Background
Methods
Searching and study selection
Quality assessment
Data extraction
Analysis
Results
Systematic reviews and quality assessment
Primary studies and quality assessment
Study characteristics | Total [references] |
---|---|
Outcome:
| |
Uptake in CRa
| |
Completed CR | |
Design:
| |
Cross sectional | |
Cohort | |
RCT | 1 [77] |
Prospective/retrospective:
| |
Prospective | |
Retrospective | |
Country: | |
USA | |
UK | |
Australia/New Zealand | |
Canada | |
Rest of Europe (Sweden, Denmark, Poland) | |
Middle East |
Summary of findings
Key themes
Factors | References of studies examining uptake | ||
---|---|---|---|
Facilitates | Deters | No association | |
Emotions
| |||
Increased anxiety | 56** | 31, 35, 38, 50a, 52, 60, 70 | |
Depression | 31**b, 38, 50, 55**, 61, 67 | 31 b, 44, 35, 52, 60, 66, 70 | |
Stress | 50**, 54 | 52 | |
Less distress, lower mental QOL, denial, greater health concerns, higher role resumption | 43, 61, 72, 35, 37 | ||
Psychological beliefs
| |||
Illness less attributed to lifestyles, increased denial of severity of illness | 33**, 31** | ||
Less control/ cure over course of illness/ lower self efficacy | 30m, 56** | 54, 37 | |
More symptoms attributed to illness / better understanding of illness/ illness has greater consequences | 30 m
| ||
Information & communication
| |||
Less education | 31**, 35**, 34**, 36, 41, 61 | 38, 50, 60, 66, 76, 77 | |
Less awareness of blood pressure level | 67 | 33 | |
Less awareness / knowledge of total cholesterol level or recommended activity levels | 33**, 67 | ||
Friends & family support
| |||
Not married / not living with a partner / being single | 29m , 34, 38, 52**a, 53**, 65** | 35, 36, 49, 50, 52b, 60, 66,77 | |
Transport & related costs
†
| |||
Longer commute time | 31**,60** | ||
Greater distance from venue | 49 | 40, 50, 60 | |
Problems with transport, rurality | 51**, 76**c, 36**, 45** | ||
Occupation type - blue collar (vs white) | 31, 65 | 77 | |
Unemployed / retired/home maker | 65 | 33, 35, 34**, 38**, 50, 54**, 76 | 32, 36, 41, 49, 52, 67, 77 |
Higher income | 61, 65** | 35, 56** | 50, 53 |
Having health insurance | 77 |
Factors | References of studies examining completion | ||
---|---|---|---|
Facilitates | Deters | No association | |
Emotions
| |||
Increased anxiety | 74** | 55, 73 | |
Depression | 74 | 47, 55, 73, 78**a
| |
On antidepressant medication | 47, 62 | ||
Greater neuroticism | 55** | ||
Emotion focused coping | 74** | ||
Greater optimism | 55** | ||
Psychological & spiritual beliefs
| |||
Greater personal control & less treatment control | 78** | ||
Illness has greater consequences / Timeline (acute/chronic) and (cyclical) | 78** | ||
More symptoms attributed to illness | 78 | ||
Information & communication
| |||
Less education | 71** | 69, 76, 74 | |
Friends & family support
| |||
Not married/not living with a partner/being single | 47, 62** | 69, 76 | |
Transport & related costs
†
| |||
Unemployed / retired/home maker | 69 | 68, 76**b
| 74 |
Category | Factors |
---|---|
Uptake - Anxiety stait; alexithymia; distress caused by symptoms; emotional health (profile of mood state; post traumatic stress disorder, self motivation | |
Completion - problem focused coping; maladaptive coping | |
Uptake – Overall health beliefs; multidimensional health locus of control; illness perceptions personal control; illness perceptions treatment control; illness perceptions timeline | |
Completion - Emotional representations; time cyclical (symptoms change) | |
Information and communication[67] |
Uptake - Knowledge of smoking recommendation |
Uptake - Living alone; relationship difficulties | |
Completion - Living arrangements | |
Uptake – occupation; transport cost and financial difficulty; distance from centre | |
Completion – Transport problems; income; occupation, ‘practical barriers’ (broadly defined) |
Other categories
Factors | References of studies examining uptake | ||
---|---|---|---|
Facilitates | Deters | No relation | |
Language barriers
| |||
Non-English speaking background / less likely to speak English | 45** | 52, 60, 76, 77 | |
Physical wellbeing
| |||
(History of) CHD | 51 | 38, 41, 75 | 33, 66, 67, 70, 77 |
History of neurological / cognitive impairment | 45** | ||
ACS (compared to IHD) | 61 | ||
Angina pain / MI | 65, 51 | 32 | |
Previous cardiac event or cardiac procedurea†
| 34, 41, 54, 65, 67, 75 | 34, 38**, 40**, 45**, 76** | 31, 32, 33, 52, 65, 67, 76 |
Presence of clinical cardiac risk factorsb‡
| 32, 34, 65c, 75, 76, 77 | 34, 67, 75 | 19, 35, 38, 45, 50, 52, 60, 67, 77, 76 |
Co-morbid long-term conditionsd
| 31, 45**, 75, 67, 76e
| 35, 38, 42, 50, 52, 60, 65, 77 | |
Family history of CHD | 34, 76 | 75 | 52, 77 |
Increased weight & body mass index | 60, 75 | 33, 50, 60, 67, 76, 77 | |
Various indicators of cardiac conditionf
| 75 | 38, 40, 65**, | 50 |
Less frequent diagnosis of angina | 41 | ||
Poorer physical functioning/physical QOL | 35**, 61** | 36, 50, 60 | |
On medication for cardiac problems | 38, 40, 65 | 67g
| 67h
|
Balancing and integrating health care needs with daily life
| |||
Family obligations | 50 | ||
Referrals
| |||
Not receiving an outpatient appointment | 40 | ||
Culture
| |||
Foreign citizen | 65, 77 | ||
