DOI: https://doi.org/10.21203/rs.3.rs-1845746/v1
Aims
To investigate barriers to hospital-based phase II cardiac rehabilitation among coronary heart disease patients in China and to explore the deeper reasons.
Design
An explanatory sequential mixed method design.
Methods
This study was conducted in a university hospital in China from July 2021 to December 2021.160 patients completed the survey by using the Cardiac Rehabilitation Barrier Scale and then 17 patients participated in the unstructured face- to- face interviews. Inductive qualitative content analysis was used to analyze data.
Results
Patients who are working or do not have healthcare insurance are less likely to participate in cardiac rehabilitation, while patients after percutaneous coronary intervention or have participated in phase I cardiac rehabilitation were more likely to take the program. The main barriers were distance (3.29±1.565), transportation (2.99±1.503), cost (2.76±1.425), doing exercise at home (2.69±1.509) and time constrain (2.48±1.496). Six themes were identified, logistics factors, social support, misunderstanding of cardiac rehabilitation, program and health system-level factors, impression on cardiac rehabilitation team and psychological distress. The first four themes confirmed the quantitative results and provide a deeper explanation for the quantitative results. The last two themes were new information emerged in the qualitative phase.
Conclusion
This mixed methods study provided a better understanding of the barriers to hospital-based phase II cardiac rehabilitation among coronary heart disease patients in the Chinese context. It is time to move from barriers to solutions. Innovative program might be considered to overcome some of these barriers. Additionally, psychosocial interventions should be conducted to transform patient’s cognition problems and build trusted nurse(doctor)-patient relationship.
With the development of society and improvement of living standards, coronary heart disease (CHD) has increasingly become a leading cause of morbidity and premature death in the world [1]. According to the latest data, China as a middle-income country, about 11 million CHD patients was estimated, which is the greatest proportion of cardiovascular diseases (CVDs) [2]. In China, the mortality of CHD in 2020 was 126.9/100 000 in urban areas and 135.88/100 000 in rural areas [2]. The incidence of CHD has been continuously increasing and will continue an upward trend in the next decade [2].
Cardiac rehabilitation (CR) is a comprehensive and continuum of care for patients with CHD after initial treatment. It has been approved to improve cardio-pulmonary function, promote wellness, and improve quality of life [3]. Normal, the CR was divided into three phases. Phase 1 starts in the hospital which focusing on recover basic functional mobility. Phase 2 begin when patients discharge from hospital which involves structured and closely monitored exercises and activities. It is often lasted for at least 3–6 months after discharge. Phase 3 focus on keeping up exercises and maintain a healthy life style [4]. In China, the average hospitalization time of patients with CHD is currently controlled at 7 days. So, the time for phase I is limited. Phase II rehabilitation is the core stage for CHD patients because it is a continuation of phase1 and also the basis for phase III [5].
The benefits of CR are clear, which is going beyond improved functional capacity and include greater ease with activities of everyday life, improved quality of life [6]. A study reported that the left ventricular ejection fraction of CHD patients was significantly improved after hospital-based CR for 6 months [7] .CR was also proved to reduce cerebrovascular events, hospital readmission rate, and mortality rate [8]. A large cohort study included 73,000 patients who had undergone CR revealed that mortality rate reduced 58% at 1 year and 21–34% at 5 years [9].
Regardless of the well-described benefits of CR, CR utilization remains low around the word. Even in the western countries, CR utilization only ranges from 19–34% [10, 11]. In China, hospitals with CR center have increased significantly in the past five years. However, participate rate was quite lower. The currently available data showed less than 5% of CHD patients participated in CR [12, 13].
It’s a challenge to increase the CR participation. Effective intervention measures can only be proposed after adequate investigation of the barriers. Researchers need to study the reasons of CR obstacles before exploring new methods to improve patient’s attendance.
