3.2 Qualitative Results
A total of 17 participants completed the interview. Their sociodemographic are presented in Table 3. Six themes were identified after analyzing the content of the transcriptions, namely logistics factors, social support, misunderstanding of CR, program and health system-level factors, impression on healthcare providers and hospital surroundings and phycological distress (Table4).
Table 3
Sociodemographic of interview participants
Sociodemographic | Total n = 17 |
Age in years, n (%) | |
45–60 | 9(52.9%) |
61–80 | 8(47.1%) |
Gender, n (%) | |
male | 10(58.8%) |
Female | 7(41.2%) |
Marital status (%married) | 11(64.7%) |
Nationality (% Han) | 17(100%) |
Residence (% city or town) | 8(45.5%) |
Education, n (%) | |
Junior high school and below | 8(47.1%) |
Technical secondary school/senior high school | 9(52.9%) |
Work status (% working) | 8(47.1%) |
Monthly income, n (%) | |
<3000RMB | 7(41.2%) |
3000-8000RMB | 10(58.8%) |
Healthcare insurance coverage, n (%) | |
Government or insurance | 5(29.4%) |
Out-of-pocket | 12(70.6%) |
Regular exercise (% ≥3 times/wk for ≥ 30 min) (% yes) | 7(41.2%) |
Undergone PCI (Yes) | 9(52.9%) |
Participant in the phase 1 rehabilitation (Yes) | 12(70.6%) |
Table 4
Themes and categories of the findings
Themes | Categories |
Logistics Factors | Distance |
Inconvenient traffic |
Insufficient economic support |
Parking difficulty |
Social support | Lack of family support |
Caregiver role conflict |
Work Conflict |
Misunderstanding of CR | Believing that daily activities can replace CR |
Doubt the effectiveness of CR |
Program and health system-level factors | Limited CR centers and inflexible time |
Covid-19 test |
Psychological distress and personality | Pessimism |
Anger and Hostility |
Escaping |
Impression on cardiac team | Believe doctors rather than nurses |
Impressions on surroundings |
Impressions on healthcare-providers |
Theme1: logistics factors
Distance
Patients from nearby cities or rural area claimed they could not participate due to the far distance. When asked about how far is acceptable. Most of them told that more than 40 minutes driving distance is unacceptable.
P4: "It's too far. I live in ChengHai. It takes me more than 40 minutes to drive here."
P6: "I can't take part in it. My home is too far away from here. It takes me about 40 or 45 minutes even I drive on expressway."
Inconvenient traffic
Some patients come to the hospital by public bus. However, the public bus is limited in some areas and sometimes there is no directly bus to the hospital. Therefore, some patients need to transfer many times and it will waste a lot of time on the road. Meanwhile, some patients said that they are living in the rural area where there is no public transportation. This is a big barrier for them.
P3: " There is no directly bus. I have to transfer three times."
P7: "It takes me half an hour to get here by bus and I have to spend more than one hour to wait for the bus, it's so inconvenience.”
P9: There is no public transportation in my living area. So, I need to call the taxi every time. It is really inconvenience.
Parking difficulty
Some participants think there is limited access to parking in the hospital. Sometimes they need to find the parking space outside the hospital and then walking to the hospital. It is not convenience.
P1, P12 and P15: "Hospital parking make me crazing.”
P5: The parking service is terrible, you know, it is always full.
Insufficient economic support
CR requires high costs and are not covered by medical insurance. For patients with poor economic conditions, the cost problem will be a major obstacle to their decision making.
P7: "it's too expensive. I really cannot understand why this (CR) is not included in my medical insurance?”
P8, P11: "I have no income. I borrowed money from relatives to pay for the expensive cardiac surgery. I do not have extra money to do the rehabilitation.”
P16: "I heard that this will (cardiac rehabilitation) cost at least thousands of dollars a month, and I can't afford it."
Theme 2: Social support
Lack of family support
Family support plays an important role in the CR program. Most of elderly patients come to hospital with the accompany of their family members. However, their family members cannot always provide support for them.
P3: "It takes my son two hours to drive me here. It's too far. My son needs to work and he can't take me to here every time."
P6: "My son has to go to work, so he can't pick me up every time."
Caregiver role conflict
P2: "my grandchild is only 4 years old. His father and mother are working in another city. I need to take care of my grandchild".
P4: “I know rehabilitation will benefit for me, but I have so much house work to do. Go to the market every day and cook the three meals for my daughter’s whole family. I do not think I have spare time to take part in the CR."
