Benefits, Facilitators, and Barriers of Alternative Models of Cardiac Rehabilitation: A QUALITATIVE SYSTEMATIC REVIEW : Journal of Cardiopulmonary Rehabilitation and Prevention

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Benefits, Facilitators, and Barriers of Alternative Models of Cardiac Rehabilitation

A QUALITATIVE SYSTEMATIC REVIEW

Platz, Katherine RN, BSN; Kools, Susan PhD, RN, FAAN; Howie-Esquivel, Jill PhD, FNP, FAAN

Author Information

University of Virginia School of Nursing, Charlottesville.

Correspondence: Katherine Platz, RN, BSN, University of Virginia School of Nursing, 225 Jeanette Lancaster Way, Charlottesville, VA 22903 ([email protected]).

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com).

The authors declare no conflicts of interest.

Journal of Cardiopulmonary Rehabilitation and Prevention 43(2):p 83-92, March 2023. | DOI: 10.1097/HCR.0000000000000738

KEY PERSPECTIVE

  • Alternative models of cardiac rehabilitation improve self-efficacy, which is an important predictor of physical activity and health-related quality of life.
  • Top two facilitators: family/peer support and convenience.
  • Top two barriers: fearful preconceptions about exercise, and complaint with the specific exercise or aspect of the program.
  • Patients described numerous physical, psychological, and social benefits not typically measured in research indicating new directions for clinical practice as well as future study designs.

Cardiovascular disease (CVD) is the number one cause of death in adults worldwide.1 Cardiac rehabilitation (CR) is utilized as a CVD secondary prevention measure and combines education and exercise to reduce and reverse risk factors for CVD-related death.2 Standard CR programs are typically in person at an outpatient center or hospital and include 36 sessions of prescribed aerobic exercise using a treadmill or cardio exercise machine over the course of 12 wk. Cardiac rehabilitation has long been shown to reduce CVD-related death, hospitalization, and to improve health-related quality of life.3 Despite clear health-related benefits, CR participation rates are low and long-term adherence is even lower.4 In the United States (US), it is estimated that one-quarter of all eligible patients initially attend CR, but just one-quarter of those patients will complete all recommended sessions.5

Lack of local CR programs (CR deserts), suspended CR programs for COVID-19, cost, lack of provider referral, rural living, lower socioeconomic status, and underinsurance are factors that lead to low CR enrollment.6–8 Patient-related factors also limit CR attendance including transportation, time conflicts for competing demands, depression, maladaptive coping, and physical limitations to exercise.8–13 Access to PA has been defined by US Department of Health and Human Services as a social determinant of health. Lack of access to resources for positive health behaviors, such as CR and physical activity (PA) programs, can perpetuate health inequity.14 By providing alternative models of PA that are more accessible and accommodate physical limitations, health inequity can be better addressed.

Accordingly, researchers and providers have recognized the need for alternative models of CR.6 For the purposes of this review, an alternative model of CR is defined as a model using either an alternative form of exercise and/or an alternative location such as a home-based or community-based setting. The aim of an alternative exercise model can be twofold: to accommodate the physical limitations of patients due to past injuries, comorbidities, or low existing cardiorespiratory fitness, or to provide a type of exercise that may be more convenient or accessible to the patient. Examples of alternative exercises include swimming, exergaming (videogaming for exercise), mind-body exercises, and chair-based exercises, among others. Home-based or community-based CR models reduce or eliminate patient travel needs. Home-based CR models can use either synchronous or asynchronous communication via phone, text, web dashboard or live video to communicate, potentially increasing CR access both geographically and for scheduling flexibility.15

While a systematic review has been undertaken to determine the effectiveness of alternative models of CR,16 a synthesis of qualitative data that describe the effectiveness has yet to be published. A systematic review of qualitative studies is well-suited to capture the participant perspective that can better inform CR program design and implementation, as well as to identify new directions for research.17 Therefore, our aim is to systematically review the qualitative evidence exploring patient experiences with alternative models of CR.

