A total of 30 participants participated in this study between July and December 2024. The mean age of patients and HCPs was 51.9 and 37 years, respectively. There were 14 male and 06 female patients, whereas 5 HCPs were males and 5 were females. The mean experience of HCPs was 11.5 years (Table 1). The purpose of taking interviews from a heterogeneous group was to get maximum contextual insights to cover a larger CAD population. Therefore, HCPs from both private and public sector hospitals were invited for interviews. Nine themes emerged from participants’ data: (1) Lack of Discharge Education by Healthcare Professionals, (2) No Written guidance - Patients’ Need Written Health Information, (3) Low Prescription and Challenges in Doing PA and Exercise, (4) Duration of Rest and Activities to Commence With, (5) Activities to be Performed Daily, (6) Activities to Improve Exercise Endurance, (7) Convenient and Safe Exercises, (8) Exercises for Patients with Joint Pain, (9) Frequency, Intensity, Time, and Type of Exercise (Figure 2).
Table 1: Demographic Characteristics of Participants (n=30)
Variables
|
Participants n=30
|
Patients (n=20)
|
Mean Age
|
51.9 Years
|
|
Frequency
|
Percentage
|
Gender
|
Male
|
14
|
70%
|
Female
|
06
|
30%
|
Co-morbidities
|
DM
|
10
|
50%
|
HTN
|
10
|
50%
|
Diagnosis
|
STEMI
|
13
|
65%
|
NSTEMI
|
07
|
35%
|
HCPs (n=10)
|
Mean Age
|
37 Years
|
|
Frequency
|
Percentage
|
Gender
|
Male
|
05
|
50%
|
Female
|
05
|
50%
|
Affiliation
|
Private Tertiary Care
|
06
|
06%
|
Public Tertiary Care
|
04
|
40%
|
Mean Experience
|
10.2 Years
|
Data from patients and healthcare professionals revealed different physical activity and exercise strategies that can be adopted by patients living in LMICs, particularly in Pakistan, where there is no structured cardiac rehabilitation program available or being offered to them.
Theme 1: Lack of Discharge Education by Healthcare Professionals
The data from participants revealed dissatisfaction with the healthcare professional’s education about future prevention. The responses from the majority of Participants showed a lack of understanding about their diseases and their causes. They also shared that they did not receive any discharge education related to their disease, risk factors, and rehabilitation.
“Nobody told me what I should do and what should not be done to prevent further heart attack.” (P8, M, 49, DM, Smoker, Carpenter), another participant shared, “I was not told to do anything else except take medicines…” (P9, M, 50, DM, HTN, Smoker, Self-employed).
In support of participants' responses, Healthcare professionals accepted that there is a gap in the care for cardiac patients regarding cardiac rehabilitation. Patients are not referred for rehabilitation due to a lack of rehabilitation facilities and referral mechanisms:
“I think that the main reason is that in our doctors’ society, they are not referring the patients to the physiotherapy department or asking the physiotherapist to do those patient exercises. (Physiotherapist 1)”.
Another cardiologist with 7 years of experience in a private-sector tertiary care hospital shared that patients are not provided with the proper instruction about physical activity and exercise at the time of discharge, so the care provided to patients by HCPs is lacking.
“They do not know what to do. I mean, they are not being taught at the time of the discharge” (Cardiologist, 1).
Theme 2: No Written guidance - Patients’ Need Written Health Information
When asked about the sources of health information, participants expected after a heart attack that, health information should be provided to the patients in a written form in an easy language, and the same should be made available electronically, such as on their mobile to have the information available all the time after the heart attack.
“I would say it should be given in writing on paper in easy language as well as sent in mobile so that if paper misplaces the other option, it should be in hand” (P8, M, 49, DM, Smoker, Carpenter).
