Barriers to Participation in and Adherence to Cardiac Rehabilitation Programs: A Critical Literature Review
from Progress in Cardiovascular Nursing
Reprinted from MedScape.com
John Daly, RN, PhD ; Andrew P. Sindone, BMed (Hons), MD, FRACP ; David R. Thompson, RN, PhD, FRCN ; Karen Hancock, BSc (Hons), PhD ; Esther Chang, RN, PhD ; Patricia Davidson, RN, MEd
Abstract and Introduction
Abstract
Despite the documented evidence of the benefits of cardiac rehabilitation (CR) in enhancing recovery and reducing mortality following a myocardial infarction, only about one third of patients participate in such programs. Adherence to these programs is an even bigger problem, with only about one third maintaining attendance in these programs after 6 months. This review summarizes research that has investigated barriers to participation and adherence to CR programs. Some consistent factors found to be associated with participation in CR programs include lack of referral by physicians, associated illness, specific cardiac diagnoses, reimbursement, self-efficacy, perceived benefits of CR, distance and transportation, self-concept, self-motivation, family composition, social support, self-esteem, and occupation. Factors associated with non-adherence include being older, female gender, having fewer years of formal education, perceiving the benefits of CR, having angina, and being less physically active during leisure time. However, many of the studies have methodologic flaws, with very few controlled, randomized studies, making the findings tentative. Problems in objectively measuring adherence to unstructured, non-hospital-based programs, which are an increasingly popular alternative to traditional programs, are discussed. Suggestions for reducing barriers to participation and adherence to CR programs, as well as for future research aimed at clearly identifying these barriers, are discussed.
Introduction
Heart disease is the leading cause of death in the developed world, accounting for approximately one quarter of deaths. [1] Most deaths occur within the first 2 days after the onset, while those who survive this period progress well if they have not developed heart failure or serious arrhythmias. Participation in a cardiac rehabilitation (CR) program can promote recovery, enable patients to achieve and maintain better health, and reduce the risk of death in people who have heart disease. [2] It has been shown that exercise-based CR can reduce fatal events by 25% in the first year of recovery and can significantly reduce overall mortality from cardiac illness. [3,4] More recent studies of psychosocial and education-based CR have shown even more impressive benefits in terms of mortality, morbidity, and quality of life. [5,6]
CR may be defined as "services that are comprehensive, long-term programs involving medical evaluation, prescribed exercise, cardiac risk-factor modification, education and counselling." [7] CR programs are now regarded as an essential component of the overall care of patients following a myocardial infarction (MI). [8] The overall aims are to improve function, relieve symptoms, and enhance the patient's quality of life. [9] Cardiac programs are designed to improve both the physiologic and psychological status of cardiac patients. Rather than the traditional approach of discouraging physical activity, in the past 40 years there has been a shift to encouraging as much activity as a patient's symptoms and medical status permit. [10] A CR multidisciplinary team typically offers exercise training, education, and counselling of both client and family about risk factors, lifestyle changes, and coping with the disease process. [11] Not only do the programs focus on enhancing recovery, they also focus on teaching ways of modifying risk factors (e.g., weight loss, cessation of smoking, stress management). Participation in these programs has been found to result in improved exercise capacity and habits, improvement in blood lipid and lipoprotein levels, body weight, blood glucose, and blood pressure levels, and cessation of smoking, [12] and to have psychological benefits, such as reductions in anxiety and depression. [13,14] Another benefit of CR is that it increases the functional independence of patients, as measured by a return to appropriate and satisfactory work. [8,12] In terms of cost effectiveness, an additional benefit is reduced costs for subsequent hospital treatment. [15]
Despite the multifaceted benefits of CR programs, US figures suggest that only 15%-30% of patients who have had an MI participate in such programs. [8,16] Similar rates have also been reported in Australia. [17] An additional problem is that those who do participate tend to have poor adherence to these programs. A pattern of increasing attrition has been found in the first 3-6 months of a CR program, and by 6 months, only 30%-60% of individuals who attend CR programs participate in an exercise program. [18-20] After 6 months, the dropout rate slows. [19] Clinical trials have demonstrated that the benefits of CR are greatest in those who adhere to the program. [12,19] While the problem of adherence to CR has been extensively studied, the attributes which characterize adhererents and nonadherents have been less conclusively established. However, research conducted since 1978 reveals some consistent factors to be associated with nonadherence to CR programs: being older, being female, having fewer years of formal education, having angina, and being less physically active during leisure time. [19,21-23] Other studies have found lack of referral by physicians, associated illness, specific cardiac diagnoses, reimbursement, self-efficacy, distance and transportation, self-concept, self-motivation, family composition, social support, self-esteem, and occupation to influence participation in CR programs. [25-28] Rather than single factors predicting adherence to CR programs, most studies have found combinations of variables to be related to participation and adherence to CR.
This paper critically reviews studies conducted over the last 15 years that have investigated barriers to participation and adherence to CR programs, and offers suggestions for improving participation and adherence rates to CR.
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John Daly, RN, PhD ; Andrew P. Sindone, BMed (Hons), MD, FRACP ;, David R. Thompson, RN, PhD, FRCN ; Karen Hancock, BSc (Hons), PhD ; Esther Chang, RN, PhD ; Patricia Davidson, RN, MEd ; University of Western Sydney, Penrith, Australia; Concord Hospital, Sydney; University of York, York, United Kingdom; and St. George Hospital, Sydney, Australia
Prog Cardiovasc Nurs 17(1):8-17, 2002. © 2002 Le Jacq Communications, Inc
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Dave Murphy, Ph.D.
is a clinical
psychologist specializing in behavioral medicine, with an emphasis on cardiac care.
In association with:
Santa Rosa Memorial Hospital Erickson Institute
Private practice:
Sebastopol, CA
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