METHODS

This review follows the six stages for developing a qualitative systematic review protocol outlined in Butler et al's guide: (1) developing a research question, (2) developing a search strategy, (3) designing a review process, (4) critically appraising the studies, (5) extracting the data, and (6) synthesizing the data.18 Additionally, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines19 as well as the enhancing transparency in reporting the synthesis of qualitative research statement.20 The review was pre-registered with PROSPERO (no. 261207) and conforms with the principles outlined in the Declaration of Helsinki.

SEARCH STRATEGY

We searched databases PubMed, CINAHL, Web of Science, and PsycINFO in January of 2022 in consultation with an expert health sciences librarian using Boolean operators combining the following keywords: cardiac disease, heart disease (MeSH term), heart failure, walking, Wii (gaming console), home-based, yoga, tai chi, stretch, dance, qigong, aquatic exercise, water exercise, calisthenics, gardening, weight-support exercise, mind-body, tele-rehabilitation (MeSH term), qualitative research (MeSH term), interviews, and focus group (MeSH term). Date restrictions were set to studies published since 2009 to capture the most current CR studies. We restricted the search to peer-reviewed studies published in the English language. We also hand-searched reference lists of relevant papers. We saved all articles to a citation manager and removed duplicates prior to screening.

STUDY SELECTION PROCESS

The search resulted in 459 studies after duplicates were removed. We reviewed the title and abstracts of all articles for inclusion criteria (Figure 1), and reviewed the full text of remaining articles for exclusion criteria. We included studies if they used qualitative study methods to assess the participant experience of an adult with CVD in a multicomponent or stand-alone exercise intervention for the secondary prevention of CVD. We excluded studies if they did not have results, if the exercise protocol was poorly described, or if the intervention was standard CR.

F1
Figure 1.:
PRISMA flow diagram describing search strategy and study selection.

CRITICAL APPRAISAL

Two researchers (K.P. and J.H.E.) independently conducted a critical appraisal of each study using the Critical Appraisal Skills Program qualitative checklist that comprises 10 questions to evaluate the quality, trustworthiness, and rigor of the findings (Table 1).21 Disagreements in scoring were discussed between reviewers until consensus was achieved. A third person was designated to resolve disagreements in scoring if necessary; however, that third person was not needed.

Table 1 - Qualitative Critical Appraisal Skills Program Scores of Included Studiesa
Article Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Score
Adsett et al (2019)25 1 1 1 1 1 1 1 1 1 1 10
Cacciata et al (2022)34 1 1 1 1 1 0.5 1 1 1 1 9.5
Clark et al (2016)40 1 1 1 0.5 1 0 1 1 1 1 8.5
Conboy et al (2020)73 1 1 1 1 1 0.5 1 1 1 1 9.5
Pfaeffli Dale et al (2015)74 1 1 1 1 1 0 1 1 1 1 9.0
Devi et al (2014)35 1 1 1 1 1 0 1 1 1 1 9.0
Dinesen et al (2019)75 1 1 1 1 1 1 1 1 1 1 10
Frost et al (2019)27 0.5 1 1 1 1 1 0.5 1 1 1 9.0
Hägglund et al (2017)28 1 1 1 1 1 0.5 0.5 1 1 1 9.0
Hannan et al (2021)76 1 1 0.5 1 1 1 1 0.5 1 1 9.0
Heron et al (2017)37 1 1 0.5 0.5 1 0.5 1 1 1 1 8.5
Hwang et al (2017)29 1 1 1 1 1 1 1 1 1 1 10
Jones et al (2007)38 1 1 1 1 1 0 0 0.5 1 1 7.5
Jones et al (2009)77 1 1 1 1 1 0 0 0.5 1 1 7.5
Klompstra et al (2017)26 1 1 1 1 1 0.5 1 1 1 1 9.5
Klompstra et al (2021)31 1 1 1 1 1 1 1 1 1 1 10
Knudsen et al (2021)78 1 1 1 1 1 0 1 1 1 1 9.0
Murphy et al (2021)39 1 1 0.5 1 0.5 0 1 0.5 1 1 7.5
O'Shea et al (2020)79 1 1 1 1 1 0.5 1 1 1 1 9.5
Okwose et al (2020)32 1 1 1 1 1 1 1 1 1 1 10
Selman et al (2015)23 1 1 1 1 1 0.5 1 1 1 1 9.5
Smith et al (2021)30 1 1 1 1 1 1 0.5 1 1 1 9.5
Thorup et al (2016)33 1 1 1 1 1 1 1 1 1 1 10
Wahlstrom et al (2018)36 1 1 0.5 1 1 0 1 1 1 1 8.5
Yeh et al (2016)24 1 1 1 1 1 0.5 1 1 1 1 9.5
aYes: 1; unsure: 0.5; no: 0.