Similarly, when healthcare professionals were asked about the suitable source of information for patients then, they shared that giving patients health information in a booklet at the time of discharge followed by a proper follow-up mechanism would be more convenient to HCPs and patients as well:
"Give them the educational material as an Urdu booklet; if we involve their caregivers and family caregivers, they can help them understand that information. So, at the time of discharge, if we give them. Resources about the education of all these components of rehabilitation, and after that, we follow them on messages and phone calls."
(Cardiologist 1)
Theme 3: Low Exercise Prescription and Challenges
The participants shared different perspectives on whether the doctors recommended exercise during the initial phase of treatment. The majority of the participants reported a lack of exercise recommendations by healthcare professionals:
“I do not exercise at all., and no one ever told me to exercise, nor did I.” (P1, M, 55, Labour).
“Doctors never told me to do physical exercise… they only told me to quit Smoking and avoid cold food. No activity suggested by doctor." (P2, M, 66, Smoker, Police Officer)
Patients also shared their challenges when they intended to initiate physical activity and exercises:
“I was terrified of doing exercises because of my first heart experience…the staff in the hospital encouraged me to walk daily, and they sent me home.” (P14, M, 40, DM, Smoker, Banker)
“After a few weeks, doctors suggested a walk, but walking with heart disease is quite difficult. It is very frightening to have chest pain during the walk, and that is the fear that does not allow exercise." (P8, M, 49, DM, Smoker, Carpenter)
“My family does not allow me to walk much due to my heart problem.” (P4, M, 61, DM, HTN, Teacher)
“After discharge from the hospital, it was not a good feeling as heart patients’ capacity gets decreased and family does not allow to do routine work." (P5, M, 59, HTN, Smoker, Shopkeeper)
Theme 4: Duration of Rest and Activities to Commence With
In this theme, different cardiologists suggested one week of bed rest for a patient soon after a heart attack:
“So, when we discuss the patient after the heart attack, the day you advise them to bed rest for a week, like up to the washroom” (Cardiologist 1)
Another healthcare professional said,
“If the patient has received the successful intervention, and so, after one week, he can start doing physical activity” (Cardiologist 2)
However, one cardiologist suggested intra-house activities such as walking inside the home from room to room or room to lounge. After one week, they should be encouraged to walk daily:
“So, I tell the patients they can resume regular activities when discharged. Intra-house activities are like walking inside and going from room to room to the lounge and outside the garden. However, I do not allow them to go outside the house until I see them at one week's follow-up” (Cardiologist 3)
Healthcare professionals suggested gardening as part of the physical activity that patients can easily incorporate at home. A cardiologist recommended that patients take care of plants to start with physical activity at home:
“So these patients can do some light gardening, like watering the plants and not just sticking out; I recommend they engage in gardening. Taking care of the plants, I can say,” (Cardiologist 1)
A cardiac nurse also suggested that patients do gardening:
“Patients can also do gardening, etc.” (Cardiac Nurse 1)
Similarly, a physiotherapist suggested that patients integrate exercises such as walking and gardening:
“Patients can integrate exercise into daily life by walking, gardening, or cycling.” (Physiotherapist 2)
Theme 5: Activities to be Performed Daily
Walking after a heart attack was a common insight among patients and healthcare professionals. Among cardiologists, cardiac nurses, and physiotherapists, walking is safe and convenient for patients after a heart attack. A cardiologist recommends commencing walking as early as possible after a heart attack:
“We recommend that they remain active as early as possible, do sports if they were doing them before, or do healthy activities like walking and running.” (Cardiologist 2)
Another cardiologist said that there are many exercises to do at home. It depends on patients what they can do and the space at the homes where they can do, such as a terrace or ample space:
“We have many exercises, but it depends on the size of their home, such as a terrace or open space. If they can walk, they can.” (Cardiologist 2)
Similarly, a cardiac nurse recommends that patients walk regularly at home:
“Patients can take regular walks at home.” (Cardiac Nurse 1)
Two other cardiologists advised that patients should walk because it is the most beneficial activity for heart patients in the long run:
“I advise them to walk because brisk walking, if they can achieve it without symptoms, is the best activity I can do, which is you. Know which has shown to be effective in the long term from cardiac.” Cardiologist 3; “The best exercise is walking, which can be done in many ways.” (Cardiologist 4)
Likewise, three physiotherapists suggested that regular walking is easy and accessible for patients, which they can safely do at home:
“If talking about walking is very important, jogging or brisk walking is very important in cardiac patients.” Physiotherapist 1: Walking is an easily accessible and effective exercise patients can perform at home; low-impact aerobic exercise such as walking, stationary cycling, and swimming are generally safe.” Physiotherapist 2; “Brisk walking is recommended in the initial days.” (Physiotherapist 3)
Additionally, a psychologist recommended a daily walk to reduce patients’ anxiety:
“That is, they can walk daily. They can do it. Once they feel anxiety or some of these feelings, they must do it first.” (Cardiac Nurse 2)
Regarding the patients' experiences, several patients who suffered a heart attack were able to incorporate walking into their daily routine. One participant said that he used to walk about 2 to 3 kilometers daily at his job, which had helped him towards recovery:
“I did not exercise because I walk a lot due to my work…almost 2 to 3 kilometers daily with the workers and field staff…it helped me a lot in recovery because I used to avoid staying at home just because I had a heart attack.” (P9, M, 50, DM, HTN, Smoker, Self-employed).
Similarly, a housewife shared that she used to walk at home at her convenient time and remained symptom-free:
“…in my free time, I used to walk at home and do sitting exercises as suggested in the online programs…I still used to read information from the internet and follow it…I did not feel any pain again after they inserted the stents…I take medicines, and life is going on…” (P19, F, 51, DM, Housewife)
Likewise, a patient who was a laborer by occupation shared that despite the doctor’s recommendations for a walk, he did not walk due to his normal routine;
“Doctors suggested walking as much as possible is good for me. I did not walk other than my routine.” (P1, M, 55, Labour).
Another patient who was a teacher shared his perception that exercise was only done in the gym. However, he used to walk minimally:
“I used to walk minimally because I live near my shop, which is hardly 100 meters from home… I do not know about the benefit of exercise because the exercise I know is what people do in gyms to shape their bodies.” (P4, M, 61, DM, HTN, Teacher).
On the other hand, a shopkeeper shared his concern about the current unhealthy activities of people, such as being dependent on vehicles instead of covering the minimal distance by walking, which has affected health badly:
“So, people started shifting from healthy to unhealthy activities and travel on motorbikes and cars…this has affected our health significantly.” (P11, M, 47, DM, HTN, Smoker, Shopkeeper).
Another patient who was a carpenter shared that walking with heart disease was difficult for him, and fear of chest pain associated with the walk did not allow him to do it much:
“After a few weeks, doctors suggested I walk, but walking with heart disease is quite difficult. It is very frightening to have chest pain during the walk, and that is the fear which does not allow to exercise.” (P8, M, 49, DM, Smoker, Carpenter)
Similarly, a housewife patient reported a contextual challenge: responsibilities do not allow them to do self-care, and all the time is spent meeting family expectations:
“Completing household chores is a challenge for women. What other tasks we can do? We are expected to fulfill our responsibilities at home, such as preparing meals and caring for our children and husband.”(P3, F, 45, DM, Housewife).