P8: "I am in charge of everything at home. I have to pick up my two grandchildren, buy food, cook, wash clothes and mop the floor. There is no time for CR."
Work Conflict
Some adult patients have to return to work after cardiac events. It is difficult to participate in CR due to the conflict between working hours and rehabilitation time.
P9: "I have to work after discharge. You know, I cannot stop. I have to pay the mortgage every month. It is impossible for me to do the rehabilitation two times each week during the working day. You know, the CR center does not open on the weekend”.
P10: "I operate a water and electricity decoration company. Now it is the end of the year, and many families need to decorate their house. I have a lot of work to do now, and I have been rushing to make sure everyone can move in to the new decorated house before the Spring Festival. I don't have enough time to arrange the rehabilitation."
Theme 3: Misunderstanding of rehabilitation
Daily activities can replace CR
Although CR has been promoted in China for more than ten years, the public awareness of rehabilitation is inadequate. Patients do not have a correct understanding of CR and think that daily activities and exercises outside the hospital can replace CR.
P1: "I go to the gym near my house every day"
P5: "I have a treadmill at home, and I insist on running every day."
P9: "For exercise, I can exercise at home after I leave the hospital."
P11: "There are a lot of fitness equipment downstairs in my community. I can do that in the community."
Doubt the effects of CR
P9: “I just want to treat the disease, there is no need to do rehabilitation. “
P10: “After surgery, the most important thing is to reduce exercise to help the body recovery.”
P15: “This is a big surgery for me (PCI), I probably need half to one year to recovery. Surgery has exhausted my Qi(yang Qi), I need to stay at home quietly and drink some traditional Chinese medicine soup to help me restore the Yang Qi.”
Theme 4: Program and health system-level factors
Limited CR centers and inflexible time
There are only a few CR centers and most of which are in the third-class A general hospitals and these hospitals always located in the center of the town.
P1 and P9: "the center open on 8am to 5:30 pm from Monday to Friday and it closed on weekend. You know, for me, I just have time on weekend. So, that might be the most obstacle for me."
P10: “If the center (cardiac rehabilitation center) likes the convenience stores which opened everywhere. It might be easier for me to get the access.”
Covid-19 test
P7 and P14: Every time when I go the hospital, I need to show the negative result of Covid-19, I feel burnout for that.
Theme 5 Impression on cardiac team
For some participants, their impression on the healthcare providers especially the person who refer them to the CR center impacting their decision-making process. Patients believe that doctor’s advice is more believable and valuable than that given by the nurses.
Believing doctors rather than nurses
P12: “It is so strange that a nurse come to my bed and said I need the CR program. Who is this nurse? Why my doctor did not recommend me.
Impression on surroundings
P12: “the nurse brings me to the CR center, I saw so many people (both men and women) running on the treadmill, it is so strange that men and women exercise in the same room.”
Impression on healthcare providers
P17: “you know, the nurse informs me that take part in the program will help me to lose my weight. I know, I am too fat. But, you know, the nurse is fatter than me actually. I do not believe that she can help me losing weight.”
Theme 6 Phycological distress and personality
Pessimism
Some participants explain their cardiac disease in a very negative way and think rehabilitation is useless for them. Some people express their conditions in a sense of hopelessness.
P3: “it is unfair, you know, I did a lot of good things in my life. I always support others and help others. I think I will get good fortune in my life. However, it is not....... I don't want to think about these things(rehabilitation). Let it go......”
P16: “My mother in law is 83 years old, she did nothing every day. Her son (my husband) died 26 years ago. I have no choices but to take care of her. She is healthy without any disease. Why it is me? Why I get the heart attract. It is unfair. Is not it?” (tears in her eyes)
Escaping
Some patients express their wishes to leave the hospital as soon as possible after discharge.
P6: “please do not ask me anything about my heart. I do not believe I got the heart disease.”
P11: “This hospital is a dirty place with a lot of unlucky things. It was a cemetery many years ago. It’s horrible, I don't want to stay here. “
P15: “do not ask me to the hospital every week. I want to stay at home.”
Anger and Hostility
P6: “I am an experienced coach. Do you want to teach me how to do exercise? ”(with a contemptuous smile)
P9: “Exercise in the hospital? Are you kidding? I think your hospital just want to get more money from me” (with anger facial expression)
P12: “the surgery cost me a lot. You want to get more money from me?”