DATA EXTRACTION AND THEMATIC ANALYSIS

We analyzed the coded data using the three stages of thematic analysis.22 First, we inductively coded every word of the results section of each study including only that which pertained to participant perspectives of alternative models of CR. Second, we organized and combined codes into related categories. Lastly, we compared categories and merged them into analytical themes. The cross-platform program Dedoose was used to manage data analysis. Discussion among authors was ongoing during each stage of data extraction and synthesis and was facilitated with memos to track decision-making and thematic conceptualizations.

RESULTS

Twenty-five studies were included in this review (see Supplemental Digital File, available at: https://links.lww.com/JCRP/A419) representing eight countries and 487 individuals (female patients = 144, male patients = 295, caregivers = 37, and professionals = 11) with an age range of 34-85 yr who participated or supported patient participation in an alternative model of CR. A variety of alternative models of CR were represented (Table 2). Exercises included walking, tai chi, yoga, aquatic exercise, exergaming (videogaming for exercise), chair-based exercises, aerobics, PA trackers, and individualized exercise plans. Nineteen of 25 studies used home-based models, two of which were live video. Twelve of the studies included patients with heart failure (HF),23–34 one included patients with stable angina,35 one included patients with paroxysmal atrial fibrillation,36 and one focused on patients who experienced transient ischemic attack.37 Qualitative study methodology varied and the majority used either thematic or qualitative content analysis. Twenty study designs included individual semistructured interviews and five included focus groups.24,32,37–39

Table 2 - Alternative Models of Cardiac Rehabilitation
Author (yr) Further Specified CR Population Exercise Type Home-Based Center-Based Group-Based Live Video CR Monitoring Equipment Pedometer or Wearable Communication
Adsett et al (2019)25 HF Aquatic X X
Cacciata et al (2022)34 HF Exergaming X Phone
Clark et al (2016)40 Walking X Phone
Conboy et al (2020)73 Tai chi X X
Pfaeffli Dale et al (2015)74 IHD Individualized exercise prescription X Text; website
Devi et al (2014)35 Angina Individualized exercise plan X Website; chat room
Dinesen et al (2019)75 Individualized exercise plan X X X Web portal
Frost et al (2019)27 HFrEF Chair-based or walking X Home visits or phone
Hägglund et al (2017)28 HFrEF Tai chi X X
Hannan et al (2021)76 Personal Activity Intelligence score X X Face-to-face visits
Heron et al (2017)37 TIA Moderate physical activity X X Phone
Hwang et al (2017)29 HF Exercise class X X X X
Jones et al (2007)38 Exercises and walking X Home visits; phone
Jones et al (2009)77 Exercises and walking X Home visits; phone
Klompstra et al (2017)26 HF Exergaming X
Klompstra et al (2021)31 HF Exercise advice and motivational support X Hospital visits or phone
Knudsen et al (2021)78 Biking or running or local gym X X Phone, text, or e-mail
Murphy et al (2021)39 Yoga X X
O'Shea et al (2020)79 Aerobic and resistance exercise class with Avatar coach X X Dashboard; text
Okwose et al (2020)32 HFrEF Walking X X Phone
Selman et al (2015)23 HF/COPD Yoga X X X
Smith et al (2021)30 HFpEF Chair-based or walking X Home visits or phone
Thorup et al (2016)33 Includes HF Walking X X X
Wahlstrom et al (2018)36 PAF Yoga X X
Yeh et al (2016)24 HFrEF Tai chi X X
Abbreviations: COPD, chronic obstructive pulmonary disease; CR, cardiac rehabilitation; HF, heart failure; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; IHD, ischemic heart disease; PAF, paroxysmal atrial fibrillation; TIA, transient ischemic attack.