Another housewife shared that she could not get time for herself as she had all the other family responsibilities on her:
“I did not get time to exercise, and all that you know, being a housewife, I have many responsibilities.” (P19, F, 51, DM, Housewife)
Theme 6: Activities to Improve Exercise Endurance
In this theme, the physiotherapists recommended jogging and cycling for patients after a heart attack as these are safe and require less monitoring by healthcare professionals:
“Patients should be briefed about cardiopulmonary exercises and cycling, jogging, and running.” (Physiotherapist 1)
“Running and cycling are the safest exercises for heart attack patients. Running needs less monitoring as compared to other exercises.” (Physiotherapist 2)
“Brisk walking is recommended in the initial days and then changes into jumping and jogging.” (Physiotherapist 3)
A cardiologist recommended running to the patients to improve muscle strength and body endurance:
“Do healthy activities like walking and running. To increase muscle strength and body endurance” (Cardiologist 2)
On the other hand, a shopkeeper patient shared that bicycling in the evening has benefitted him. He also shared his concern that nowadays, people do not bother traveling on bicycles due to the stigma attached to it in society:
“I started bicycling in the evening, and it benefited me a lot…previously, people used to cycle and were healthy. In this era, we prefer not to do cycling as it is considered a label for poor people…” (P11, M, 47, DM, HTN, Smoker, Shopkeeper)
Healthcare professionals in this theme mentioned the convenience of doing exercises. A cardiologist suggested that patients climb one floor to increase their exercise capacity:
“I recommend they start light activities like climbing one floor, coming out of their room, and sitting in the drawing room.” (Cardiologist 1)
Another cardiologist, when asked about the safe exercises that would benefit patients at home, suggested that patients can climb 2-3 flights of stairs at home if they have:
“…and if they have stairs, they can have 2-3 flights.” (Cardiologist 2)
Similarly, a physiotherapist advised that patients incorporate maximum physical activity into their lives, such as walking, and prefer stairs over the elevator in their routine:
“Patients can integrate exercise into daily life by walking, gardening, or cycling. Choosing stairs over elevators, scheduling regular short walks, and engaging in household chores are practical ways to maintain physical activity.” (Physiotherapist 2)
Theme 7: Convenient and Safe Home-based Exercises
In this theme, healthcare professionals suggested different exercises for the patients that can be done safely at home. A physiotherapist recommends heart patients perform in-bed exercises, stretching exercises, and range of motion (ROM) exercises 2-3 times daily. After a week, when they get better:
“The activities that they can easily adopt are some of the in-bed exercises, generalised body exercises, some stretching exercises for their leg muscles, or even some in-bed active range of motion exercises for their upper and lower extremities that we Used to perform and educate them to do twice or thrice in a day and later on when after a week or so when they get better.” (Physiotherapist 1)
A cardiac nurse suggested that patients be prescribed sitting exercises because those are safe and involve low risk:
“Low-risk activities such as walking and sitting activities are safe and low risk. However, those are safe if they do not show symptoms during activities.” (Cardiac Nurse 1)
Different cardiologists suggested that patients should do walking and sitting exercises after a heart attack. However, they observed the low uptake of these exercises:
“So that should at least again equal 150 minutes of moderate exercise per week, such as a daily cycle sitting position.” (Cardiologist 1)
“The best exercise is the walk, which can be done in many ways. If the patient is sitting, he can move his arms and legs, and patients with very minimum numbers, 9 to 10% do it after discharge.” (Cardiologist 4)
Regarding the experience of home-based exercises by the patients, a patient who was a farmer by occupation shared that his brother, who was a physiotherapist, taught him some exercises that he used to do at home, which was a good experience for him even though he experienced a little anxiety initially related to chest pain which he never developed it during exercise:
“…my brother is a physiotherapist, and he guided me to some exercises, and I started doing it at home…so I did it….it was a good experience because I never felt any difficulty doing it, but yet I was anxious about my chest pain (laughs) in early days.” (P20, M, 55, DM, HTN, Smoker, Farmer)
Similarly, another patient who was a driver shared that exercise is important for heart patients to recover, and he was used to doing it without any difficulty; however, it gave him a little fear in the initial days;
“Exercise is very good; you know the active person can recover most quickly… being active is the good thing, and after the heart attack, I used to be very active, although I was frightened in the initial days but did it very easily…” (P18, M, 59, DM, HTN, Smoker, Driver)
A patient who was labor by occupation shared that exercise is beneficial for heart patients, but he was not suggested to do it by the doctors:
“Exercise has many benefits; it does not have any harm if a person does it. I was never told to exercise by doctors.” (P1, M, 55, Labour)
Another patient, who was a retired police officer, shared his experience that he was not recommended to do exercise when he was under active treatment because no one suggested he never did it:
“Doctors never told me to do physical exercise… they only told me to quit smoking and avoid cold food. No activity suggested by the doctor.” (P2, M, 66, Smoker, Police Officer)
A response from a patient who was a teacher showed no recommendation for exercise by the doctors to him. However, he was advised to walk as much as possible:
“My doctor suggested walking as much as I can…but has not suggested any exercise at home.” (P4, M, 61, DM, HTN, Teacher)
Theme 8: Exercises for Patients with Joint Pain
When asked about the activities for patients who also suffer from joint pains such as arthritis, physiotherapists suggested that such patients can do exercises that involve no weight, such as sitting exercises and stationary cycling:
“We change physical activity according to a complaint, like guided about static cycling, swimming, and non-weight bearing exercises.” (Physiotherapist 3)
Similarly, another shared:
“Non-weight bearing does not provoke their pain, and they can swim or even do terminal extension exercises while lying or sitting. So these are the exercises. We could encourage them to do, or even they can do some breathing exercises, like diaphragmatic breathing exercises, if the patient cannot walk with knee pain. So we ask them to do stationary cycling because it is effective.” (Physiotherapist 1)
The response by a cardiologist indicated that patients with joint issues should walk as per their capacity, such as instead of walking for a longer duration at once, they can do it in short breaks and intervals:
“Regarding joint pains, patients with such issues should be advised to walk as per their capacity and divide the duration into short intervals. Instead of 30-35 minutes of walking, ask the patient how much they can easily walk. If they say 5 minutes, they can divide 30 minutes of walk into 5-minute intervals.” (Cardiologist 4)
A cardiac nurse shared her experience and suggested that such patients should do non-weight-bearing exercises and walk as much as possible:
“They can do some non-weight-bearing PA or walk as much as possible.” (Cardiac Nurse 1)
Similarly, a cardiologist shared his experience that patients who are overweight or have joint pains that make them less active are suggested to do sitting exercises to burn their calories:
“We suggest that patients who are overweight or cannot walk due to pain in their knees should do sitting exercises and move their legs and arms to burn calories.” (Cardiologist 2)
A physiotherapist indicated that patients with joint issues can be advised to do safe exercises such as minimal walking, stationary cycling, and swimming:
“Low-impact aerobic exercises such as walking, stationary cycling, and swimming are generally safe.” (Physiotherapist 2)
On the other hand, the experiences of the patients highlight the inability to walk due to joint pains, for which healthcare professionals have suggested many strategies above:
“I never walk because of my knee pains. If I try, it hurts me a lot…so I am on many medicines due to my diseases like heart, sugar, and joint pain.” (P19, F, 51, DM, Housewife)
Theme 9: Frequency, Intensity, Time, and Type of Exercise
Healthcare professionals recommended physical activity and exercise frequency and intensity in this theme. A physiotherapist shared that patients should do activities aiming for perceived exertion 5-6 on a scale of 0-10 as it allows patients to improve their breathing and heart rate with the ability to conversate. He also suggested monitoring heart rate during exercise to stay within the recommended targeted heart rate:
“Start with moderate-intensity activities aiming for a perceived exertion level of 5-6 on a scale of 0-10. This level allows for increased heart rate and breathing but still allows conversation. Priorities a safe environment by choosing well-lit and clutter-free spaces. Begin with low-intensity exercise, gradually progressing as tolerated. Always have a communication plan, and consider using wearable devices to monitor heart rate and stay within recommended limits.” (Physiotherapist 2)
Regarding the frequency and duration of physical activity, a physiotherapist suggested 150 minutes per week, which can be increased after a few months:
“Patient adopted most exercises as a day living activity for walking, 150 minutes at the start. After two to three months, the patient increases the walking duration.” (Physiotherapist 2)
A cardiologist shared that patients should begin physical activity within 5-10 minutes initially, which can be increased to 35 minutes depending on their targeted heart rate:
“What I do with my patients is I start with very low and do not ask them to start with 35 minutes from day one. I asked them to tell me the time and how much they could walk. Based on the individual targeted heart rate, we can also do it as a 5-10-minute walk for 3-4 days.” (Cardiologist 4)
A cardiologist for post-heart attack patients with gradual ascending of the time and duration also suggested a daily walk for 30 minutes:
“I usually advise my post-heart attack patients to start gradually increasing their activities and doing their routine walks. Daily for 30 minutes.” (Cardiologist 1)