The CR obstacles have been well investigated in some western countries. A quantitative study included 31,297 patients who have suffered from Acute Myocardial Infarction (AMI). Logistic regression analyses showed that the strongest predictor for non-attendance was distance. Other predictors included smoking, history of stroke, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), AMI or diabetes and male. Patients with ST-elevation myocardial infarction (STEMI) and those intervened with PCI or CABG were more likely to attend CR [14]. However, another study conducted in four university hospitals among patients with acute coronary syndrome indicated that logistical factors (such as transportation and parking) and functional status were main barrier to CR enrollment. Demographic characteristic such as age and gender were not the predictors [15]. One cross-sectional study investigated the barriers from the perspective of healthcare administrators, CR providers and patients. The importance of CR and lack of resources to deliver CR were main barriers from the administrators’ perspective; CR providers believed that lacking of referral is the main barrier; Patients thought that functional status, perceived need, personal/ family issues and access were barriers [16]. These studies investigated the barriers by using solely quantitative survey. Therefore, it is difficult to understand these barriers in a deeper level. In addition, results from these quantitative studies were not accordance with each other.
One study explored CR barriers by using qualitative method. This study included 14 participants and the semi-structured interviews were conducted to collect data. Results indicated that social support, perceived outcomes from participation were major barriers to attendance [17].
Compared with western countries, China is still at the preliminary stage of developing CR. According to the recent global survey of CR programs, 216 hospital-based CR programs are available in China [13]. Even through hospitals with CR center have increased significantly in the past five years, participate rate was still lower. The currently available data showed less than 5% of CHD patients participated in CR [12, 13]. Within this unique context, it is important to have an in-depth understanding of CR obstacles in the Chinese context. However, there are few studies that investigated CR obstacles in China. Through literature review, only two previous studies focus on Chinese CR obstacles. One qualitative study using structured face-to-face interviews on 328 patients. The results indicated that factors associated with non-participating were female gender, older age, less education, low income and lack of health insurance. The most common reason for refusing to participate in CR was that patients could not afford it [12].
Another quantitative research conducted in 11 hospitals in the city of Shanghai which included 380 cardiac patients reveled that distance, lack of awareness, weather and transportation were main factors impacting patients to take part in the CR program [13]. Economic status was not observed to be a barrier which is different from the quantitative study conducted in Shanghai.
Many of these studies have been solely quantitative or qualitative study. There was no previous research explore barriers in hospital based-phase II CR by using mixed methods. In addition, CR barriers might be quite different regarding to the resource in different countries. Nanjing and Shanghai are both Megacities with much richer health resource when compared with other cities in China.
Therefore, the aim of this research is to investigate barriers to hospital-based phase II Cardiac Rehabilitation among Coronary Heart Disease patients in China by using mixed methods. It will provide a better and more deeper understanding of CR obstacles in current China and also provide evidences for future intervention programs.
To investigate barriers to hospital-based phase II cardiac rehabilitation among coronary heart disease patients in China and to explore the deeper reasons for this phenomenon.
This study uses an explanatory sequential mixed methods design. The study included a quantitative and a subsequent qualitative phase (Fig. 1) [18]. Quantitative data was collected and analyzed first and then qualitative data was collected to explore the quantitative results with an in-depth way [18]. The quantitative phase informed the patients who were recruited for the qualitative phase and guided question development [19]. This mixed method design enables researchers to use a qualitative lens to explore findings of quantitative results by exploring the participants’ view in a greater depth and thus better describe missed data than either method alone [19].
The study setting is a university hospital which has about 1400-beds with a PCI center, two cardiology units, a coronary care unit (CCU) and a CR center. This CR center is the first center which certified as the standard national CR center in the city of Shantou in 2019. It provides structured and standard phase I to phase III CR programs. The CR involved medical assessment, structured, supervised exercise sessions, patient education, stress reduction, cigarettes cessation and weight management. Patients discharged from our three cardiovascular units who are eligible to CR program are highly recommended and referred. Then a consent inform was signed by participant if they want to take part in the CR program.