RESULTS OF THEMATIC ANALYSIS

Participant perspectives can be summarized in three central themes: (1) exercise benefits, (2) exercise facilitators, and (3) barriers that influenced or prevented participation. Themes and categories along with supporting studies are provided in Table 3.

Table 3 - Themes and Categories From Qualitative Studies
Theme Category—Supporting Studies Center-Based (6) Home-Based (19) Heart Failure (12) Total Studies (25) Total Studies (25)
Benefits Self-efficacy and lifestyle changes23–40,73–79 6 19 12 25 25
Physical or health improvements23–40,73,77–79 6 16 12 22
Psychological improvements23,24,27–31,34–40,73,76,77,79 5 13 8 18
Improved access to health-related care23,25–27,29,33–38,76–79 2 13 7 15
Increased peer or family support24–26,28–30,32,34,39,73,79 5 6 8 11
Facilitators Convenience23,26–38,73,75–79 3 17 10 20 25
Family or peer support23–34,37–39,73–75,77,79 5 15 12 20
Feeling safe and/or supported from staff or medical endorsement23,25–33,35,37,38,73–75,77–79 3 16 10 19
Being accountable26,29–35,37,38,40,74–79 0 17 7 17
Subcategory: Performance feedback 26,29–35,37,40,74–79 0 16 7 16
Subcategory: Goal setting 26,30–35,37,74–78 0 13 6 13
Subcategory: Logging exercise 30,31,33,35,75–79 0 9 3 9
Subcategory: Being prompted 32,33,38,74,77,79 0 6 2 6
Tailoring or individualizing to preference or ability23,27,29–33,35,39,40,73–79 2 15 8 17
Enjoyment or preference23,25,26,28,29,31,33,34,36,38,40,77,78 3 10 8 13
Anticipating or experiencing physical or psychological benefits23,29,30,33,34,36–38,73,76,78,79 2 10 5 12
Perceiving the exercise as attainable23,25–28,30,32,40,73,74,77,78 3 9 7 12
Barriers Fearful, negative, or false preconception about exercising23,25,27–29,31,32,35,38,73,75–78 3 11 7 14 22
Complaint with exercise or program design23,25,26,28,30,33,34,38,73,75,76,79 3 9 7 12
Physical limitations to exercising23,26,27,30,31,33,38,40,76,77,79 0 11 6 11
Weather, terrain, or transportation28,31–33,35,38,40,73,76,77,79 2 9 4 11
Competing responsibilities26,31,35,38,40,73,76,77,79 1 8 2 9
Already have an exercise routine26,28,30,35,38,40,74,76 1 7 3 8
Technical difficulties, technology illiteracy23,29,37,40,74,76,79 0 7 2 7
Lacking motivation26,27,34,35,38,76,78 0 7 3 7
Misunderstanding or confusion25,27,30,38,76,79 1 5 3 6

Theme 1: Exercise Benefits

All study participants reported benefit(s) from study participation. Five categories of benefit are listed in order of prominence (Table 3). Improvement in self-efficacy was the most commonly reported benefit noted in all 25 studies. Participants described self-efficacy in terms of exercise or in managing health conditions and symptoms, including making important lifestyle changes. Many participants remarked that exercise participation gave them confidence to increase and try new exercises or activities they would not have previously attempted. Some participants expressed that they were able to return to activities they had enjoyed earlier in life.