Another experienced cardiologist recommended 20 minutes of daily walking for 5 days, which can be increased as per the tolerance level of patients:
So, at least to begin with, after a heart attack, when they undergo angioplasty, they have they have some degree of LV dysfunction. So 20 minutes of work every day, maybe five days a week, is what they should start from. Moreover, I tell them that if they do not have symptoms, they can progress in their activities as long as they can tolerate and enjoy it. (Cardiologist 3)
A cardiologist shared that patients should walk for 30 minutes five days a week, and this is what they suggest to patients in their routine practice:
“We just said in our routine service that you should walk for 30 minutes, a brisk walk for five days.” (Cardiologist 2)
Regarding the frequency, duration, and intensity of home-based exercises, a physiotherapist suggested doing exercises with 30 repetitions three times a day, which can be continued for 4-6 months:
“It depends on the patient's age and the recommended set for these exercises, usually three times a day with a minimum. Repetitions for these exercises are ten repetitions and can gradually increase to 30 repetitions. We can continue this for as long as four to six weeks." (Physiotherapist 1)
Similarly, another physiotherapist recommended doing low to moderate-intensity aerobic exercise along with muscle strengthening and light resistance exercises:
The gradual incorporation of physical activity is key. Begin with low-intensity activities like walking and gradually increase intensity. Engage in moderate-intensity aerobics exercises such as brisk walking, cycling, or swimming. Additionally, include muscle-strengthening activities like bodyweight exercises or light resistance training.” (Physiotherapist 2)
A physiotherapist suggested doing aerobic exercise 3-5 times daily, including muscle-strengthening activities, for at least two days. He also suggested one day of rest between sessions to promote recovery:
“Perform aerobic exercises at least three to five times weekly. Include muscle-strengthening activities on two or more days a week. Allow for at least one rest day between sessions to promote recovery.” (Physiotherapist 3)
A cardiologist shared his concern that there should be a structured program for exercise based on the gradual increase in intensity, load, and time over weeks:
“There should be a structured programme for exercise, which needs to be done gradually. For example, the exercise intensity, load, and time must gradually increase over weeks.” (Cardiologist 4)
A cardiac nurse suggested that heart patients perform 10-15 minutes of low-intensity exercise for 2-3 days initially, which should be increased to 4-5 days based on patient capacity and tolerance level. She further suggested that the intensity shall be increased over weeks to months and should be continued doing it for six months:
“10-15 minutes of low-intensity exercise at home is enough for heart patients, which should be continued for 3-6 months. Initially, 2-3 days or alternate days should be increased to 4-5 days a week. The intensity should be based on the patient's capacity to tolerate and should be increased gradually from weeks to months.” (Cardiac Nurse 1)
Regarding the patients' experience of commencing physical activity and exercise after the heart attack, a teacher shared that in the initial days, she started doing a walk and exercise, which she thought was not easy. However, after a few days to weeks, she became habitual of walking and realized it was not impossible:
“When I started walking and doing little exercises, I thought that I could not do this, but after a few days, I realized that no, I can do it…even after it I became habitual of a daily walk and few exercises which I have learned from the internet.” (P12, F, 42, DM, Teacher)
Another patient who was employed in a private company responded that she started walking and gradually increased the speed; however, when she felt shortness of breath, she stopped and started again. It has helped her develop the exercise capacity from 5 minutes to 40 minutes:
“I felt a little shortness of breath when I increase my speed while walking, but if I sit for a while, it goes away, and I then again start walking…this has helped me a lot because if I tell you. Initially, I could not walk even for 5 minutes, but now I can do it for 30 – 40 minutes, so it is a big difference now if I compare my initial days and this time…” (P16, F, 43, HTN, Employed)
A driver also shared his experience walking early in the morning; he mentioned that he could perform all routine activities after five weeks. The mention of other people walking in the park has highlighted a factor of motivation in the participant, which has helped him maintain a healthy walk:
“…gradually I used to increase the walking early in the morning, and you see many people come in the park they are fit…the same I did, and after almost five weeks, I could do all the normal things in routine activity.” (P18, M, 59, DM, HTN, Smoker, Driver)
Another patient who was a housewife shared her experience of walking twice a week for six weeks: “I started walking on my own twice a week for four to six weeks”; however, the mention of “I never tried exercise, and nobody told me to do so.” (P10, F, 52, HTN, Housewife), indicates low exercise recommendations by healthcare professionals.
