory motivation [36]. Lastly, satisfying psychological needs fosters a sense of belonging. Through interactions with other patients or the rehabilitation team, patients feel supported and connected, reducing feelings of isolation and enhancing their motivation to participate actively [37].
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As regulatory motivation continues to internalize and HBCR practice advances, patients are likely to sustain and adjust their exercise regimen over time. The internalization of regulatory motivation means that patients not only externally comply with the exercise prescription but also internally recognize the importance and necessity of HBCR. When motivation is internalized, patients autonomously choose to engage in HBCR. This internalization process and the perceived clinical benefits give patients a sense of satisfaction. Furthermore, internalized motivation helps patients overcome exercise-related challenges, boosting their sense of efficacy [11]. Finally, when exercise becomes an internal need, patients derive enjoyment from every stage of the process, from physical improvement to psychological satisfaction and achievement [13]. This sense of fulfillment drives them to set specific rehabilitation goals and continuously adjust their HBCR plan, leading to long-term and consistent exercise habits, thereby improving rehabilitation outcomes.
In conclusion, enhancing regulatory motivation through meeting psychological needs is critical for improving exercise adherence in the HBCR setting. Healthcare providers should pay close attention to patients’ early psychological needs and motivation and intervene when necessary to nudge patients towards sustained and regular HBCR participation.
Our findings emphasize that meeting psychological needs and internalizing motivation are essential for sustaining behavioral change. Integrating nudge theory with a behavioral economics approach in clinical nursing practice can help design effective digital nudging strategies. Specifically, setting goals can meet patients’ competence needs, applying loss aversion principles can support their autonomy needs, and employing social norms can fulfill their relatedness needs. Such alignment facilitates the satisfaction of psychological needs, leading to the internalization of exercise motivation and ultimately improving adherence to rehabilitation exercises.
Limitations
This study has several limitations that should be considered when interpreting the findings. First, the generalizability of the results may be limited due to the specific sample of chronic heart failure patients in a particular region. The findings may not be directly applicable to other populations with different demographic characteristics or health conditions. Second, while the study presents rich qualitative data, only positive qualitative quotes were included in the results section. This decision was made to maintain coherence and clarity in the integration of results, as including both positive and negative quotes would have significantly complicated the interpretation and reduced the overall consistency of the findings. We recognize that this approach limits the presentation of divergent perspectives and acknowledge the potential value of exploring negative experiences in future research.
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Conclusion
In this study, an explanatory sequential mixed-methods design was used to construct a model of the driving mechanisms of HBCR exercise adherence in CHF patients, emphasizing the key role of exercise motivation. Meeting patients’ psychological needs for exercise activates their exercise regulation motivation and triggers adherence behaviors. As this motivation becomes increasingly internalized, patients are able to set clear goals and consistently maintain and adjust their home-based cardiac rehabilitation exercises over time. Therefore, early attention to meeting psychological needs and promoting the internalization of motivation is essential for improving exercise adherence.
Acknowledgements
The authors are grateful to patients with chronic heart failure who participated in this study, and also to the health providers for their strong support in sampling.
Declarations
Ethics approval and consent to participate
After explaining the purpose, significance, and voluntary nature of the study, patients were invited to complete an informed consent form. All participants provided informed consent. All procedures were conducted in accordance to the Declaration of Helsinki of 1964 and its further modifications. The study protocol was approved by the ethics Review Committee of the First Affiliated Hospital of China Medical University (No. 2023. 66).
Consent for publication
Not applicable.
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Competing interests
The authors declare no competing interests.
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