A number of participants reported improvements in managing bothersome symptoms. For example, a participant in a center-based group yoga intervention reported improved stress self-management, which, in turn, eliminated bothersome atrial fibrillation symptoms.36 Similarly, a home-based yoga group participant with HF experienced improved management of breathlessness during exercise.23 The authors speculate that self-efficacy is more likely to occur when participants also experience psychological improvements, physical or health improvements, being accountable, improved access to health-related care, convenience, and tailoring or individualizing to preference or ability, as these categories frequently co-occurred. These frequent co-occurrences could signify the potential mechanism by which patients came to have feelings of improved self-efficacy.

Lifestyle changes encompassed prioritizing and planning for exercise by increasing either the intensity of or time spent completing exercise. Changing diet and quitting smoking were also among the lifestyle changes reported by study participants.

Physical benefits were the next most prominent category with evidence in 22 studies. Physical improvements included enhanced balance, flexibility, coordination, range of motion, strength, increased PA, and a return to activities previously enjoyed. An older male adult with HF attributed participation in center-based group tai chi with improvements in his balance and restoring a steady gait from his previous shuffling walk.28 Improvements in health or comorbid conditions included weight loss, improved blood sugars, symptom control, blood pressure, cardiac function, sleep quality, and avoiding invasive procedures. A participant in a home-based walking intervention stated that her blood sugar levels were normal for the first time in 30 yr.32

Reported psychological benefits included decreased anxiety and stress, increased resilience, motivation to exercise, alertness, and positive mood. The authors speculate that psychological benefits are more likely to occur when participants also experience self-efficacy and physical or health improvements, as these categories frequently co-occurred. Additionally, participants from all six programs that used either tai chi or yoga reported psychological benefit. Five of those programs were in person and the sixth used live video instruction, suggesting that peer support may also contribute to psychological benefit.

Improved access to PA and/or medical care was expressed as a benefit in 15 studies. Improved social support, whether in the form of peer or family support, was also an important benefit noted among participants in 11 studies.

Theme 2: Exercise Facilitators

Participants in all 25 studies reported factors that facilitated initiation and continued engagement with PA participation. Facilitators comprised eight categories (Table 3). Equally cited as a facilitator were the categories of convenience and family or peer support, each represented in 20 studies. Exercise as being adaptable to the environment of the participant was highlighted by study participants who remarked that they used yoga at work or even sitting in a traffic jam.36 Convenience also related to the alternative setting. For example, one participant commented on the convenience of a home-based live-video group exercise class as eliminating the burden of driving for his wife.29

The presence of peer or family support was an equally referenced facilitator across studies regardless of whether the exercise was center- or home-based, despite wide variations in social connection and study designs. Participants in center-based programs noted the importance of, and positive, motivating influence of group meetings with peers who shared their diagnosis. One participant in a center-based group tai chi class for HF patients remarked that the social interaction among group participants was the most enjoyable part of exercise participation and reason for adherence.28

Peer and family support was also an important facilitator in home-based programs. For some participants, having their exercise program at home meant that family or caregiver support could naturally occur, as family members and caregivers were frequently present during exercise sessions, some of them joining in alongside the participant.29 Some participants noted friendly competition or accountability to exercise occurred with family members.37 Family and peer support was mentioned as a facilitator in all 12 HF programs and in five of the six center-based programs.

Across 19 studies, participants cited that feeling safe through staff contact was an important exercise facilitator. This contact ranged from an initial medical endorsement, to asynchronous monitoring or communication (email, messaging, and dashboard), to direct communication (phone calls, video calls, and home visits). Feeling safe and/or supported was mentioned in 16 of 19 home-based programs and 10 out of 12 programs for patients with HF.