For the quantitative session, patients diagnosed with CHD who are eligible for the CR program were invited to participate. The inclusion criteria were 1) age 18 or more than 18;2) without severe comorbidities; 3) can speak and listen Mandarin or local language (ChaoShan language). For the qualitative part, a subsample of 17 participants who completed the survey and refused to participate the CR were purposefully invited to participate in the unstructured in-depth face to face interview. In each session, patients were invited to sign the informed consent. All methods were carried out in accordance with relevant guidelines and regulations in the Helsinki declaration.
The survey began with items regarding sociodemographic as well as clinical characteristics. The Cardiac Rehabilitation Barriers Scale (CRBS) was used to investigate patient’s barriers to CR. The original English version CRBS consists of 4 domains and 21 items. Each item is rated by using a five-point Likert scale (1—strongly disagree to 5—strongly agree). Higher scores indicate greater barriers to CR [20]. The scale was translated, cross-culturally adapt and psychometrically validated into Mandarin [13]. The adapted Chinese version scale also includes 21 items but five domains and was tested to have acceptable validity and reliability [13]. Therefore, in the quantitative phase, the Chinese version scale was used. Data collection for quantitative phase took place from July 2021 to December 2021 by the authors.
A purposive sample was used to recruit participants for interviews to maximize the depth and richness of data [19]. Participants who finished the quantitative survey, the demographic characteristics showing statistical significance, refused to participate the phase II CR was contacted and invited to participate in the qualitative phase. Patients who agreed and signed the informed consent were arranged an interview. Data collection process ended until information saturation was met.
An in-depth, face to face unstructured interview was used as the main data collection approach. The interview was conducted in a private room in the CCU. Interviews began with a warm up conversation. During the interview process, the recording was conducted by using a digital recorder. The interview began with an open question, “can you tell me your thoughts or feelings about being invited to participant in the CR program?” After this open question, the subsequent questions were asked to understand the barriers for their decision making. Some probing questions such as ‘can you tell me what's keeping you from coming to cardiac rehabilitation༟” or “can you tell me a little bit more about what are you worried about?” The interviews were flexible enough to generate richer information. Patients were allowed to add any information they deemed to fit the questions.
The interview last for about 30 minutes to 45 minutes. During the interview, field notes were taken to record the non-verbal behavior and activities of participants.
The cross-sectional survey data were analyzed by using (SPSS) Statistics Version 25 (SPSS Inc). A descriptive examination of participant characteristics, as well as CRBS was performed. Spearman’s correlation, independent samples t-tests, and analysis of variance were used to explore associations between sociodemographic or clinical characteristics of study participants and total CRBS score. A p value < 0.05 indicated significance.
Qualitative data was analyzed by using inductive qualitative content analysis [21]. The data analysis was concurrent with the data collection process. After each interview, the researcher transcribed the data within one week. The recording was listening again and again to gain familiarity with the scope of the content of each data sources and build a contextualized and holistic understanding of the participants. During the transcribe process, the tone of voice, silences, and pauses of participant was noted. The transcripts were cross-checked and labelled by the first and second authors independently. After the transcript was done, coding began and then grouping these codes into categories. The categories were compared for similarities and differences and then grouped into more abstract level(themes). When no more new information was emerging, data saturation was considered achieved and then data collection was ended.
The integration was conducted in the design, methods, and interpretation stage, respectively [18]. In the design stage, the study is an explanatory sequential design which integrate quantitative first and then qualitative phase [18]. For the methods, the samples in the qualitative phases were from the quantitative phase and based on the results of quantitative part. In the interpretation part, results from both quantitative and qualitative are compared, integrated and then joint displayed.
The CRBS (Chinese version) used in the quantitative phase was tested to have acceptable validity and reliability [13]. Member checking was used to enhance the credibility. All participant in this study were invited to review the transcript to make sure the transcript reflected their real thinking. In addition, the peer review was conducted by inviting two colleagues who are familiar with this area to review the transcript and the findings. Researchers discussed with colleagues to make sure that we did not bring our own assumptions to the findings. An audit trail was conducted to improve dependability. During data analysis, we set aside to make sure that the data analysis does not be colored by our previous experience or idea.
