The Combined Effect of Psychological and Relational Aspects on Cardiac Patient Activation

  • Giada RapelliEmail author
  • Silvia Donato
  • Anna Bertoni
  • Chiara Spatola
  • Ariela F. Pagani
  • Miriam Parise
  • Gianluca Castelnuovo


The literature assumes that activating patients in the treatment is associated with positive health-related outcomes, such as clinical indicators in the normal range, high medication adherence, and low emergency department utilization. In the cardiac population, patient activation, that is the patient’s knowledge, skills, confidence, and behaviors needed for managing one’s own health and health care, has been less investigated. In addition, limited attention has been given to the role of the partner as an informal caregiver. However, the patient in the care process is rarely alone, and the partner may play a key role in this process. The goal of this dyadic study (N = 100 heterosexual couples with one partner suffering from an acute cardiac event) is to analyze how individual factors (patients’ anxiety, depression, medication adherence, pessimistic perception of illness) and the couple’s relationship functioning (e.g., different kinds of partner support and dyadic coping) are associated with patient activation. The results showed that patient activation is not a mere question of age. It is positively related to medication adherence and to the partner’s support patient activation. It is negatively correlated with the patient’s psychological distress, pessimistic perception of illness, and to the partner’s hostility. The need for a dyadic approach to both research and intervention with this population is discussed.


Cardiac illness Couple relationship Partner support Distress Dyadic coping Patient activation 


Compliance with Ethical Standards

Conflict of interest

Giada Rapelli, Donato Silvia, Bertoni Anna, Chiara Spatola, Ariela F. Pagani, Miriam Parise, and Castelnuovo Gianluca declare that they have no conflict of interest.

Human and Animal Rights

All procedures performed involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all individual participants included.


