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Abstract
Title- What are the factors which determine patient adherence to cardiac rehabilitation post Myocardial Infarction?
Objective- This integrative literature aims to review current literature which examines factors which have an influence and impact on participation adherence to Cardiac Rehabilitation (CR) post Myocardial Infarction (MI).
Background- Clinical studies emphasise clear benefits to CR indicating the reduction of reoccurrence of further cardiac related events such as MI and Coronary Artery Disease (CAD). In spite of these benefits uptake remains underutilised as mirrored in statistics. Although uptake of this remains underutilised which is mirrored in statistics globally. Within the UK (United Kingdom), participation to CR after MI diagnosis is 39%.
Methods- The study utilised a number of different data bases including Medline, CINHAL, Cochrane, Google Scholar and Summon to research and identify ten research articles. Inclusion and exclusion criteria’s was considered and applied during the search to help filter the research to the need of the proposed research question. Integrating the relevant critical appraisal skills tool (CASP)
Results- Out of the articles identified throughout the search process, only ten studies were chosen for this integrative literature review; two were secondary articles and eight were primary research articles. Upon appraisal of these articles using CASP and extracting vital data, there were three themes among each of the articles which includes; age, gender and accessibility These identified themes held significance in regard to the correlation between participation and attendance to CR services. The consensus among the research indicate that gender played
Implementation of findings- As discussed in results it was evident that age and accessibility were fundamental in determining whether participants attended or discontinued CR. With the constant changes in society in regard to technology advances, budget cuts within the NHS a new method of CR is proposed. Distance, work commitments and family commitments prevented individuals from attending, thereby utilising technology advances and integrating service via SMART phones can be of benefit, to those who are unable to commit to a CR programme. Additionally, it should be noted for further research that tailoring CR programmes to age categories can support those who’s perceptions of the exercise phase to CR were negative.
Conclusion-
This literature reviews draws on multiple types of research which addresses the topic question of determining what factors influence attendance to CR post myocardial infarction. Although attendance has a slow increase of 6.6%, there still remains a proportion of population that aren’t consuming CR. Accessibility is chosen as a potential change agent, in utilising technological advances to produce a programmes which can be accessible from SMART phones thereby which is freely accessible and available to those whom cannot attend the more traditional CR approach. Cardiac nurses/ CR nurses must ensure that upon educating patients during hospital admissions that they sign-post patients to alternatives which meet their individual needs. Furthermore in accordance with the NMC (2015) education and health promotion must occur from CR/nurses to ensure patients understand accurately information provided.
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Introduction
Myocardial Infarction (MI), most commonly known as a heart attack, is an acute condition mainly caused by Coronary Artery Disease (CAD). Statistics dictate that within England, an MI occurs every 3 minutes (NHS Digital, 2017). This makes it, as of 2016, the second cause of mortality in England and Wales (Office for National Statistics, 2017). Additionally, it is the leading cause behind the deaths of individuals aged 50-64 years old (Office for National Statistics, 2017).
The pathophysiology of a myocardial infarction (MI) transpires when the coronary artery is occluded/blocked, typically due to a build-up of atherosclerotic plaque preventing blood flow to the heart resulting in death to the cardiac myocytes. There are two categories of MI, referred to as STEMI and NSTEMI. Clinical presentation is illustrated by severe central chest pain which can radiate to the jaw and arm, diaphoresis and a pale complexion. NICE (2013) guidelines indicate an MI can be diagnosed through changes in electrocardiogram (ECG) in regard to the ST-segment. Additionally, a protein (Troponin) is released as a response to the heart being under stress. A blood test is conducted to measure troponin levels to confirm an MI (National Institute for Health Care Excellence (NICE, 2015).
Under the guidelines of secondary prevention of MI, NICE (2013) recommends that those whom have experienced cardiac-related events such as MI and CAD should be offered cardiac Rehabilitation (CR). Furthermore, CR services are offered to patients undergoing medical interventions such as percutaneous coronary intervention (PCI), coronary angioplasty or bypass (Lewin and Doherty, 2016; BHF, 2016). CR integrates health promotion in a magnitude of forms addressing factors which impact on cardiovascular disease, including exercise training, counselling, and health education programmes (BHF, 2017).