A total of 160 participants completed the survey. The sociodemographic, clinical characteristics of participants and association of these variables with total CRBS score which responded to the survey are shown in Table 1.
| Total (n = 160) | p | |
|---|---|---|
| Sociodemographic | ||
| Age in years, n (%) | 0.730 | |
| 45 or younger | 19(11.9%) | |
| 46–60 | 52(32.5%) | |
| 61–80 | 85(53.1%) | |
| 80 or older | 4(2.5%) | |
| Gender, n (%) | 0.577 | |
| male | 126(78.8%) | |
| Female | 34(21.3%) | |
| Marital status (%married) | 148(92.5%) | 0.486 |
| Nationality (% Han) | 159(99.4%) | 0.471 |
| Residence (% city or town) | 53(33.1%) | 0.234 |
| Education, n (%) | 0.144 | |
| Junior high school and below | 82(51.2%) | |
| Technical secondary school/senior high school | 69(43.1%) | |
| College degree | 9(5.6%) | |
| Work status (% working) | 67(41.9%) | 0.004 |
| Monthly income, n (%) | 0.379 | |
| <3000RMB | 78(48.8%) | |
| 3000-8000RMB | 74(46.3%) | |
| >8000RMB | 8(5.0%) | |
| Healthcare coverage, n (%) | 0.017 | |
| Government or insurance | 129(80.6%) | |
| Out-of-pocket | 31(19.4%) | |
| CABG (% yes) | 1(0.6%) | 0.349 |
| PCI (% yes) | 112(70%) | 0.003 |
| Heart failure (% yes) | 16(10%) | 0.426 |
| Hypertension (% yes) | 86(53.8%) | 0.506 |
| valvular heart disease (% yes) | 5(3.1%) | 0.141 |
| Diabetes (% yes) | 42(26.3%) | 0.987 |
| hyperlipidemia (% yes) | 66(41.3%) | 0.591 |
| Tobacco use(% yes) | 94(58.8%) | 0.583 |
| Family history of CVD (% yes) | 10(6.3%) | 0.496 |
| Regular exercise (% ≥3 times/wk for ≥ 30 min) (% yes) | 38(23.8%) | 0.359 |
| BMI | 26.17 ± 19.069 | 0.870 |
| Participant in the phase 1 CR | 126(78.7%) | 0.002 |
BMI: body mass index; CRBS: Cardiac Rehabilitation Barriers Scale; PCI: percutaneous coronary intervention; CABG: coronary artery bypass grafting.
As shown in Table 1, significant associations were observed between work status (patients who are working reported more barriers), healthcare insurance coverage (Out-of-pocket reported more barriers), PCI (those undergone PCI reported less barriers) and whether patients have participated in phase I CR. The main barriers were logistical factors (distance, transportation problems, and cost), CR need (patients think they are already doing exercise at home) and time conflict (family and work responsibility, time constraints) (Table 2)
| Subscale | Items | Total sample(n = 160) |
|---|---|---|
| External logistical factors | 1…of distance | 3.29 ± 1.565 |
| 2…of cost | 2.76 ± 1.425 | |
| 3…of transportation problems | 2.99 ± 1.503 | |
| 8…severe weather | 1.73 ± 0.888 | |
| CR need | 5…I did not know about cardiac rehab | 1.61 ± 0.825 |
| 6…I do not need cardiac rehab | 1.82 ± 1.069 | |
| 7…I already exercise at home, or in my community | 2.69 ± 1.509 | |
| 17… many people with heart problems do not go, and they are fine | 1.66 ± 0.785 | |
| 18… I can manage my heart problem on my own | 1.68 ± 0.879 | |
| 21…I prefer to take care of my health alone, not in a group | 1.70 ± 0.896 | |
| Time conflicts | 4…of family responsibilities | 2.17 ± 1.299 |
| 10…travel | 1.74 ± 1.019 | |
| 11…of time constraints | 2.48 ± 1.496 | |
| 12…of work responsibilities | 2.43 ± 1.666 | |
| Program and health system-level factors | 16…my doctor did not feel it was necessary | 1.54 ± 0.743 |
| 19… I think I was referred, but the rehab program did not contact me | 1.64 ± 0.842 | |
| 20…it took too long to get referred and into the program | 1.65 ± 0.818 | |
| Comorbidities/ Functional status | 9…I find exercise tiring or painful | 2.00 ± 1.208 |
| 13…I do not have the energy | 1.99 ± 1.171 | |
| 14…other health problems prevent me from going | 1.75 ± 0.938 | |
| 15…I am too old | 1.86 ± 1.141 | |
| Mean score of subscales 1 | 2.69 ± 0.99 | |
| Mean score of subscales 2 | 1.85 ± 0.71 | |
