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Barriers to Patients Participation in Cardiac Rehabilitation

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Med. Forum, Vol. 32, No. 10 193 October, 2021
Original Article
Barriers to Patients Participation Barriers to
Patients in
in Cardiac Rehabilitation Cardiac
Rehabilitation
Mahtab Ahmed Mukhtar Patafi1, Ayesha Bashir1, Muhammad Kaleem2,
Hafiz Muhammad Wassam3 and Muhammad Iqbal4
ABSTRACT
Objective: To identify the barriers faced by patients to participate; both attendees and non-attendees, in cardiac
rehabilitation.
Study Design: A cross-sectional study
Place and Duration of Study: This study was conducted at Different Hospitals providing Cardiology and Cardiac
Surgery services in Karachi from June 2019 to June 2020.
Materials and Methods: The total duration of the study was 6 months and Modified Cardiac Rehabilitation Barrier
Scale (CRBS) questionnaire was used.
Results: About 100 participants took part in the study, out of which 63% where male and 37% where female. The
mean age of the participants was 57.2900; age 88 being maximum and age 35 being minimum. It was seen that
majority of the adults were illiterate and almost 50% being unemployed. Additionally, it highlights that distance,
cost, transportation, family responsibilities and patient referral system was the major barrier for the respondents not
attending or missing few sessions of cardiac rehabilitation program. Subsequently, not major but, time constraints,
energy to continue and work responsibilities were also a barrier.
Conclusion: It has been concluded from the study that non-attendees show more barriers to cardiac rehabilitation as
compared to attendees. It is expected in the future that the scale of developing cardiac rehabilitation centers and its
performance will be increased, and efforts will be made to overcome the major barriers.
Key Words: Cardiac Rehabilitation, Barriers, Patients
Citation of article: Patafi MAM, Bashir A, Kaleem M, Wassam HM, Iqbal M. Barriers to Patients
Participation in Cardiac Rehabilitation. Med Forum 2021;32(10):193-197.