  1. Acitelli, L. K., & Badr, H. J. (2005). 2F—My illness or our illness—Attending to the relationship when one partner is ill. In T. A. Revenson, K. Kayser, & G. Bodenmann (Eds.), Couples coping with stress: Emerging perspectives on dyadic coping (pp. 121–136). Washington, DC: American Psychological Association. Scholar
  2. Barello, S., Graffigna, G., Vegni, E., Savarese, M., Lombardi, F., & Bosio, A. C. (2015). “Engage me in taking care of my heart”: A grounded theory study on patient-cardiologist relationship in the hospital management of heart failure. British Medical Journal Open, 5, e005582. Scholar
  3. Baroletti, S., & Dell’Orfano, H. (2010). Medication adherence in cardiovascular disease. Circulation, 121, 1455–1458. Scholar
  4. Bauer, L. K., Caro, M. A., Beach, S. R., Mastromauro, C. A., Lenihan, E., Januzzi, J. L., & Huffman, J. C. (2012). Effects of depression and anxiety improvement on adherence to medication and health behaviors in recently hospitalized cardiac patients. The American Journal of Cardiology, 109, 1266–1271. Scholar
  5. Bertoni, A., & Bodenmann, G. (2010). Satisfied and dissatisfied couples: Positive and negative dimensions, conflict styles, and relationships with family of origin. European Psychologist, 15, 175–184. Scholar
  6. Bertoni, A., Donato, S., Acquati, C., & Rapelli, G. (2017). La coppia di fronte alla malattia cardiaca: il ruolo della relazione nel processo di cura. In C. Acquati & E. Saita (Eds.), Affrontare insieme la malattia (pp. 163–177). Roma: Carocci Faber.Google Scholar
  7. Bertoni, A., Donato, S., Graffigna, G., Barello, S., & Parise, M. (2015). Engaged patients, engaged partnerships: Singles and partners dealing with an acute cardiac event. Psychology, Health & Medicine, 8506, 1–13. Scholar
  8. Bertoni, A., Donato, S., & Molgora, S. (2018). When “we” are stressed: A dyadic approach to coping with stressful events. Hauppauge, NY: Nova Science Publisher.Google Scholar
  9. Bodenmann, G. (1997). Dyadic coping-a systematic-transactional view of stress and coping among couples: Theory and empirical findings. European Review of Applied Psychology, 47, 137–140.Google Scholar
  10. Bodenmann, G. (2005). Dyadic coping and its significance for marital functioning. In T. A. Revenson, K. Kayser, & G. Bodenmann (Eds.), Couples coping with stress: Emerging perspectives on dyadic coping (pp. 33–50). Washington: American Psychological Association. Scholar
  11. Bodenmann, G., Arista, L. J., Walsh, K. J., & Randall, A. K. (2018). Dyadic coping inventory. In J. Lebow, A. Chambers, & D. Breunlin (Eds.), Encyclopedia of couple and family therapy (pp. 1–5). Cham: Springer. Scholar
  12. Bodenmann, G., Meuwly, N., & Kayser, K. (2011). Two conceptualizations of dyadic coping and their potential for predicting relationship quality and individual well-being: A comparison. European Psychologist, 16, 255–266. Scholar
  13. Brummett, B. H., Barefoot, J. C., Feaganes, J. R., Yen, S., Bosworth, H. B., Williams, R. B., & Siegler, I. C. (2000). Hostility in marital dyads: Associations with depressive symptoms. Journal of Behavioral Medicine, 23, 95–105. Scholar
  14. Burns, J. W., Peterson, K. M., Smith, D. A., Keefe, F. J., Porter, L. S., Schuster, E., & Kinner, E. (2013). Temporal associations between spouse criticism/hostility and pain among patients with chronic pain: A within-couple daily diary study. Pain, 154, 2715–2721. Scholar
  15. Burns, J. W., Post, K. M., Smith, D. A., Porter, L. S., Buvanendran, A., Fras, A. M., & Keefe, F. J. (2018). Spouse criticism and hostility during marital interaction: Effects on pain intensity and behaviors among individuals with chronic low back pain. Pain, 159, 25–32. Scholar
  16. Cano, A., & Tankha, H. (2018). Spousal criticism and hostility in response to pain: What is the alternative? Pain, 159, 1–2. Scholar
  17. Castelnuovo, G., Pietrabissa, G., Manzoni, G., Cappella, E. A., Baruffi, M., Malfatto, G., … Molinari, E. (2014). The need of psychological motivational support for improving lifestyle change in cardiac rehabilitation. Experimental and Clinical Cardiology, 20, 4856–4861.Google Scholar
  18. Chauvet-Gelinier, J.-C., & Bonin, B. (2017). Stress, anxiety and depression in heart disease patients: A major challenge for cardiac rehabilitation. Annals of Physical and Rehabilitation Medicine, 60, 6–12. Scholar
  19. Conway, B. (2015). Understanding illness perception as a barrier to cardiac rehabilitation uptake. British Journal of Cardiac Nursing, 10, 21–25. Scholar
  20. Coyne, J. C., & Smith, D. A. (1991). Couples coping with a myocardial infarction: A contextual perspective on wives’ distress. Journal of Personality and Social Psychology, 61, 404–412.CrossRefGoogle Scholar
  21. Coyne, J. C., & Smith, D. A. F. (1994). Couples coping with a myocardial infarction: Contextual perspective on patient self-efficacy. Journal of Family Psychology, 8, 43–54. Scholar