| Mean score of subscales 3 | 2.20 ± 1.02 | |
| Mean score of subscales 4 | 1.61 ± 0.73 | |
| Mean score of subscales 5 | 1.90 ± 0.85 | |
| Mean total CRBS score | 2.06 ± 0.66 |
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).
| 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%) |
| 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?”
Some findings from the qualitative research confirmed the findings from quantitative research and also helped explaining the quantitative results in more details.
For the first domain (logistical factors), distance and transportation problems are the most important barrier with the higher score. In the qualitative phase, these barriers were confirmed and participant mentioned that more than 40mins driving distance might be a cut point. In addition, participants who live in the rural area without public transportation seems less likely to take the program.
For the cost of CR, in the quantitative part, it focusses on the cost on transportation and gas. But in the qualitative part, it focuses on the grogram cost. The program cost was not covered by outpatient medical insurance in China. Participants need to pay the expensive assessment fee (like cardiopulmonary exercise testing) and the 36 session guided exercises fee by themselves. Some participants think this is a big burden for them.
For the severe weather, it was not evaluated as the important barrier both in quantitative and qualitative result. Lacking of parking Space in hospital is the new barrier emerged in the qualitative phase.
In terms of the second domain (CR need), “I already exercise at home, or in my community” is the biggest barrier. This is also confirmed by the qualitative result. Participant think they can go to the gym or some of them have treadmill at home. They think rehabilitation is the same as the normal physical activities.
For the third subscale (time conflicts). The qualitative result confirmed that caregiver role conflict and work conflict are the main barriers.
Therefore, most of the results from quantitative research were confirmed by the results from the qualitative research. However, during the qualitative phase, some new themes emerged. Such as impression on healthcare provider and hospital surroundings, and psychological distress and personality. It will be a supplement to the quantitative findings. The results of both quantitative and qualitative phases are joint display in table
| Subscales | Items | Scores | Qualitative Themes | Categories | Merging/Integrating results |
|---|---|---|---|---|---|
| Domain 1 logistical factors | 1…of distance | 3.29 ± 1.565 | Theme1 logistics factors | Distance | Confirmed by quantitative and qualitative results Details: more than 40 minutes driving distance seems too far for participants |
| 2…of cost | 2.76 ± 1.425 | Insufficient economic support | Confirmed by quantitative and qualitative results However, the detail of cost is different. In quantitative result, the cost focus on gas, parking, but in qualitative result, the cost refers to grogram cost. The program cost was not covered by outpatient medical insurance. | ||
| 3…of transportation problems | 2.99 ± 1.503 | Inconvenient traffic | Confirmed by quantitative and qualitative results. Detail: living in rural areas without public transportation | ||
| 8…severe weather | 1.73 ± 0.888 | In qualitative result, no people mentioned weather as a barrier | |||
| Parking difficulty | New information emerged in qualitative result Detail: lack of parking space in hospital and it costs time to find the parking space | ||||
| Domain 2 CR need | 5…I did not know about cardiac rehab | 1.61 ± 0.825 | Theme2 Misunderstanding of CR | Not a big barrier. In qualitative part, all patients claimed they were referred and they have heard cardiac rehabilitation | |