INTRODUCTION A variety of national entities have described cardiac

rehabilitation with their own perspectives, which
The diseases related to cardiac system are considered to encompasses “Cardiac rehabilitation is a secondary
be the first leading causative reason of death worldwide preventive, long term and comprehensive approach
or over globe. Hence, least possible treatment measures which involves the process from patients evaluation to
and protocols are present or if they are available then it discharge planning; involving exercise prescription,
is beyond the reach of people. The term Cardiac counseling, education and knowledge, and cardiac risk
Rehabilitation (CR) is a structured program of exercise factors.(3)
and education, which not only helps in subsiding Cardiac rehabilitation is tailored to each cardiac patient
problems related to cardiac diseases but also helps in according to his requirements. Although nearly all
reducing other related co-morbidities. It helps the cardiac patients can benefit from rehabilitation but it is
patient to return to optimal fitness and functioning important that patients do not follow their own exercise
following cardiac event. (1,2) program and only follow the program prescribed.
1.
Rehabilitation involves patient’s education regarding
Cardiac Center, Quaid e Azam Medical College
the cardiac symptoms and issues, stress management
Bahawalpur.
2. Department of Physiotherapy, Bahwal Victoria Hospital, and modification, nutrition and diet consultation and
Bahawalpur. modification of lifestyle. On the other hand, patient
3. Department of Physiotherapy, National College of should fully understand the significance of motivation
Physiotherapy, Bahawalpur. and rehabilitation. (4)
It is considered that cardiac events are a major threat to
Correspondence: Mahtab Ahmed Mukhtar Patafi, patient’s life physically as well as psychologically. If a
Physiotherapist, Cardiac Center, Quaid e Azam Medical person has had gone through Heart Failure (HF),
College Bahawalpur.
Coronary Artery Bypass Graft Surgery (CABG),
Contact No: 03017766019
Email: [email protected] Myocardial Infarction (MI), Valve Repair or
Percutaneous Coronary Artery Intervention than they
Received: May, 2021 have fear of having any of the condition again due to
Accepted: July, 2021 which they are psychologically disturbed. The fear
Printed: October, 2021 takes the patient into anxiety and isolation and if these
fear becomes dominant than counseling is a necessity.
Med. Forum, Vol. 32, No. 10 194 October, 2021
In today’s world counseling have profound beneficial was also given to ensure participants voluntary
effects on patient’s health and life style, and participation.
rehabilitation not only treats cardiac issues but also Data analysis Procedure: Data was analyzed by using
treats fears and puts it to rest. (5) the software Statistical Packages of Social Sciences
In 2001 by the Institute of Medicine, which is in United (SPSS) version 21.0. Descriptive statistical methods
States, serious demands were raised because of safety such as mean, median and frequency were used for
failures and suboptimal benefits from the physical analysis.
therapy practice. As a result, the health care system was
redesigned and the main domains of quality were RESULTS
covered in it. These main domains which are necessary
The sample for this study comprised of 100 participants
for quality appraisal are: safety, effectiveness, patient-
who consented to participate in the study and completed
centeredness, timeliness, efficiency, and equity. (5, 6)
the Cardiac Rehabilitation Barrier Scale (CRBS). The
Cardiac rehabilitation was prescribed for those who
mean age of the study was 57.2900, for which
suffered or had heart failure. But with time elapse the
minimum age of the respondent was 35 years and
inductions have changed. Among the heart failure
maximum age of the respondent was 88 years. (Fig. 1).
group, only stable class II and II group who don’t have
The quantitative data for the exceeding barriers in
complex arrhythmias can go for exercise trainings
percentages is detailed as followed: 85% agreed and
protocols. Cardiac rehabilitation is prescribed to heart
15% disagreed to it; 82% agreed that and 18%
transplant patients as well. (6,7)
disagreed to it; 86% agreed that I was unable to go to
Currently, it is seen that acute cardiac care and
the CR program, or if I went to the program I missed
rehabilitation has already decreased the mortality rate
few of the sessions for the reason: of transportation
so much that exercise training program, isolated
problems and 14% disagreed to it; 52% agreed that I
interference, might not be able to cause any further
was unable to go to the CR program, or if I went to the
change in the mortality and morbidity rate.
program I missed few of the sessions for the reason:
Consequently, now for cardiac rehabilitation the
travel (e.g., holidays, business, and cottage), 30%
outcome measure is to improve quality of life (QOL).
disagreed and remaining 18% neither agreed nor
Services of cardiac rehabilitation are safe and effective
disagreed; 83% agreed that I was unable to go to the
interventions and these services are potential for
CR program, or if I went to the program I missed few
contemporary treatment of patients with multiple
of the sessions for the reason: I don’t have any idea
cardiac issues or problems.
about CR program (example; my physician or health
MATERIALS AND METHODS care provider did not tell me regarding it), 16%
disagreed and only 1% neither agreed or disagreed;
Study Design: Descriptive cross sectional study. 81% agreed that I was unable to go to the CR program,
Setting: The study was conducted in cardiac hospitals/ my physician or health care provider didn’t felt that it
institutes; private and government, at Karachi was needed and 19% disagreed; and 53% agreed that I
Sample Size: Sample size of 100 patients were selected was unable to go to the CR program, or if I went to the
for the study by convenient non-probability sampling program I missed few of the sessions for the reason: of
technique. family responsibilities (e.g., care giving), 35%
Inclusion Criteria: Following criteria was considered disagreed and 12% neither agreed nor disagreed (Table
to be necessary to the inclusion of the subjects: I; respectively for distance, cost, transportation, travel,
 Patients with cardiac issues; inpatients and didn’t know about cardiac rehabilitation, doctor did not
outpatients. feel it was necessary and family responsibility).
 Patients prescribed for cardiac rehabilitation but 41% agreed that I was unable to go to the CR program,
were not attending. or if I went to the program I missed few of the sessions
 Patients prescribed for cardiac rehabilitation but for the reason: of time constraints (example; too busy,
were not regular. inconvenient class time), 39% disagreed and 20%
Exclusion criteria: neither agreed nor disagreed, and 42% agreed that I was
 Patients who did not have/ had cardiac issues and unable to go to the CR program, or if I went to the
age less than 18 years. And with any visual, program I missed few of the sessions for the reason.
cognitive or serious mental conditions were And, when the respondents were interviewed about
excluded from the study. whether they find exercise tiring and painful or if they
Data collection tool: Modified Cardiac Rehabilitation feel that they don’t have energy to continue program
Barrier Scale (CRBS) questionnaire was used in this then 47% disagreed, 33% agreed and 20% neither
study. agreed nor disagreed and 48% disagreed that I was
Data collection method: Data was collected from the unable to go to the CR program, or if I went to the
participants by face to face interview. Consent form program I missed few of the sessions for the reason: I
Med. Forum, Vol. 32, No. 10 195 October, 2021
do not have enough energy, 34% agreed and 18% agreed nor disagreed that I was unable to go to the CR
neither agreed nor disagreed. program, 33% disagreed and only 3% agreed. Also,
Furthermore, 71% disagreed that I was unable to go to 65% neither agreed nor disagreed, 31% disagreed and
the CR program, or if I went to the program I missed only 4% agreed, and 66% neither agreed nor disagreed
few of the sessions for the reason: I did not want CR, that I was unable to go to the CR program, or if I went
18% neither agreed nor disagreed and 11% agreed, 74% to the program I missed few of the sessions for the
disagreed that I was unable to go to the CR program, or reason. (Table I).
if I went to the program I missed few of the sessions for
the reason.
Compatibly it is seen that 68% disagreed that I was
unable to go to the CR program, or if I went to the
program I missed few of the sessions for the reason:
most of the people with heart related conditions do not
go, and they are absolutely well, 21% neither agreed
nor disagreed and remaining 11% agreed and 64%
disagreed that I was unable to go to the CR program, or
if I went to the program I missed few of the sessions for
the reason: I am capable of managing my own heart
related conditions, 27 neither agreed nor disagreed and
9% agreed.
Moreover, when the participants were questioned about Figure No.1: Gender of participants
taking care of health alone or in group then 64% neither
Table No.1: Barriers Faced by patients towards participation in cardiac rehabilitation
S Barriers Strongly Disagree Neither Agree Strongly
# Disagree (Frequency) Agree or (Frequency) Agree
(Frequency) Disagree (Frequency)
(Frequency)
I was unable to go to the CR
program, or if I went to the
program I missed few of the
sessions for the reason of:
1 Distance (e.g., not located in 14 1 0 1 84
your area, too far to travel)
2 Cost (example; parking, gas) 16 2 0 2 80
3 Transportation problems 14 0 0 1 85
(example; access to car,
public transportation)
4 Family responsibilities (e.g., 35 0 12 4 49
care giving)
5 I don’t have any idea about 16 0 1 1 82
CR program (example; my
physician or health care
provider did not tell me
regarding it)
6 I did not want CR (example; 71 0 18 1 10
heart problem treated, feel
well, not severe)
7 I am exercising in my 74 0 21 0 5
community, or at home
8 Severe weather 75 0 21 0 4
9 I find exercise tiring or 46 1 20 2 31
painful
10 Travel (e.g., holidays, 30 0 18 5 47
business, cottage)
11 Time constraints (example; 38 1 20 4 37
too busy, inconvenient class
Med. Forum, Vol. 32, No. 10 196 October, 2021
time)
12 Work responsibilities 40 0 18 2 40
13 I do not have enough energy 48 0 18 2 32
14 Additional health related 72 0 19 2 7
issues restrict me from going;
like kidney stones or dialysis,
knee osteoarthritis, common
flue or fever
15 I am too old 68 3 9 3 17