Similarly, another patient reported his experience of daily walks. His friends, who were also survivors of heart attacks in the past, supported him in doing walks 3-4 times a week with a gradual increase in the time, starting from 10 minutes in the beginning, then 15, and so on. He enjoyed this technique despite the family’s concerns over physical activity after the heart attack. Due to family’s concerns, he also fears chest pain initially, which disappeared when he started walking more frequently:
“My friends were the biggest support for me; they used to go with me in the evening mostly, and this has given me the courage to walk and have a good time with them…not daily but 3-4 times a week we used to go, and even they want me to set the time of walk for every week, for example, one week they told me to walk for 10 minutes, and the next week they told me to walk for 15 minutes you know this was an amazing technique to help me on my legs…my family was worried about me because they do not want me to go outside due to my heart problem and 2 of my friends already experienced it…that is why they were sure that I will cope with it…and I did it Alhamdulillah…I was very nervous initially due to the fear of chest pain, but I never came again…I am fine now and still walk very frequently.” (P17, M, 60, DM, Smoker, Employed.
Development of Home-based PA and Exercise Instructional Module
The module was initially developed in English and converted into Urdu by the researcher. The English and Urdu booklets were given to bilingual Urdu experts so they could vet and check for errors. Errors identified in Urdu booklets were fixed and returned to experts for final review. Once approved by the Urdu experts, the end user assessed the module for readability and understandability.
Readability and Understandability of the Module
After the booklet had been designed, it was assessed for its readability and understandability. The Patient Educational Material Assessment Tool (PEMAT-P) was administered to 10 patients and 10 Content Experts along with the Complete module in Urdu language. Patients' qualifications ranged from below primary to Bachelor, while the healthcare professionals included five Cardiac Nurses, two Urdu Experts, two Cardiologists, and two physiotherapists. They were given two 15 days to read and rate the booklet on PEMAT-P. However, the process took 25 days to get the booklets back from the raters. Scores given by the raters (patients and Content Experts) were entered and analyzed in Microsoft Excel. The final patient scores were 95.9%, whereas from experts Content Experts scored 95%.
Content Validity Index of Booklet
After receiving satisfactory readability and understandability scores from the raters, nine experts examined the booklet for content relevancy and clarity. The content validity index was calculated using a 4-point Likert scale. The relevancy of the booklet's content was rated as 1=Not relevant, 2=Somewhat relevant, 3= Quite relevant, 4=Highly relevant. The clarity was rated as 1=Not clear, 2=Somewhat clear, 3=Quite clear, 4=Highly clear. The scores 3-4 were acceptable; however, if rated 1-2, the raters were requested to write how it could be improved. A total of nine experts from different private and public sector tertiary care hospitals rated the booklet for CVI, which includes four interventional cardiologists with more than ten years of experience, three physiotherapists with more than seven years of experience, and four cardiac nurses with more than five years of experience. The scores given by raters were entered in Microsoft Excel and analyzed for CVI, and the score was 0.89. As per Lynn (1986), a CVI score of at least 0.78 is acceptable with nine experts [12].