Barriers and facilitators to participating in cardiac rehabilitation and physical activity: A cross-sectional survey

Table 1 Response rate to questions

Question	Response rate
1	162 (55.2%)
2	130 (44.3%)
3	98 (33.4%)
4	236 (80.5%)

Table 2 Topic: Cardiac rehabilitation experience

Sub-theme	Element	Description	Example quotes
Barriers and reasons for non-attendance	Barriers to attending regular cardiac rehabilitation	Barriers to attending class. Includes aspects such as the type of activity, distance and timing of the classes as well as lack of information on when the classes are or failure to be referred.	Participant 74: “Inconvenience, chest pains, shortness of breath when doing physical work.” (Male, 60-79, no classes).
			Participant 318: “I found the traveling, 1 hour each way too much.” (Male, 80+, some classes).
			Participant 135: “No classes out with working hours.” (Male, 60-79, 9 classes).
			Participant 259: “It was difficult to get information as to where and when these classes were.” (Male, 60-79, some classes).
			Participant 354: “6 months wait to be contacted regarding rehab is not good enough. We don't all live in large towns or cities.” (Male, 40-59, no classes).
			P243: “It is difficult in rural areas to travel to venue far away.” (Male, 60-79, all classes)
	Striving for independence	Wanting to take responsibility for own health, feeling the need to figure it out independently.	Participant 360: “Living in a relatively remote place I feel it is particularly incumbent on me to take responsibility for my own rehabilitation - and I feel that this should be an underlying principle. This would mean that resources could then be focussed on those who, for whatever reasons, cannot do this themselves.” (Male, 60-79, no classes).
			Participant 542: “I had already started my own rehabilitation exercises at local gym.” (Male, 60-79, some classes).
Benefits	Peer support	Being amongst other people who have shared experiences. This is not always perceived as a good thing.	Participant 575: “Good to be able to talk to people with similar problems as me. Made me realise I was getting better and helped me regain some confidence.” (Female, 60-79, some classes).
			Participant 282: “Mixed with others and talked about how others coped.” (Male, 40-59, all classes).
			Participant 441: “Just felt embarrassed and out of place.” (Male, 40-59, some classes).
			Participant 48: “Assumed it would involve group activity. I'm not very good with group activity.” (Male, 60-79, no classes).
	Healthcare provider support	Being supported by knowledgeable staff.	Participant 33: “They were carried out locally with excellent physiotherapist who carefully provided and monitored exercise which suited each individual member of small group. Relaxed atmosphere, advice and encouragement. Benefit felt.” (Female, 60-79, all classes)
			Participant 52: “The pace and programme were tailored to my needs. The physios were superb - always supportive and encouraging. Meeting with and talking to, others in a similar situation was reassuring. It was great to see my heart-rate recovery time improving as the weeks went by. The post-exercise discussions and presentations were very helpful.” (Male, 60-79, all classes).
	Being in safe hands	Being cradled gently in safe hands. Being supported and encouraged to take the steps necessary to return to physical activity. This leads to increasing confidence and motivation.	Participant 430: “To be able to exercise in an Hospital where I can feel safe. If anything happens to me I know that I have the full benefits to immediate health care that isn't available in the local communities.” (Male, 40-59, all classes).
			Participant 473: “I could exercise under supervision which took away anxiety about how much to do, how much to push myself. I could ask questions, no questions too small or silly, provided reassurance and enabled me to do exercise at home without having to worry.” (Female, 40-59, some classes).
			Participant 327: “After my cardiac event I felt some apprehension to participating in physical activity, but after attending a session, I felt more confident.” (Male, 60-79, all classes).
			Participant: 367: “I felt motivated and encouraged to carry on with exercises at home.” (Female, 60-79, all classes).
	Health benefits	Benefits and outcomes gained through attending classes. Includes both physical and mental benefits as well as increased knowledge of their condition.	Participant 146: “They restored my fitness following surgery. They were convenient and well run.” (Male, 60-79, all classes).
			Participant 449: “Controlled and supervised exercise giving much benefit to wellbeing and fitness.” (Male, 60-79, all classes).
			Participant 599: “They helped me to understand that exercise helps not hinders recovery.” (Male, 60-79, all classes).
			Participant 149: “Understanding of illness explained well and why the exercises and diet helped recovery taking into account my Parkinson's disease.” (Male, 60-79, all classes).
			P49: “Did not feel any significant difference to my condition - but I'm sure they are beneficial.” (Male, 60-79, all classes).
			P50: “I only attended one session, because I was getting reasonable exercise at home and thought there would be others who would benefit more than me.” (Male, 60-79, some classes).
Solutions and ideas to increase attendance	Time and duration		Participant 599: “The classes I attended were on the afternoon, which was not a problem for me, but could be for those still in employment. It may help to hold some classes in the evening.” (Male, 60-79, all classes).
			Participant 5: “Would have liked a class every day or every other day instead of once a week.” (Male, 40-59, all classes).
			Participant 466: “Would have liked longer than 8 weeks cardiac rehab.” (Female, 60-79, all classes).
			P67: “Make it sooner after the OP/procedure.” (Male, 60-79, all classes).
	Class Structure		Participant 116: “Not really, I would like to have been worked harder; however, as the classes have to satisfy different age groups and conditions, it would be difficult.” (Male, 60-79, some classes).
			Participant 325: “Give more interest, doing the same exercises every week is boring - virtually no equipment is used.” (Male, 60-79, some classes).
			P6: “As far as I know I attended all my classes, there was talk of more advanced classes, but I haven't heard any more news. I would like to attend more classes if there are any.” (Male, 40-59, all classes).
			P101: “I do find any gym based exercise very boring, perhaps any walking activities could be explored? A booklet on country walks suitable for people with heart problems, local community green gyms etc. Any outdoor activity organised in the Summer months to bring local communities together.” (Male, 60-79).
			P44: “Have more experts to give talks on cardiac problems and how to avoid another event. This may include food, exercise, medical advice etc.” (Male, 60-79, all classes).
	Location		P141: “Make them more reliable in my part of the world (Highlands - Caithness).” (Male, 60-79, some classes).
			P133: “Include them at the local gym so that people could attend whenever the wanted to. (Cost may be prohibitive though).” (Male, 60-79, all classes).
			P227: “Make the classes available in all medical centres.” (Female, 60-79, some classes)
			P430: “Help with travel arrangements and travel expenses out with Inverness for people not on benefits. Possible age-related groups and group buddies.” (Male, 40-59, all classes).
			P41: “Information on local support groups that are available. Discounted fees on joining local sports centres.” (Male, 60-79, some classes).