Being held accountable to exercise participation was a facilitator mentioned in 17 studies, but one that was implemented in a variety of ways by the research teams. Accountability to exercise strategies included performance feedback, goal setting, logging exercise, and prompting. Whether accountability was enacted by the individual or the health team, and to what extent, varied by individual study design. Accountability was not referenced by any of the center-based programs, but was mentioned in 17 of 19 home-based programs.

Tailoring or individualizing exercise to physical ability or preference was an equally cited facilitator as referenced in 17 studies. Tailoring could mean increasing or decreasing the difficulty, or suggesting an alternative exercise if previous injury prevented certain activities or simply if the patient disliked an aspect of the exercise that could be modified. Feeling safe, tailoring to preference or ability, and being accountable were frequently mentioned together suggesting a potentially significant relationship.

Thirteen studies referenced enjoyment and preference as facilitating participation; often enjoyment acted as a distractor that participants said enabled exercise to pass without their notice, sometimes resulting in exercising longer, as was noted in a study that examined pairing music to walking.40 Equally cited facilitators were anticipating or experiencing desirable physical or psychological health benefits, reported in 12 studies, and perceiving exercise as attainable or realistic.

Theme 3: Barriers That Influenced or Prevented Exercise Participation

Exercise barriers that influenced or prevented participation were reported in 22 of the 25 studies and comprised nine categories (Table 3). A fearful, negative or false preconception about exercise by the participant or their family presented a barrier to exercise in 14 studies. Many participants or their family members were concerned that exercise or too much exercise may cause further heart damage. Some were unsure of what kind of exercise was appropriate for their heart condition. Others were concerned that exercise would exacerbate a previous back or knee injury or that frailty would prevent exercise participation.

Complaint with a specific exercise or an exercise program design was cited in 12 studies as a barrier to participation. For example, a participant who found an exercise boring or stated that they preferred outdoor exercise limited their study participation.

Physical and/or health conditions such as back pain, arthritis, knee pain, and CVD symptoms altered or prevented participation in 11 studies. One participant remarked of a home-based walking program that her knee pain simply prevented her from walking and that the music intervention could not change that.40

Weather, terrain, and transportation also emerged as barriers to participation in 11 studies; nine of these studies were home-based programs that included walking outdoors as the primary mode of exercise. Weather was often the cited barrier that altered or prevented participation in these studies.

Competing obligations such as work or caring responsibilities was a barrier in nine studies. Other barriers included technical difficulties and/or technology illiteracy, lacking motivation, and misunderstanding or confusion about the exercise. There were no frequent co-occurrences of barriers with any other category.

DISCUSSION

This qualitative systematic review revealed that all alternative models of CR were beneficial to participants physically, psychologically, and/or socially despite differences in types and delivery methods found in exercise programs. We agree with past reviews that there is no need to rely on the traditional model of CR.16,41,42 Rather, CR models that offer an alternative location and/or an alternative exercise should be made available to better meet patient need and preference. Participants described influential facilitators and barriers that informed the initiation and continuation of exercise. These insights offer pragmatic data with which to improve the delivery of CR to be accessible and appealing. Our qualitative systematic review also reveals a wide array of physical, psychological, and social benefits over and above exercise capacity and CVD risk factor modification that are typically presented as benefits in quantitative systematic reviews examining the effects of alternative and traditional CR.41–45 Thus, our findings reveal many new directions for clinical practice and future research.

EXERCISE BENEFITS

Physical and health benefits were reported in the vast majority of studies. Physical benefits included improved balance, flexibility, coordination, range of motion, strength, and increased PA. Although numerous patients with CVD stand to gain from these important benefits, many of these benefits are critical in reversing sarcopenia (muscle loss) commonly associated with aging.46,47 Older adults with CVD are currently underreferred to standard CR4; these findings suggest that this absence represents not only the lack of secondary CVD prevention measures, but also a missed opportunity to reverse sarcopenia and potentially avoid associated adverse outcomes.