DISCUSSION 84% said no they are currently not attending the CR

program and reaming 14% said that they were attending
Cardiac Rehabilitation is a broad spectrum for the CR program. And, when the respondents were asked
management of cardiovascular diseases and cardiac about that did they ever attend the cardiac rehabilitation
issues; whether recurring or may occur once. CR is program, 96% of them said they never attend the CR
significantly related to reduce mortality and morbidity program earlier in their life but only 4% said that they
rate and hence it is grossly practiced around the globe. had previously attended the CR program as well.
April 2007, an article was published by the name of
barriers to participation in cardiac rehabilitation. In this CONCLUSION
article it was resulted that rural persons feel that lack of
It has been concluded from the study that there are
resources perceived distance is the major barrier.(8)
numerous barriers at the level of health care system,
Many of the participants in this study said that they
patients, society and environment that prevent patients
were never referred for cardiac rehabilitation program
to participate in the program of cardiac rehabilitation.
or their physician or health care provider didn’t felt that
Many of the participants found distance, cost, travel,
it was needed. As depicted earlier as well that 83%
and transportation and family responsibilities as their
agreed that I was unable to go to the CR program, 16%
major barrier.
disagreed and only 1% neither agreed nor disagreed,
and 81% agreed that I was unable to go to the CR Author’s Contribution:
program, or if I went to the program I missed few of the Concept & Design of Study: Mahtab Ahmed Mukhtar
sessions for the reason, and 19% disagreed. Hence, in Patafi
year 2016, “Assessing Physician Barriers to Cardiac Drafting: Ayesha Bashir,
Rehabilitation Referral Rates in a Tertiary Teaching Muhammad Kaleem
Centre” article was published. This survey has Data Analysis: Hafiz Muhammad
concluded that there are physician barriers; which Wassam, Muhammad
include staff and medicine residents. (10) Iqbal
In year 2008, resulted that barriers were seen for both Revisiting Critically: Mahtab Ahmed Mukhtar
patients and health care professionals. It was concluded Patafi, Ayesha Bashir
that health care professionals should take measures Final Approval of version: Mahtab Ahmed Mukhtar
including making changes in health policies, increasing Patafi
referral ratio and enhancing CR program with
Conflict of Interest: The study has no conflict of
respective to women needs and preferences (11,12).
It is seen one of the studies published in year 2013, interest to declare by any author.
mounting a questionnaire to recognize apparent
obstacles to put into practice the Dutch physical therapy
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