  22. Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenhuth, E. H., & Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral Science, 19, 1–15.CrossRefGoogle Scholar
  23. DiMatteo, M. R. (2004). Social support and patient adherence to medical treatment: a meta-analysis. Health Psychology, 23, 207–218. Scholar
  24. DiMatteo, M. R., Lepper, H. S., & Croghan, T. W. (2000). Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Archives of Internal Medicine, 160, 2101–2107.CrossRefGoogle Scholar
  25. Donato, S., & Bertoni, A. (2018). A relational perspective on patient engagement: Suggestions from couple-based research and intervention. Health care delivery and clinical science: Concepts, methodologies, tools, and applications (pp. 1–24). IGI Global: Hershey, PA.Google Scholar
  26. Donato, S., Iafrate, R., Barni, D., Bertoni, A., Bodenmann, G., & Gagliardi, S. (2009). Measuring dyadic coping: The factorial structure of Bodenmann’s “Dyadic Coping Questionnaire” in an Italian sample. TPM—Testing Psychometrics Methodology, 16, 25–47.Google Scholar
  27. Donato, S., Pagani, A. F., Parise, M., Bertoni, A., & Iafrate, R. (2014). The capitalization process in stable couple relationships: Intrapersonal and interpersonal benefits. Procedia-Social and Behavioral Sciences, 140, 207–211. Scholar
  28. Donato, S., Parise, M., Iafrate, R., Bertoni, A., Finkenauer, C., & Bodenmann, G. (2015). Dyadic coping responses and partners’ perceptions for couple satisfaction: An actor-partner interdependence analysis. Journal of Social and Personal Relationships, 32, 580–600. Scholar
  29. Fiske, V., Coyne, J. C., & Smith, D. A. (1991). Couples coping with myocardial infarction: An empirical reconsideration of the role of overprotectiveness. Journal of Family Psychology, 5, 4–20.CrossRefGoogle Scholar
  30. French, D. P., Cooper, A., & Weinman, J. (2006). Illness perceptions predict attendance at cardiac rehabilitation following acute myocardial infarction: A systematic review with meta-analysis. Journal of Psychosomatic Research, 61, 757–767.CrossRefGoogle Scholar
  31. Goldstein, C. M., Gathright, E. C., & Garcia, S. (2017). Relationship between depression and medication adherence in cardiovascular disease: The perfect challenge for the integrated care team. Patient Preference and Adherence, 11, 547–559. Scholar
  32. Graffigna, G., Barello, S., Bonanomi, A., Lozza, E., & Hibbard, J. (2015). Measuring patient activation in Italy: Translation, adaptation and validation of the Italian version of the patient activation measure 13 (PAM13-I). BMC Medical Informatics and Decision Making, 15, 109. Scholar
  33. Graffigna, G., Barello, S., Riva, G., Savarese, M., Menichetti, J., Castelnuovo, G., … Bosio, A.C. (2017). Fertilizing a Patient Engagement Ecosystem to Innovate Healthcare : Toward the First Italian Consensus Conference on Patient Engagement. Frontiers in psychology.
  34. Hibbard, J. H., Mahoney, E. R., Stock, R., & Tusler, M. (2007). Do increases in patient activation result in improved self-management behaviors? Health Services Research, 42, 1443–1467. Scholar
  35. Hibbard, J. H., Stockard, J., Mahoney, E. R., & Tusler, M. (2004). Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Services Research, 39, 1005–1026. Scholar
  36. Hilpert, P., Randall, A. K., Sorokowski, P., Atkins, D. C., Sorokowska, A., Ahmadi, K., … Bettache, K. (2016). The associations of dyadic coping and relationship satisfaction vary between and within nations: A 35-nation study. Frontiers in Psychology, 7, article n. 1106.
  37. Le Grande, M. R., Jackson, A. C., Murphy, B. M., & Thomason, N. (2016). Relationship between sleep disturbance, depression and anxiety in the 12 months following a cardiac event. Psychology, Health & Medicine, 21, 52–59. Scholar
  38. Leifheit-Limson, E. C., Kasl, S. V., Lin, H., Buchanan, D. M., Peterson, P. N., Spertus, J. A., & Lichtman, J. H. (2012). Adherence to risk factor management instructions after acute myocardial infarction: The role of emotional support and depressive symptoms. Annals of Behavioral Medicine, 43, 198–207. Scholar
  39. Leuchtmann, L., & Bodenmann, G. (2018). New perspectives on dynamics of dyadic coping. In A. Bertoni, S. Donato, & S. Molgora (Eds.), When “we” are stressed: A dyadic approach to coping with stressful events (pp. 3–14). Hauppauge, NY: Nova Publisher.Google Scholar
  40. Leventhal, H., & Cameron, L. (1987). Behavioral theories and the problem of compliance. Patient Education and Counseling, 10, 117–138.CrossRefGoogle Scholar
  41. Maeda, U., Shen, B. J., Schwarz, E. R., Farrell, K. A., & Mallon, S. (2013). Self-efficacy mediates the associations of social support and depression with treatment adherence in heart failure patients. International Journal of Behavioral Medicine, 20, 88–96. Scholar
  42. Mattsson, N. B., Williams, H. V., Rickels, K., Lipman, R. S., & Uhlenhuth, E. H. (1969). Dimensions of symptom distress in anxious neurotic outpatients. Psychopharmacology Bulletin, 5, 19–32.PubMedGoogle Scholar