Increased exercise self-efficacy was a psychological benefit in all included studies. Self-efficacy is a well-documented determinant of PA engagement and maintenance and is the only consistent predictor of PA benefits; high self-efficacy predicts low exercise lapse and relapse.48,49 Self-efficacy is also associated with better health-related quality of life among patients with CVD50; among patients with HF, improving self-efficacy, attitudes, and managing relapse are integral to long-term exercise adherence.51 That said, self-efficacy was measured in only 10 of 83 studies in Clark et al's alternative models of CR systematic review.16 Knowledge of which models of CR result in high self-efficacy and the further isolating of key ingredients to support self-efficacy is imperative to improving exercise initiation and adherence.

Participants reported psychological benefits that included decreased anxiety and stress, increased resilience, motivation to exercise, alertness, and positive mood. Our findings mirror and potentially provide important qualitative context to quantitative studies that show significant improvements in anxiety and depression among patients with CVD completing exercise-based CR.52–54 Some studies have suggested a bidirectional relationship between depression and cardiovascular health.55,56 These pathophysiological pathways are not fully understood and require additional examination. Additionally, qualitative studies are needed to explore for whom psychological benefits occur, and what ingredients of CR facilitate those outcomes.57

We found participants reported improved family/peer support in nearly half of the included studies. Previous data show that psychosocial factors, such as family and peer support, are a protective factor for all cause and early mortality associated with social isolation in patients with CVD.58–60 Further, family/peer support was associated with improved mental health in one study.61 Importantly, our review found that two-thirds of the participants who reported an improvement in family and peer support had HF, a population with highly prevalent social isolation and loneliness and increased risk for adverse effects from social isolation and loneliness.58 Thus, it is possible that alternative models of CR could serve the additional purpose of improving social isolation and loneliness. Further research examining how and why improvement in social support occurs and for whom is needed.

EXERCISE FACILITATORS

Family/peer support was also one of the most prominent facilitators across all reviewed studies. Family and peer support often naturally occurred as a result of the CR program design. For example tai chi was taught in person to a group of patients with HF; patients described the shared diagnosis, space, and learning experience as contributing to a unique social environment that many stated was the best aspect of their participation.28 One home-based design meant family support could naturally occur because families were often present when the patient exercised.29 Similar to findings in previous reviews, future CR design models may involve or augment existing family and peer relationships to improve exercise adherence.62,63

Convenience was an equally cited facilitator and was mentioned more often by participants in home-based programs as well as programs for patients with HF. This is a significant finding in that geographic distance from CR, lack of transportation, difficulty leaving the home, and inability to drive are known barriers to traditional CR that home-based programs could potentially allay.6,7,9 Although there is preliminary evidence that home-based telerehabilitation programs may have higher adherence than traditional CR,15 further research is needed to determine whether convenience mitigates CR access barriers and improves adherence. Interestingly, although convenience was a prominent facilitator in home-based programs, barriers such as weather, terrain, and transportation as well as competing responsibilities were still mentioned by participants in nearly half of the home-based programs. However, these home-based programs all included walking as a primary exercise; inclement weather for walking accounted for many of these barriers.

Another exercise facilitator in home-based programs was accountability. Accountability was reported by participants in 90% of home-based programs whereas this was not reported by center-based participants. This is unsurprising given that home-based programs can have less physical visibility and many rely on the participant to be self-motivated.35,64 Also comparatively higher in home-based programs than center-based programs were the facilitators of feeling safe and/or supported, as well as tailoring or individualizing the exercise to preference or ability. Participants with HF also seemed to value feeling safe and/or supported, and participants in all of the included HF programs referenced family and/or peer support as a facilitator. These facilitators are consistent with the specific challenges of living with HF such as difficulty leaving home, social isolation, loneliness, and navigating bothersome, unpredictable, and physically limiting symptoms.65

EXERCISE BARRIERS

Similar to the qualitative review by Neubeck et al9 that examined traditional CR participation, we found no predominant exercise barrier across studies, but rather barriers were individual or program dependent. Barriers ranged from mere participation hesitancy to unwillingness. Each barrier could pose a threat to the individual while forming the intention to exercise and/or while choosing whether or not to continue long-term exercise. Overall, barriers were inconsistently reported and not reported in three of the included studies.