| 6…I do not need cardiac rehab | 1.82 ± 1.069 | Doubt the effect of cardiac rehabilitation | Confirmed by quantitative and qualitative results. In qualitative part, some participants said they just want to treat the disease, there is no need to do rehabilitation | ||
| 7…I already exercise at home, or in my community | 2.69 ± 1.509 | daily activities can replace rehabilitation | Confirmed by quantitative and qualitative results. Detail: participant think they can go to the gym or some of them have treadmill at home. They think rehabilitation is the same as physical activities. | ||
| 17… many people with heart problems do not go, and they are fine | 1.66 ± 0.785 | ||||
| 18… I can manage my heart problem on my own | 1.68 ± 0.879 | ||||
| 21…I prefer to take care of my health alone, not in a group | 1.70 ± 0.896 | ||||
| Domain 3 Time conflicts | 4…of family responsibilities | 2.17 ± 1.299 | Theme3 Low social support | Lack of family support Caregiver role conflict | In qualitative part, most participants claimed that take care of their grandchildren or family members is a barrier. |
| 10…travel | 1.74 ± 1.019 | ||||
| 11…of time constraints | 2.48 ± 1.496 | The center opens on daytime and just open from Monday to Friday, it is conflict with the working time | |||
| 12…of work responsibilities | 2.43 ± 1.666 | Work Conflict | In qualitative part, some younger patients claimed that they need return to work and there is no spare time to do the rehabilitation in the center | ||
| Domain4 Program and health system-level factors | 16…my doctor did not feel it was necessary | 1.54 ± 0.743 | Theme4 Program and health system-level factors | ||
| 19… I think I was referred, but the rehab program did not contact me | 1.64 ± 0.842 | ||||
| 20…it took too long to get referred and into the program | 1.65 ± 0.818 | ||||
| Limited cardiac rehabilitation center | No CR center near their home | ||||
| Covid-19 test | New information emerged in qualitative phase. It is a trouble to show the negative result every time when enter the hospital | ||||
| Domain5 Comorbidities/ Functional status | 13…I do not have the energy | 1.99 ± 1.171 | No information emerged in this domain in the qualitative phase | ||
| 14…other health problems prevent me from going | 1.75 ± 0.938 | ||||
| 9…I find exercise tiring or painful | 2.00 ± 1.208 | ||||
| 15…I am too old | 1.86 ± 1.141 | ||||
| Theme5 Impression on healthcare team | New information emerged in qualitative phase Referred by physicians or cardiologists is better than referred by nurses | ||||
| Theme 6 Psychological distress | Escaping | New information emerged in qualitative phase | |||
| Anger and Hostility | New information emerged in qualitative phase | ||||
| Pessimism | New information emerged in qualitative phase | ||||
The results of this mix-method study indicated multi-level barriers for patients with CHD to take part in the hospital-based phase II CR program. From the demographic characteristics, participants who have work or do not have medical insurance are less likely to attend the rehabilitation program. This result is accordance with previous research [22]. The result also was verified in the quantitative phase and be deeply explored in the qualitative phase in this research.
Patients who undergone PCI or have participated in phase I CR program are more likely to take the phase II CR program. The results are contrast with the previous study which indicated that patients who have a CABG were more likely to participate in the CR than patients after PCI [13]. That might because most patients (70%) in our study have undergone PCI and 78.7% patients after PCI were received the phase I CR and being referred to phase II CR in our hospital.