  43. McGrady, A., McGinnis, R., Badenhop, D., Bentle, M., & Rajput, M. (2009). Effects of depression and anxiety on adherence to cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation and Prevention, 29, 358–364. Scholar
  44. Molloy, G. J., Perkins-Porras, L., Strike, P. C., & Steptoe, A. (2008). Social networks and partner stress as predictors of adherence to medication, rehabilitation attendance, and quality of life following acute coronary syndrome. Health Psychology: Official Journal of the Division of Health Psychology, American Psychological Association, 27, 52–58. Scholar
  45. Mosen, D. M., Schmittdiel, J., Hibbard, J., Sobel, D., Remmers, C., & Bellows, J. (2007). Is patient activation associated with outcomes of care for adults with chronic conditions? The Journal of Ambulatory Care Management, 30, 21–29. Scholar
  46. Moss-Morris, R., Weinman, J., Petrie, K., Horne, R., Cameron, L., & Buick, D. (2002). The revised illness perception questionnaire (IPQ-R). Psychology and Health, 17, 1–16. Scholar
  47. Norton, R. (1983). Measuring marital quality: A critical look at the dependent variable. Journal of Marriage and the Family, 45, 141–151. Scholar
  48. Nunnally, J. C. (1978). Psychometric Theory (2nd ed.). New York: McGraw-Hill.Google Scholar
  49. Pagani, A. F., Donato, S., Parise, M., Bertoni, A., Iafrate, R., & Schoebi, D. (2019a). Explicit stress communication facilitates perceived responsiveness in dyadic coping. Frontiers in Psychology, 10, 401. Scholar
  50. Pagani, A. F., Donato, S., Parise, M., Iafrate, R., Bertoni, A., & Schoebi, D. (2015). When good things happen: Explicit capitalization attempts of positive events promote intimate partners’ daily well-being. Family Science, 6, 119–128. Scholar
  51. Pagani, A. F., Parise, M., Donato, S., Gable, S., & Schoebi, D. (2019b). If you shared my happiness, you are part of me: Capitalization and the experience of couple identity. Personality and Social Psychology Bulletin. advance online publication.CrossRefPubMedGoogle Scholar
  52. Parise, M., Donato, S., Pagani, A. F., Ribeiro, M. T., & Manzi, C. (2015). Couple identity processes in young adulthood: An experimental study on the role of intrusive parenting for romantic partners’ other-serving bias. In A. M. Columbus (Ed.), Advances in psychology research (Vol. 111, pp. 123–138). Hauppauge, NY: Nova Publisher.Google Scholar
  53. Parise, M., Donato, S., Pagani, A. F., & Schoebi, D. (2017a). Keeping calm when riding the rapids: Optimism and perceived partner withdrawal. Personal Relationships, 24, 131–145. Scholar
  54. Parise, M., Manzi, C., Donato, S., & Iafrate, R. (2017b). Free to love? The role of intrusive parenting for young adult children’s romantic relationship quality. Journal of Prevention & Intervention in the Community, 45, 187–201. Scholar
  55. Parise, M., Pagani, A. F., Donato, S., & Sedikides, C. (2019). Self-concept clarity and relationship satisfaction at the dyadic level. Personal Relationships, 26, 54–72. Scholar
  56. Rajpura, J., & Nayak, R. (2014). Medication adherence in a sample of elderly suffering from hypertension: Evaluating the influence of illness perceptions, treatment beliefs, and illness burden. Journal of Managed Care Pharmacy, 20, 58–65.CrossRefGoogle Scholar
  57. Saunders, M. (2008). Factors associated with caregiver burden in heart failure family caregivers. Western Journal of Nursing Research, 30, 943–959. Scholar
  58. Scheier, M. F., Carver, C. S., & Bridges, M. W. (2001). Optimism, pessimism, and psychological well-being. In E. C. Chang (Ed.), Optimism & pessimism: Implications for theory, research, and practice (pp. 189–216). Washington, DC: American Psychological Association. Scholar
  59. Schoebi, D., Pagani, A. F., Luginbuehl, T., & Bradbury, T. N. (2015). Committed to maintain: A brief measure of maintenance-oriented relationship commitment (MORC). Family Science, 6, 160–169. Scholar
  60. Thompson, K., Kulkarni, J., & Sergejew, A. A. (2000). Reliability and validity of a new Medication Adherence Rating Scale (MARS) for the psychoses. Schizophrenia Research, 42, 241–247. Scholar
  61. Uchino, B. N. (2006). Social support and health: A review of physiological processes potentially underlying links to disease outcomes. Journal of Behavioral Medicine, 29, 377–387. Scholar
  62. Vellone, E., Chung, M. L., Cocchieri, A., Rocco, G., Alvaro, R., & Riegel, B. (2014). Effects of self-care on quality of life in adults with heart failure and their spousal caregivers: Testing dyadic dynamics using the actor–partner interdependence model. Journal of Family Nursing, 20, 120–141. Scholar

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Authors and Affiliations

  1. 1.Department of PsychologyUniversità Cattolica del Sacro Cuore - MilanoMilanItaly
  2. 2.Family Studies and Research University CentreUniversità Cattolica del Sacro Cuore - MilanoMilanItaly
  3. 3.Psychology Research LaboratoryIstituto Auxologico Italiano, IRCCSMilanItaly

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