Our results revealed that participants or family members in over half of the included studies feared that exercise could cause negative cardiac consequences. We provide qualitative context to the study by Farris et al,66 who similarly found 40-50% of patients attending CR feared negative health consequences of exercise. Interestingly, a previous qualitative systematic review that examined traditional CR does not mention fear of exercise as a reason for CR nonattendance.9 Armed with knowledge that many patients with CVD are uncertain whether or not exercise will cause negative cardiac consequences, or are unsure of the amount of exercise that is appropriate, clinicians can work to address these concerns when describing CR. Providing reassurances early on in an exercise program and throughout can provide support to facilitate exercise participation. Our broad recommendations for the future design of CR programs that incorporates the facilitators while minimizing the impact of barriers can be found in Figure 2.

F2
Figure 2.:
Recommendations for designing cardiac rehabilitation programming.

PHYSICAL ACTIVITY AS A SOCIAL DETERMINANT OF HEALTH

Physical limitations to exercising such as back pain and knee pain were barriers reported in nearly half of the included studies. Our results provide a qualitative comparison to the study by Platz et al67 that estimates 42% of US adults with CVD have difficulty walking or climbing stairs. The Centers for Medicare & Medicaid Services has included PA as a social determinant of health. Physical activity is included in the Health Resources Social Network screening tool used to identify all potential sources of health inequity.68,69 Recently, the Million Hearts think tank has called for innovative delivery of CR to broaden access and address health inequity.70 Many of the models of CR in this review represent less resource-intensive models that could potentially expand program capacity to address the worldwide underutilization of CR.71 These patient insights could also aid in upstream public health efforts to develop programs to launch PA programs for adults and simultaneously combat the 40% US obesity prevalence, a major risk factor for CVD.72

STRENGTHS AND LIMITATIONS

The primary limitation of this review is that the included studies are not uniform either in type of intervention or in qualitative design. Lack of direct contact with the interview data limits our ability to fully understand the participant experiences. Although all included studies received good to excellent CASP scores, the authors complete the analysis and interpretation process with implicit biases. Half of the studies did not include participant demographic information. Without demographics we cannot ascertain whether patients from underrepresented communities are offered CR, participate, and/or have similar or unique facilitators and barriers to participation. We offered our interpretations of the frequent co-occurrences of categories, which we speculate signify underlying mechanisms and relationships. However, there is a need to analyze which combinations of benefits, facilitators, and barriers work best and for whom, and how it relates to program adherence.

CONCLUSIONS

All alternative models of CR were found to be physically, psychologically, and/or socially beneficial to participants. Despite the variety of program designs, there were several common facilitators identified across studies that led to both initial and ongoing participation such as peer and/or family support, convenience, feeling safe through contact with staff or medical endorsement, being accountable, tailoring to individual preference or ability, enjoyment, anticipating or experiencing health benefits, and the perception that prescribed exercise is attainable. Exercise barriers included fearful, negative or false preconceptions about exercise, complaint with the specific exercise or aspects of the program, physical limitations to exercise, weather, terrain, or transportation, competing responsibilities, technical difficulties or technology illiteracy, lacking motivation, and misunderstanding that resulted in participation hesitancy and unwillingness. These patient insights offer pragmatic data with which to design CR that is appealing, accommodates physical limitations, and broadens access to address health inequity and worldwide underutilization of CR.

Acknowledgments

The authors would like to thank the contributions of Mr Chance Platz and expert health sciences librarian Mr Dan Wilson.

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Keywords:

cardiac rehabilitation; cardiovascular disease; musculoskeletal pain; qualitative research; telerehabilitation

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