In the quantitative survey phase, distance has been shown to be the first major factor impacting participation which is accordance with most of the previous studies [13, 15, 22]. In the qualitative phase, participants told that normally more than 40 minutes driving distance would be a cut point for them. In our study, transportation is a practical CR obstacle, which have been also widely proved in the previous studies [13, 16]. Specific reasons found in our qualitative part are patients living in remote areas often face the situation that lack of public transportations. Even there are public bus, they need to wait for a long time to take the bus. Therefore, they think it is not convenience. some people need to call taxi which would increase their financial burden. With the development of the internet and the popularity of mobile phone, establishing patient-centered remote rehabilitation or home-based CR might be effective ways to alleviate this problem [23]. A research suggested that transporting staff and equipment to community settings might be a good way to overcome some of these types of barriers [24].
Different with Liu’s study [13], the main barriers cited for non-participants in the Shanghai were not only include distance and transportation, but also bad weather and patients did not know about the CR. In our study, bad weather was not a barrier. It might because our hospital located in the south of China with lovely weather for the four seasons. For the awareness of CR, we have established national standard CR center in the hospital. Patients hospitalized in our hospital received the standard Phase1 CR grogram and be recommend and refereed to the phase 2 CR if they are eligible. Therefore, most patients in our study have heard about CR during their hospitalization. However, in Liu’s study, 90% of participants had not even heard of CR. So, lack of awareness was thought to be a key barrier to CR in their study. Therefore, we think inviting patients to take part in phase I CR might helpful to create a space to motivate patients to take the Phase II CR. However, it is important to notice that in our research, even most patients have heard about CR, they are not fully understood CR. Patients believe CR is similar to exercise they do at home or in the gym. Qualitative results confirmed this cognitive barrier. From this point of view, just simply telling patients to enroll in CR and do not tell the program in detail is not always sufficient to motivate program participation.
Cost of CR is a common reason for patients’ refusal to attend CR, which agrees with previous study [12]. According to National Healthcare Security Administration[25], China has achieved 95% health coverage in 2020, and the inpatients can be reimbursed for 70–80% medical expenses during hospitalization. However, outpatient’s participation in a CR program is not covered by the National Health Service. Therefore, some patients could not afford CR program after hospital discharge. It is better to include the CR program into the government insurance system to promote the attendance of CR. Additionally, considering the CR cost, more innovative and cost-effective possibilities should be explored.
Time conflict is also a big barrier for patients. For elderly patients, they have to take a lot of family responsibilities such as taking care of their grandchildren and do house work for their next generation’s family. This is very normal in the Chinese culture. For the younger patients, time conflict refers to they need to work from Monday to Friday and they only have free time on weekend. But, the CR center in public hospital always closed on weekend and night. Therefore, a flexible time schedule might be a way to improve CR attendance for elderly and working patients. Likewise, replacing some of the day classes with evening options could make it easier for some patients to attend.
Results from the qualitative phase confirmed most of the quantitative results and provide a deep explanation for the results. In addition, two new themes also emerged in the qualitative phase which provide new insight into patients’ subjective decision-making about whether or not to enroll in CR.
Parking difficulties is a new barrier emerged in the qualitative phase. Many patients blamed that it is quite difficult to find a parking space in the hospital. It might be a specific phenomenon in our local hospital and it provides insight that hospital should think about this issue ahead when establish the CR center. Limited CR center nearby their home and COVID-19 are new barriers emerged. Some patients live in other cities and they claimed that there is no CR center in their home town. In addition, the breakout of COVID-19 and management policy limited their decision making. Some of them blamed that it is terrible to do the swab and show the negative result every time when they enter the hospital. So, during the pandemic, some remote or online programs might be explored to overcome some of these barriers.
In the qualitative phase, two new themes emerged, namely impression on healthcare provider and hospital surroundings, and phycological distress and personality. Some patients were refereed by nurses whom they are not familiar with. Therefore, they are not fully believing what the nurse told them. It reminds us that CR is a comprehensive program which need the cooperation of multidisciplinary team. Cardiologists play an important role in referral process.
Healthcare provider’s impression also be viewed as a barrier in this study. Some patients believe that nurses or physicians who guide the CR should be healthy and slim. They do not think a nurse who seems not slim can help them maintain weight. For some participants, their impression on the rehabilitation center surrounding also impact their decision-making process.
