Engagement with Cardiac Rehabilitation: A mixed-methods investigation into factors that influence patient engagement in Wales

Abstract

Introduction
Cardiac rehabilitation (CR) is a well-established program that aims to improve the physical, psychological and social wellbeing of individuals who have experienced a cardiac event. Despite its proven benefits, a considerable proportion of patients do not attend cardiac rehabilitation. This thesis aims to investigate the reasons as to why patients do not pursue cardiac rehabilitation in Wales. I also wish to find viable solutions to enhance CR engagement in Wales.

Methodology
The research for this thesis will be conducted using a mixed-methods approach. This will include a systematic review of the existing literature on the interventions to enhance CR engagement, as well as an online survey of Welsh CR staff to understand their perspective regarding barriers and solutions. This is followed by a novel secondary analysis of Welsh National Audit of Cardiac Rehabilitation data linked with the Welsh Indices of Multiple Deprivation, using a logistical regression model to identify barriers and solutions to patient engagement in Wales. A narrative review using a meta-synthesise of qualitative research, exploring patient’s experiences with CR to find facilitators to engagement is undertaken and I finally I will use methodological triangulation when examining issues surrounding patient engagement in Wales.

Results
The systematic review revealed various interventions aiming to enhance engagement – including motivational interviewing, gendered approach, theory-based letter of invitation, early appointments, inductive learning and coping strategies, reduced CR and home-based CR with the use of technology. The secondary analysis revealed a range of patient and service-level characteristics associated with CR engagement, these included age, gender, ethnicity, social deprivation, confirmation of start date and prompt referrals. The narrative review found a range of factors that contribute to patients not engaging with CR. These factors ranged from logistical barriers (such as lack of transportation or difficulty in taking time off work) to psychological barriers (fear of exercise, lack of motivation and poor understanding of the benefits of rehabilitation).

Conclusion
The results of this thesis will supply a detailed understanding of the reasons why patients do not engage in CR. This information will be available to aid healthcare professionals and policymakers when looking to improve access to CR and ensure that more patients are able to benefit from this important intervention.

Recommendations
Based on the findings of this thesis, several recommendations are made to enhance CR engagement. These may include improving organisational health literacy, tailoring health messages, providing a more flexible mode of delivery (e.g., home-based CR, reduced CR and a gendered approach), using the ‘Integrated Change Model’ for understanding patient engagement, the use of behaviour change techniques, tailoring exercise demands dependent of patient, and increasing patient education and support.

Date of Award	2024
Original language	English
Sponsors	KESS 2 PhD Student, University of South Wales & Aneurin Bevan University Health Board
Supervisor	Linda Ross (Supervisor), David Pontin (Supervisor) & Jackie Miles (Supervisor)