Jewish (compared to Muslim) | 61 | ||
Social support
| |||
Practical support | 64** | ||
Less social support | 36 | 37, 56 | |
Medium to large social network (versus small) | 64 | ||
Role of health care professional
| |||
Perceived strength of physician recommendation / involvement of a cardiologist | 31, 42, 75 | ||
Attitudes to rehabilitation
| |||
CR more suited to younger and more active individuals | 48 | ||
CR is necessary/ intention to attend, previously attended CR | 33, 36, 48, 51 | ||
Attitudes to exercise
| |||
Sedentary lifestyle / less regular exercise | 52 | 38, 35, 67 | 32, 33, 76 |
Personal choices and cultural preferences
| |||
Current smoking | 34, 38, 45, 75 | 50, 67 | 32, 33, 35, 52, 60, 67, 77 |
Demographics
| |||
Greater deprivation | 36, 38, 40, 42 | 70 | |
Female | 34**, 35, 37, 38, 39**, 46, 57, 75, 77 | 31, 33, 36, 40, 42, 45, 49, 50, 52, 53, 56, 60, 65, 66, 67, 70 | |
Older age | 36, 77 | 31, 33**, 37, 38, 39**, 45**, 57, 75, 77 | 31, 33, 36, 40, 42, 49, 50, 52, 53, 56, 60, 65, 66, 67, 70 |
Age between 55–74 years (compared with younger and older groups) / being a pet owner | 54 |
Factors | References of studies examining completion | ||
---|---|---|---|
Facilitates | Deters | No relation | |
Physical wellbeing
| |||
Previous cardiac event or cardiac procedure | 47, 62 | 76 | |
Presence of clinical cardiac risk factorsa
| 68b, 69b
| ||
Increased body weight / body mass index | 62,68, 69** | 55, 76 | |
Poorer physical functioning/physical QOL | 55, 68 | ||
Various indicators of cardiac conditionb
| 62, 73 | 55 | |
On medication for cardiac problems | 62 | ||
Culture
| |||
Ethnicity (white race) | 47 | 68 | |
Attitudes to exercise
| |||
Less regular exercise | 76** (females) | 68, 69 | |
Personal choices and cultural preferences
| |||
Current smoking | 47 | 62, 68, 69, 76 | 71 |
Demographics
| |||
Greater deprivation | 51 | ||
Female | 68, 69 | 47, 62, 78** | 71 |
Older age | 47, 55, 62, 69, 73 | 68, 71, 76, 78 | |
Age between 55–74 years (compared with younger and older groups) | 51, 59 | ||
Height | 69 |
Category | Factors |
---|---|
Language barriers[76] | Completion only |
Uptake – past smoker | |
Completion – calorie consumption | |
Uptake - Number of cardiac events; previous history of stroke/TIA; unstable angina; congestive heart failure; total cholesterol; triglycerides; ECG ST depression or elevation; creatine kinase levels; tropinin levels; number of risk factors present; medication for angina / arrhythmia / calcium antagonists; diuretics; level of co-morbidity | |
Completion - Previous history of MI / CABG / PCI / PTMC / valvoplasty; MI; PCI procedure; dyslipidemia; ejection fraction; fasting blood glucose; heart rate; high density and low density lipoprotein cholesterol; hypertension; hyperlipidemia; total cholesterol; triglycerides; treadmill velocity; functional capacity; heart rate after exercise; quality of life’ physical health score (SF36); waist circumference | |
Uptake - Losses in life; time stress | |
Country of birth; ethnicity | |
Attitudes to rehabilitation[48] | Greater concerns about harmful effects of exercising |
Social support [63] |
Uptake – emotional support |
Formal support[43] |
Uptake - Length of hospital stay |
Discussion
Comparison with existing literature
Summary of main findings
Strengths and limitations
Conclusions
Themes | Main message |
---|---|
Emotions Depression, anxiety, stress, poor motivation, lack of confidence, embarrassment. | Patients with depression are less likely to take up both the offer of lifestyle change support and complete any programmes. Depression is linked with obesity and poor health outcomes. Other more subtle emotional barriers may also deter patients from changing lifestyles. |
Psychological & spiritual beliefs Beliefs about role of health behaviours and extent of physical recovery | Patients who do not consider that lifestyles influence health or that they can manage their risks are less likely to take up the offer of lifestyle change support. Providing patients with evidence on how lifestyles reduce risks may encourage patients to re-think their beliefs. |
Information & communication Lack of knowledge and misperceptions about purpose of healthy lifestyles, poor understanding of communication about risks and diet | Lack of knowledge about the role of lifestyles in managing cardiovascular risk may deter patients from taking up lifestyle support. Poor knowledge may engender misperceptions and so improving knowledge may challenge beliefs. |
Friends & family support Close social support appears to impact on attempts to change and maintain healthy lifestyles. | Good support from family and friends can facilitate uptake of lifestyle behaviour change. Encouraging partners to attend Health Checks and annual reviews may increase uptake of lifestyle change programmes. |
Transport & cost Difficulties with access to specific centres to undertake rehabilitation. Costs associated with transport and daily costs of living | Transport and cost issues are a significant barrier for patients. Referral to lifestyle support should be coupled with questioning about accessibility and affordability. Referral to social services may help. |