During the interview process, we observed that some patients refused to take part in the CR are with some phycological distress and specific personalities. For example, some of them seems hopelessness, some are pessimistic and some of them do not believe health care providers. Some of them express their suspect about the program. They believe the purpose of the hospital is only to make money. Therefore, how to transform and maintain a good patients-healthcare provider relationship might be an issue need to address. In addition, how to make patients understand that cardiac rehabilitation, like cardiac surgery, is a way to help them heal and recover, not just an extra, dispensable service is quite important.
The present theme is accordance with previous research and adds information between phycological distress and poor CR attendance through demonstrating that hopelessness, pessimistic, offensive and angry can influence initial decision-making [26]. These findings, combined with the last theme (impressions on staffs and surroundings of CR center) suggest that health care providers should recognize that psychological distress and personality might interfere with patients’ decision making. Therefore, attending to the emotional context of prospective CR patients is quite important. In addition, some psychosocial assessment and intervention should be used to evaluate potential participants and built a good relationship between patients and healthcare-provides. Such as some mindfulness-based practices are reported to be effective to transform patients’ cognitive and improve the interpersonal relationship between patients and health care providers [27].
There are several limitations in this study. First, the data were only from the one university hospital. In the future, a multicenter study with a larger sample size is needed. Second, for the quantitative phase, CR barriers were assessed only the day before patients discharge. Barriers might change after patients return to their usual life. Therefore, a continues assessment after the patients’ discharge could provide more information. Finally, researcher’s personal lens might impact the interpretation of the qualitative themes. Therefore, in order to minimize this impacts, two researchers with interdisciplinary background read the transcripts independently and came to consensus about themes.
This mixed methods study involves collecting both quantitative and qualitative data and intentionally integrating the data to provide a better understanding of the barriers to hospital-based phase II CR program among CHD patients in the Chinese context. Both of the quantitative and qualitative phases confirmed that logical factors, such as distance, transportation, program cost, misunderstanding of CR, and time conflict are main barriers to participate in CR. Qualitative results provides a deep explanation about these barriers and also discovered that impressions on CR team and psychosocial distress and specific personality are barriers. Therefore, intervention programs purposed on increasing participate rate should focus on how to overcome these barriers. Some innovative methods such as home-based CR, mobile health, and hybrid program might be effective to overcome some of these barriers and improve the participate rate. In addition, psychological and social assessment are needed to evaluate the psychosocial status of patients and some psychosocial interventions might be conducted to transform their cognition problems and build trusted healthcare providers-patient relationship.
CHD：Coronary Heart Disease
CVDs：Cardiovascular Diseases
CR：Cardiac Rehabilitation
PCI：Percutaneous Coronary Intervention
CABG：Coronary Artery Bypass Grafting
AMI：Acute Myocardial Infarction
STEMI：ST-elevation Myocardial Infarction
CRBS：Cardiac Rehabilitation Barriers Scale
COVID-19: Coronavirus disease 2019
CCU：Coronary care unit
Ethics approval and consent to participate
Ethical approval for this study was obtained from the Ethics Boards of the Second Affiliated Hospital of Shantou University Medical College (Reference no. 2020-49). Written informed consent was obtained from the participants in the process of recruitment before the data collection.
Consent for publication
Not Applicable.
Availability of data and materials
The datasets generated and/or analyzed during the current study are not publicly available due to confidentiality but are available from the corresponding author on reasonable request.
Competing interests
The authors declare that they have no competing interests.
Funding
This study was funded by the Shantou Health Bureau, project no. 2020-58-23.
Authors' contributions
XXQ and HL：Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; All authors involved in drafting the manuscript or revising it critically for important intellectual content; All authors read and approved the final manuscript submitted.
Acknowledgements
The authors would like to acknowledge the participants of this study for their time and honesty. The authors also thank staff members at the CR center for their assistance with participant recruitment.