Heart failure is the only cardiovascular disease with increasing incidence and prevalence. Heart failure is, moreover, one of the most prevalent chronic conditions. It is associated with substantial illness burden for both patient and family and is also associated with substantial healthcare costs, especially in patients who experience frequent rehospitalizations.1,2

Chronic conditions, such as heart failure, are defined as "health problems that require ongoing management over a period of years or decades."2 Adequate management of chronic conditions requires not only state-of-the-art medical treatment but also involves targeting behavioral and psychosocial risk factors that could negatively affect poor outcome. Adherence to the complex treatment regimen, a key component of the behavioral dimension of heart failure management, has been recognized as a crucial component to achieve favorable outcomes.3Adherence is defined as "the extent to which a person's behaviour (taking medications, following a recommended diet, and/or executing lifestyle changes) corresponds with the agreed recommendations of a healthcare provider."4 Adherence in heart failure has been primarily studied from a quantitative perspective. This refers to research assessing the prevalence, determinants, and consequences of nonadherence using quantifiable measures. The researcher measures a limited number of predetermined variables in the population of interest as objectively as possible and uses statistical techniques to test the hypotheses or answer the research questions subsequently. The researcher strives to warrant maximal objectivity and designs the study in a way that avoids bias as much as possible. Quantitative research is best known to healthcare workers.

In contrast, qualitative research, which unravels the underlying dynamics of nonadherence with the heart failure regimen, is less known.5 Qualitative research builds on diverse philosophical and social frameworks. Different sets of scientific premises and methods are used for studying mainly psychological and social phenomena. Depending on the question, an adequate method is chosen from a range of qualitative methods (eg, Grounded Theory, content analysis, phenomenology). Of interest to qualitative researchers are complex phenomena such as living with chronic illness6 or, as in this issue, adherence with a heart failure regimen from the patient's perspective, within his or her particular life context and culture. Frequently used methods of data collection are observation or/and interviews. Observations are written down; interviews are transcribed verbatim and analyzed by continuous comparative techniques (both inductive and deductive) with the goal of identifying themes or categories that describe the phenomenon under study. Ideally, data collection and analysis are performed simultaneously. Data collection is stopped when saturation (no new information is gained) is reached.7 Credibility (both to participants and to the scientific community) is a major quality criterion for judging qualitative results.8 Increasingly, mixed methods, meaning a combination of quantitative and qualitative methods, are appreciated as a valuable approach to get a differentiated understanding of phenomena such as adherence with the heart failure regimen.

Regarding the lived experience of adherence of heart failure patients, adherence is the result of a number of subjective processes in view of acceptance and integration of the illness experience. Patients give meaning to their disease. Readiness for treatment is very much dependent on the patient accepting that he or she has heart failure, understanding what the consequences are of his or her condition, and what kind of behaviors are required to manage heart failure in daily life. Successful self-management is a dynamic process that requires time before it is successfully integrated in the routine of everyday life. Findings indicate the importance for healthcare workers to take the patient's perspective into consideration when initiating a new treatment regimen or to discover the barriers that prevent patients from integrating a heart failure regimen in their daily life.5

This qualitative study5 also focuses on factors and dynamics that were found to negatively influence adherence. More specifically, patients reported that unusual circumstances such as juggling limited budgets or bad planning negatively influenced their adherence with the treatment regimen. Furthermore, lack of motivation, personal beliefs and values, and lack of social support from not only family but also healthcare workers were stated as contributing elements in not being able to adhere to the treatment regimen. These findings partly overlap but also add to evidence from another qualitative study9 that describes facilitators for and barriers to self-care in heart failure patients. The lack of knowledge, misconceptions, physical limitations, difficulties with coping with treatment, distressed emotions, multiple comorbidities, and personal struggles were deleterious factors for patient's adherence.9

To position the evidence of the study5 in the broader adherence context, 2 documents are worthwhile mentioning. On the one hand, there is the recent World Health Organization (WHO) report on adherence4 that provides a taxonomy to categorize factors related to nonadherence discovered either through quantitative or qualitative approaches. The WHO identifies 5 interacting dimensions that affect adherence: (1) social and economic factors; (2) healthcare team and system-related factors; (3) condition-related factors; (4) therapy-related factors; (5) and patient-related factors. Scotto5 identified factors that are related to each of the categories, yet her work has not contributed to the identification of unknown factors or dynamics related to adherence/nonadherence certainly, if evidence of other chronically ill patient populations is being considered.4,6 On the other hand, Scotto's work5 is fitting into the groundbreaking work of Strauss and Glaser6 on chronic illness and quality of life. This work gives an in-depth understanding of patients' lived experiences with chronic illness, including adherence to treatment regimens, and provides the full appreciation of how qualitative work contributes to a better understanding of a phenomenon under study. Scotto's article5 remains somewhat at the surface in contrast with the wealth of insights.6

Further work in the area of adherence with the heart failure regimen should build on the existing evidence from both qualitative and quantitative research. Important in planning further work is to appreciate the view of the expert panel of the American Heart Association, stating that "adherence is a behavioural process, strongly influenced by the environment in which the patient lives, including the healthcare practices and systems. Adherence assumes that a patient has the knowledge, motivation, skills and resources required to follow the recommendations of a healthcare professional."10 To fully grasp the phenomenon, mixed methods are the only way to go!!

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