Table 3 Topic: Physical activity

Sub-theme	Element	Description	Example quotes
Benefits	Physical	Physical benefits from being active.	Participant 33: “Physical activity can help other/many other illnesses/diseases e.g., diabetes. It can also help you to feel better.” (Female, 60-79, all classes).
			Participant 423: “Keeping my weight at a good level is important and regular walking helps this. Walking helps me keep fit and helps with a good breathing pattern.” (Male, 40-59, all classes).
			Participant 101: “Being physically active not only improves recovery but stimulates the mind, especially when walking outdoors.” (Male, 72, some classes).
			Participant 49: “I am not PA as above - but I always endeavour to be active daily by other means i.e., gardening, walking, household etc., relevant to my age/weather conditions etc.” (Male, 79, all classes).
	Mental	Mental benefits from being active.	Participant 358: “Physical activity has given me a positive outlook for the future.” (Male, 60-79, all classes).
			Participant 90: “Improved confidence and mental wellbeing.” (Male, 60-70, all classes).
Challenges	Physical challenges	Physical health barriers to being active.	Participant 28: “At present I am troubled with retention of fluid which is affecting my breathing. If something could be done about this, I feel I would be able to get back to my golf and fishing.” (Male, 80+, 8 classes).
			Participant 531: “Because of my age and state of health I would find it very difficult to exercise.” (Male, 80+, no classes).
	Mental challenges	Mental barriers to being active.	Participant 87: “I don't go out by myself in case I suffer a bad turn. It's not just a physical barrier with some patients it's a mental barrier that stops them from exercise.” (Male, 60-79, no classes).
			Participant 103: “I have suffered from severe depression my whole life and lately it’s been getting worse with everything that's going on so it’s a bad place I'm in just now” (Male, 40-59, no classes).
			Participant 450: “To be honest I feel very anxious about strenuous or prolonged exercise: close to paranoia!” (Male, 60-79, no classes).
	External challenges	External barriers to being active.	Participant 61: “Normally in good weather my husband and myself are out walking about 3 d a week but with all the snow and ice we have had we have hardly been out of doors.” (Female, 60-79, no classes).
			Participant 278: “I really enjoy lifting weights and as my local gym does not have much I use a private gym. It has all health questions and if you have a health problem (heart attack etc.) you need a doctor’s letter which is £30. This could put people off.” (Female, < 39, 8 classes).
Reasons for staying physically active	Motivation	Motivation for being physically active.	Participant 160: “Would like to keep active for my grandchildren and my great grandchildren and also for my remaining son and family.” (Female, 60-79, 8 classes).
			Participant 115: “Being physically fit, for your age, helps to be mentally fit and become able to participate in family and community events.” (Male, 60-79, 8 classes).
	Preferences	Preferences of types of activity.	Participant 318: “Most of my activity is concerned with work around the home e.g., cutting trees for wood burner, splitting logs for wood burner, digging garden, looking after chicken, mowing grass etc.” (Male, 80+, some classes).
			Participant 258: “I've been involved with physical activity in my work environment all my working life. Most of my hobbies focus around exercise skiing, biking, golf, swimming and walking. Don't like to be unfit.” (Female, 40-59, no classes).