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How and why a multifaceted intervention to improve adherence post-MI worked for some (and could work better for others): an outcome-driven qualitative process evaluation
  1. Laura Desveaux1,2,
  2. Marianne Saragosa1,
  3. Kirstie Russell1,
  4. Nicola McCleary3,4,
  5. Justin Presseau4,5,
  6. Holly O Witteman6,
  7. J-D Schwalm7,
  8. Noah Michael Ivers1,8
  1. 1Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
  2. 2Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
  3. 3Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  4. 4School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
  5. 5Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  6. 6Department of Family and Emergency Medicine, Université Laval, Quebec City, Quebec, Canada
  7. 7Translation and Health Systems Research Program, Population Health Research Institute, Hamilton, Ontario, Canada
  8. 8Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Laura Desveaux; laura.desveaux{at}


Objectives To explore (1) the extent to which a multicomponent intervention addressed determinants of the desired behaviours (ie, adherence to cardiac rehabilitation (CR) and cardiovascular medications), (2) the associated mechanism(s) of action and (3) how future interventions might be better designed to meet the needs of this patient population.

Design A qualitative evaluation embedded within a multicentre randomised trial, involving purposive semistructured interviews.

Setting Nine cardiac centres in Ontario, Canada.

Participants Potential participants were stratified according to the trial’s primary outcomes of engagement and adherence, resulting in three groups: (1) engaged, adherence outcome positive, (2) engaged, adherence outcome negative and (3) did not engage, adherence outcome negative. Participants who did not engage but had positive adherence outcomes were excluded. Individual domains of the Theoretical Domains Framework were applied as deductive codes and findings were analysed using a framework approach.

Results Thirty-one participants were interviewed. Participants who were engaged with positive adherence outcomes attributed their success to the intervention’s ability to activate determinants including behavioural regulation and knowledge, which encouraged an increase in self-monitoring behaviour and awareness of available supports, as well as reinforcement and social influences. The behaviour of those with negative adherence outcomes was driven by beliefs about consequences, emotions and identity. As currently designed, the intervention failed to target these determinants for this subset of participants, resulting in partial engagement and poor adherence outcomes.

Conclusion The intervention facilitated CR adherence through reinforcement, behavioural regulation, the provision of knowledge and social influence. To reach a broader and more diverse population, future iterations of the intervention should target aberrant beliefs about consequences, memory and decision-making and emotion.

Trial registration number registry; NCT02382731

  • qualitative research
  • myocardial infarction
  • health services administration & management

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Contributors LD contributed to the study design, data analysis and interpretation of the results and drafted the manuscript. KR and MS contributed to data analysis and interpretation of the results. J-DS, JP, NMI and HW contributed to the interpretation of the results. NMI contributed to the study design and interpretation of the results. All authors read, contributed to, and approved the final manuscript.

  • Funding Funding support was available through Ontario Ministry of Health and Long Term Care (MOHLTC) Health System Research Capacity Award grant number 06683 and the Canadian Institutes of Health Research’s Strategy for Patient Oriented Research, through the Ontario Strategy for Patient Oriented Research Support Unit.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

  • Patient consent for publication Not required.

  • Ethics approval This study received ethics approval from the Research Ethics Boards at Women’s College Hospital (REB number 2017-0135-E). Informed consent was obtained from all participants.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. An aggregate summary of the data generated during this study is included in this published article. Individual data transcripts cannot be shared publicly due to confidentiality.

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