Bethell et al., (2008) argues that Cardiac Rehabilitation married together with preventative medications is the most effective form of therapy to reduce the likelihood of a recurring cardiac event. Highlighted in the NICE (2013) guidelines 1.3, emphasising beta-blockers, statins, dual antiplatelet therapy and angiotensin-converting enzyme (ACE) inhibitors must be prescribed to patients following a MI.
According to Lewin and Doherty (2013), exercise-based CR is reported to reduce cardiac mortality by 26%. A UK study suggested that CR following AMI reduces mortality by around 20% (West et al., (2011). Along with this, current research indicates an improvement in walking distances, increased well-being psychologically, and most importantly, significantly better quality of life for patients (Mckee et al., 2014; Clark et al., 2013).
Although the evidence indicates proven benefits of mortality and improvements of quality of life, it should be noted that participation rates in CR, and patient compliance with CR are not well tolerated Ruano-Ravina et al., (2016). While annual statistics from 2017 reveal some progress of participation (6.6% increase), there remains a large percentage of eligible individuals whom are not consuming this service (British Heart Foundation, 2017). Within the UK, figures highlight 51% (37% MI) of the population eligible for CR utilise the programme (British Heart Foundation, 2017).
As a part of my Adult Nursing training, I shadowed CR senior nurses whilst on placement. Witnessing CR services being offered in clinical practice to patients post MI and listening to the benefits and importance of adapting a different and healthier lifestyle and listening to patients decline these services influenced this topic to be studied further. The purpose of this study is to investigate and identify current literature to gain deeper insight into the factors which influence and prevent patients from attending cardiac rehabilitation post MI.
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Methodology
The consensus surrounding integrative reviews highlights the importance of addressing possible gaps in knowledge, appraising current and new research and, foremost, to collaboratively address the specific area of research (Aveyard, 2014). Souza et al., (2010) contributes further by citing that this form of review is the comprehensive form of approach as it allows aspects ranging from experimental studies, non-experimental and theories to combine, address and understand the research and concepts of the area of interest.
Formulating the Question
Quantitative and qualitative research, individually, will not be sufficient enough to answer my question. Thereby, selecting research which combines both techniques (commonly known as mixed-methods) will help support in gaining factors which answer the research question, but also provides statistics to determine the significance results (Aveyard, 2014). Östlund et al., (2011) informs the reader that mixed-methods is an approach of research which is widely used in nursing and health science due to it examining all aspects of a topic.
Additionally, cohort and prospective research allows researchers to integrate a group of participants to measure exposures and risk factors over a period of time. Moreover, it allows the researchers to examine numerous outcomes/risk factors for the selected group (Ahn, 2016). This form of study examines outcomes and exposure over a period of time. Mann (2003 suggests that retrospective cohort studies is a preferred research method in healthcare due to ethical protocols. Although Mann (2003) acknowledges limitations of this method which occur in relation to loss of participants to follow up in the study.
Mann (2003) acknowledges that retrospective studies utilise data that has been collected previously, which may contain flaws in the original dataset. Therefore, if used will be transferred into the study and must be acknowledged.
In respect to evidence-based practice and nursing, integrative reviews are deemed the most appropriate methodical approach of researching a health-related topic as it allows the researcher to synthesise different research concepts, health problems and theories. This is to collectively form a consensus whereby it can help influence and impact clinical practice (Hopia et al., 2016; Aveyard, 2014; Whittemore, 2005).
P – Population Individuals who have experienced a myocardial infarction (MI)
E- Exposure Factors/ influences that preventing participants from CR
O – outcome Impact on attendance and non-attendance.
