Elsevier

American Heart Journal

Volume 164, Issue 6, December 2012, Pages 835-845.e2
American Heart Journal

Curriculum in Cardiology
A qualitative systematic review of influences on attendance at cardiac rehabilitation programs after referral

https://doi.org/10.1016/j.ahj.2012.08.020Get rights and content

Background

Cardiac rehabilitation and secondary prevention programs can prevent heart disease in high-risk populations. However, up to half of all patients referred to these programs do not subsequently participate. Although age, sex, and social factors are common predictors of attendance, to increase attendance rates after referral, the complex range of factors and processes influencing attendance needs to be better understood.

Methods

A systematic review using qualitative meta-synthesis was conducted. Ten databases were systematically searched using 100+ search terms until October 31, 2011. To be included, studies had to contain a qualitative research component and population-specific primary data pertaining to program attendance after referral for adults older than 18 years and be published as full articles in or after 1995.

Results

Ninety studies were included (2010 patients, 120 caregivers, 312 professionals). Personal and contextual barriers and facilitators were intricately linked and consistently influenced patients' decisions to attend. The main personal factors affecting attendance after referral included patients' knowledge of services, patient identity, perceptions of heart disease, and financial or occupational constraints. These were consistently derived from social as opposed to clinical sources. Contextual factors also influenced patient attendance, including family and, less commonly, health professionals. Regardless of the perceived severity of heart disease, patients could view risk as inherently uncontrollable and any attempts to manage risk as futile.

Conclusions

Decisions to attend programs are influenced more by social factors than by health professional advice or clinical information. Interventions to increase patient attendance should involve patients and their families and harness social mechanisms.

Section snippets

Background

Why are effective health services not used? Cardiac rehabilitation (CR) and secondary prevention programs are common across high-income countries, but up to 50% of eligible patients who are referred do not subsequently participate.1, 2, 3, 4 Attendance after referral is essential if patients are to benefit from these evidence-based interventions. Although modifiable cardiovascular risk remains very high in populations with coronary heart disease,5, 6 patients who participate in programs are up

Methods

Because this study was focused on the complex factors and processes that influence attendance rather than preidentified predictors of attendance,3, 4 qualitative research studies were the focus of this review.13 Qualitative research methods have been used frequently to understand patient and health professional decision making in complex settings and organizations, including the provision of primary care14 and cardiac services.15, 16, 17, 18

To be included, studies had to contain a primary,

Results

From 2264 unique studies screened (Figure 2), 90 studies contained data on CR attendance (2010 patients: 1051 male, 907 female, 52 not described; mean age 62.1 ± 11.5 years; range 27-90 years; 120 caregivers; 312 professionals). A third of the studies were conducted in the United Kingdom (n = 31), and study quality was moderate (Table I).

Low insight and knowledge into services

Numerous studies identified that a lack of personal insight or knowledge regarding the nature of programs was a common barrier to attendance.48, 50, 53, 56, 58, 59, 61, 65, 73, 83, 84, 92, 99, 101, 107 Patients perceived that programs would not be beneficial generally47, 82 or for people “like them”23, 93and reported receiving little information from health professionals on what programs consisted of37, 45, 50, 58, 59, 84, 90or program benefits51, 58, 59 and little encouragement to attend.47, 58

Heart disease as controllable

A high sense of control over heart disease was commonly associated with attendance24, 26, 27, 55, 58, 59, 76, 93, 95, 97, 102, 108 and was reinforced by experiences of controlling other diseases,56 the sense of mastery33 or security associated with participating in programs,26, 30, 75, 88, 93 and self-reliance in the face of the demands created by heart disease.24, 44, 54, 95

Positive views of services

Service benefits perceived to increase attendance included reducing stress,76, 78, 79, 86 improving general health,39, 76

Long distances to services

Long travel distances to CR programs were cited as a common barrier to attendance,58, 59, 64, 65, 80, 92, 99, 109 particularly from rural settings33, 53 or when transport links were poor.55, 65

Lack of support from family

Family members curtailed attendance through both active and passive actions. Families were seen to overprotect the patient24 or “take charge” of risk factor reduction.28, 53, 57, 61, 68, 89, 101 Families also constrained attendance due to demands on patients for caregiving67, 85 or similar familial

The family and social networks

Families could also facilitate attendance97 by providing social support,67 transportation to centers,33, 40, 52, 55, 96 accompanying the patient to the program,30, 77, 93, 98 providing information on services,24, 67 communicating with health professionals,96 or making exercise normal.24, 67 Encouragement to participate in programs from previous attending patients was also cited to promote attendance.30, 34 A sense of camaraderie between patients in CR programs existed and could sustain

Discussion

Decisions to attend CR programs were strongly influenced by patients' psychosocial factors, context, and other occupational and personal commitments, including social comparisons, perceived benefits and control, occupational demands and constraints, distance to settings, and families. The influence of such a wide range of factors is common in acute111, 112, 113, 114, 115, 116and chronic stages of heart disease,117, 118 but medical reasons for low attendance (such as symptoms and comorbidities)

Research and practice

There is strong evidence from clinical trials that patients who are unable to participate in hospital-based programs can have equally positive outcomes from specially tailored programs as patients who attend hospital-based programs.121, 122, 123, 124 In preference to providing hospital-based programs outside traditional work hours, more types of programs that allow remote access via the Web, e-mail, or telephone could be available to ensure that time and distance do not act as barriers to

Limitations

This review used a recognized approach to qualitative synthesis19 to harness and synthesize relevant data from qualitative studies of diverse populations. As with all reviews, it is constrained by the quality and scope of existing published studies.21 Across the included studies, there was limited analysis of the influence of sex, age, or ethnic group membership. Study quality was moderate overall and mostly confined to high-income countries with well-funded health care systems. Attendance was

Conclusion

Attendance in CR is influenced by a range of psychosocial, familial, and contextual factors. Future interventions to promote higher access should include family members and foster patients' sense of control of cardiovascular risk, harness similarities rather than differences with patients who participate, and harness family members to support rather than curtail attendance. Peer support of both patients and families may be a particularly promising and efficient means to facilitate these aims.

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    Funding was provided by the Canadian Institutes of Health Research via a Knowledge Synthesis Grant (G118160769).

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