Reasons for non-adherence to cardiac rehabilitation programmes included lack of motivation, domestic duties, and other health problems
Dr S Greenfield, University of Birmingham, Birmingham, UK;
Why do post-myocardial infarction (MI) or revascularisation patients not adhere to home-based or hospital-based cardiac rehabilitation programmes (CRPs)?
Purposive sample of 49 patients (age range 34–87 y, 67% men) who had MI or revascularisation and did not adhere to home-based (n = 21) or hospital-based (n = 28) CRPs were identified from a randomised controlled trial. The home-based CRP included a copy of the Heart Manual (6-wk exercise and walking programme), information tapes, home visits, and telephone calls from nurses. The hospital-based CRP included group or individual exercise based on circuit training, and combined or separate sessions of education and relaxation.
At 3–20 months after randomisation, participants were individually interviewed for 40–45 minutes about their cardiac event, expectations and experience in CRPs, and lifestyle changes. Interviews were tape recorded, transcribed, and analysed for themes and subthemes.
In general, reasons for non-adherence to CRPs were multifactorial and individualistic. 4 categories of non-adherence were identified. (1) Alternative exercise and activities. Although participants did not adhere to their CRP, they exercised in other ways that better fit with their lifestyles (eg, walking, housework, or joining a gym). Participants realised that alternate exercises were less vigorous than recommended but felt they were more appropriate for them. Participants reported that their limited participation in CRPs boosted confidence in performing daily activities and other exercises. (2) Other health problems. Many participants had other health problems (eg, emphysema and arthritis) that affected their ability to participate in CRPs. They perceived these health problems as bigger barriers to exercising than their heart condition. However, participants understood the importance of exercise, and some remained active by adapting the programme to fit their needs. (3) Personal reasons. Some people could not attend hospital-based CRPs because they had to care for others who could not be left alone for long periods. 6 participants who did not adhere because they returned to work joined a gym or exercised in other ways. Participants who had recovered from their cardiac event felt it was not necessary or beneficial to attend CRPs. (4) Programme-related changes. Many participants in home-based CRPs felt that lack of motivation was a major reason for non-adherence. 3 participants in hospital-based CRPs were not offered a specific start date or misunderstood the start date. Some had difficulty accessing hospital-based CRPs because of heavy traffic, lack of parking, irregular bus service, or timing of sessions. Others felt uncomfortable because they thought hospital-based CRPs were attended by “all old people” or were overcrowded.
Reasons for non-adherence to home-based or hospital-based cardiac rehabilitation programmes included lack of motivation to exercise, domestic duties, and other health problems.
Jones M, Jolly K, Raftery J, et al. ‘DNA’ may not mean ‘did not participate’: a qualitative study of reasons for non-adherence at home- and centre-based cardiac rehabilitation. Fam Pract 2007;24:343–57.
Source of funding: National Health Service Health Technology Assessment Programme.
The study by Jones et al examined reasons for non-adherence to home-based and centre-based CRPs. Centre-based CRPs were typical of hospital-based CRPs in offering exercise, education, and relaxation on site in various combinations. Home-based CRPs used the Heart Manual as well as home visits and telephone follow-up. The highly individual reasons for non-adherence reflect the findings of other studies summarised in a review of barriers to participation and adherence to CRPs.1 There is a clear difference between non-participation and non-adherence; that is, individuals may not adhere to specific programmes but may still participate in some form of cardiac rehabilitation by working independently towards individual goals related to exercise or other lifestyle components.
The findings of this and other studies pose some challenges to clinicians involved in the design and delivery of CRPs. Traditional CRPs tend to be based on a “one size fits all” design, largely related to ease of operation and economic factors. However, the cardiac rehabilitation population is not homogenous; additional patient factors to be considered include demographics, culture, and a range of clinical conditions. If the objective of CRPs is to promote lifelong adoption of healthy lifestyles to reduce cardiovascular risk, then it matters less where and how this happens; the more important question is whether individuals reach their targets independently or with support tailored to their specific needs. Therefore, the design of CRPs should consider the following factors: automatic referral of eligible candidates to CRPs, increased flexibility of service delivery models to better accommodate individual needs, initial assessment of potential barriers to participation on referral to CRPs in order to best match the service model to the individual, better integration of formal CRPs with chronic disease management services in the community to improve access and continuity of care, greater acknowledgement of the multifactorial nature of CRPs, and most importantly, a focus on outcomes rather than process.