“Cardiac rehabilitation” “CR” “Secondary prevention” “rehabilitation”
Compliance” “Attendance” “adherence” “non-adherence”
“Myocardial infarction” “MI” “STEMI” “NSTEMI”
“Barriers” “factors” “prevents”

Inclusion & Exclusion
Integrating inclusion and exclusion criteria as Aveyard (2014) discusses, illustrates that the researcher is maximising the volume of literature which prevents the researcher from reading articles that do not fit the criteria. Furthermore, it condenses articles which include keywords as in Table 2, eliminating papers which do not fit the criteria for the proposed research topic. Databases deemed appropriate for the study comprised of; Medline, CIHNAL and Cochrane.
Inclusion Exclusion
Research articles must be within ten years from 2008-2018 to identify differences within time. Research before 2008 would not be relevant or up to date.
Articles must be published in English Articles that were not English were removed.
Study participants must include both genders; male and female Articles based on one sole gender were removed as the question aims to explore factors as a whole and not specific enough to a gender
Research must have been carried out in Europe specifically UK. Articles in countries which had a significant difference in healthcare would be excluded.
Articles must measure predictors or factors which prevent people from attending CR, or look at the difference in attendance and non-attendance. Research that measured effectiveness of CR was excluded, as the question posed to identify factors that prevents attendance.
Articles that covered MI, PCI, STEMI, NSTEMI, AMI were included. Articles that solely measured cardiac conditions such as CAD were excluded
Must be full-text Not full text or did not mention any keywords in appendix.2 were excluded.
Although the search terms used in the databases produced sufficient articles, it was difficult to find articles that fit the population sample. It should be highlighted that due to this challenge it was not possible at the time to find articles that fit the population sample. Thereby, the decision was made to broaden the search strategy to include both Summon and Google Scholar databases to find the remaining articles. Acknowledging the potential limitation in utilising these databases and the impact on scope of literature that was available the research was completed (Aveyard, 2014).
Evaluation and Analysis of Data
Aveyard (2014) proposes that in order to succumb relevance and quality of research it must be critically analysed to ensure its relevance is in accordance to the proposed research question. This is carried out in the form of Critical Appraisal Skills Tools (Casp-uk.net, 2018), which enables the researcher to understand the methodological strengths and weaknesses of the research among other aspects including results, bias etc. (Public Health Resource Unit, 2006). Upon retrieval of ten articles, each was individually CASP’d and formulated into a data extraction table which highlights key aspects of the study as represented in appendix.1. A theming table was then produced which condensed down the articles to identify key themes which were discussed in results (see appendix.2).
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Results
Theme 1: Gender
From analysing and extracting data from the articles it was apparent that nine out of the ten chosen articles revealed that gender had an influence in regard to CR participation. Secondary research performed by Ruano-Ravina et al., (2016), which, although could not perform a meta-analysis due to the variant sample sizes and variables, found most studies proposed females are less likely to attend than men. A single study argued no difference among gender and attendance (Raunao-Ravina et al., 2016).
It should be noted many of the articles within this study were conducted outside of the UK (only three UK based). These results could not be adapted to the population in the UK, as the healthcare system is not the same in terms of cost.
A meta-synthesis conducted by Clark et al., (2012) aimed to highlight the process and the factors which prevent individuals from CR upon referral. The study provided a strict inclusion and exclusion criteria which ensures that upon searching databases, results presented will be articles that were of relevance to the topic, and of high-quality when appraising evidence (Aveyard, 2014). Results demonstrate that gender had an impact in relation to CR and participation. It included 62 articles, and of the 1646 participants figures revealed that 57% were females, although it was evident from feedback that CR programmes were referred to as “men’s clubs” (Clark et al, 2012). The study illustrated via perceptions from patients that CR programmes did not acknowledge the occupational roles of females and how these demands in terms of social roles; childcare, housework, work, and family life, could impact commitment to programmes. This study also identified it was more likely that females put responsibilities of their family members above their own health, and this included their desire to attend CR.
This form of qualitative research allows the researcher to gain a deeper understanding of an experience/topic (Shin et al., 2009). A limitation, which must be considered, is secondary research has the potential to bring through weaknesses from the original content into the review (Aveyard, 2014). It is difficult to critique this study as the results were unclear and challenging to interpret. Additionally, the review acknowledges that the studies used in the meta-synthesis could have limitations.
A primary study conducted by Zhang et al (2009) aimed to gain an insight into the factors of initiation, adherence and completion of CR programmes, which was conducted in the form of a population-based study. It is argued that this type of research poses limitations in regard to generalisation of results and external validity. Szklo (1998) acknowledges that findings from this nature of research can be impacted by the limited response of participants, specifically when the query is the differences between attendance and non-attendance. However, Szklo (1998) also argues, that this method of study can be stipulated to a selected population, and it allows researchers to identify risk-factor outcomes for a specific topic.
A total of 400 patients initiated into CR, with the majority (61%) being male. Of those initiated the majority of adheres (62%) and majority of non-adherers (57%) were also male. However, it should be noted that most non-initiates were also male (57%) indicating that gender played a significant role in the uptake of CR. Although Zhang et al (2009) considered a variety of variables that could affect CR initiation, the paper focuses more towards ethnicity so reasons for the difference in gender attendance is not investigated. Additionally, with the population being predominately males it could be argued that this does not reflect actual differences among genders as it is not clear or presented with female statistics. The study was also conducted in a single location in the USA, so it cannot be applied to the rest of the world.
A UK study by Chauhan et al (2009) examined the experiences of participants following an acute cardiac event highlighting reasons for attendance of CR programmes. This study focuses more on ethnicity (Pakistani, Indian and Bangladeshi) and CR within the UK and it should be noted that all participants identified themselves as Muslim (male n=13, female n=7). In regard to gender, it was clear that females had a significance in non-attendance to CR.
Females revealed that in a mixed gender CR session it would be difficult to find suitable clothing which was appropriate for both the session and their religious beliefs. It was also mentioned that females would be embarrassed at the idea of participating in a CR exercise session in front of males. This study outlines a clear issue in regard to religion playing a part in gender initiation into CR. The population size in this study is small, and thereby findings in correlation to gender and CR do not represent nor reflect the greater population within the UK. Sample sizes in qualitative research has been debated immensely in research and the consensus demonstrates that research will continue to gather participates until they have reached saturation (Guest et al., 2006 and Mason 2010).
This study applied qualitative research methods in the form of semi-structured interviews. Atieno (2009) identifies that with some research topics this approach is suitable as it incorporates questions which will reduce the element of the data being prematurely condensed. In regard to semi-structured interviews, Jamshed (2014) argues that this technique is beneficial as it allows the researcher to explore concepts systematically ensuring the interview remains in focus. Although it should be noted that this study carried out processes of reviewing transcripts and audiotapes to help improve the validity.
Parashar et al., (2012) involved conducted interviews from intervals at one and six months on those who were offered and carried out the CR programme. During the one-month interview it was found that, out of 1450 interview participants, females were less likely to attend CR (OR 0.61; 95% confidence interval, 0.44,0.86) whereas 75% of males attended CR. During the six-month period 1347 patients participated to which 92% were male, data indicated being females among other factors did not impact on participation rates. However, the study fails to investigate deeper into why more males attended and declined CR than females.
Similar results were found by Gardiner et al., (2018) in a retrospective mixed-method study. Of 279 participants 84% were males, with an identical percentage of non-participants also being male. However, as with Parashar et al., (2012), this study does not provide reasons behind why this occurred. Also, any participants who did not attend at least 10 CR sessions was excluded from the study with no mention as to why they did not adhere.
Dunlay et al., (2009) conducted a mixed methods study involving 179 study participants. The idea of mixed gender classes did not influence attendance as it did in Chauhan et al., (2009), possibly down to most participants being Caucasian. However, it did display diabetes and BMI as role in men not attending, yet BMI appeared to influence women attending. Disadvantages of the study are, as well as the population sample being small, the vast majority of participants were male. Also, due to a high P value (p = .7113), the results could have been down to chance.
In a later paper, Dunlay et al., (2014) announced their findings of a population-based surveillance study conducted over the course of 23 years. Out of 2991 approached, 1569 participated in a CR program. More men attended CR than women (71% men, 29% women) with a P value

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