Cardiac rehabilitation women non-adherence

Resumen

The main objective of this thesis, presented as a compendium of publications, was to provide insight into the problem of non-adherence to cardiac rehabilitation (CR) programs in women. This thesis contains four chapters. Chapter 1 presents an overview of cardiovascular disease and its risk factors. In addition, a description of secondary prevention strategies and adherence issues are reviewed. Finally, the research questions and objectives of the thesis are presented. Chapter 2 is composed of three articles. Article I aimed to synthesize evidence about factors associated with non-adherence to CR programs. For this purpose, a systematic review of prospective cohort studies that evaluated the factors associated with nonparticipation in and/or dropping out from CR programs was carried out. Cohort studies were identified through electronic databases, reference lists were checked, and experts were consulted. Methodological quality was assessed and outcomes were extracted in duplicate. In the systematic review, 43 prospective cohort studies were included, with a total sample of 63,197 patients from three continents (Europe, America, and Oceania) and from ten countries (Australia, Belgium, Canada, Denmark, Ireland, New Zealand, Poland, Switzerland, the United Kingdom, and the United States). Factors associated with nonparticipation in/and dropout from CR were grouped into six-level categories: intrapersonal factors, clinical factors, interpersonal factors, logistical factors, CR program factors, and health system factors. We found that clinical factors, CR program factors, and health system factors were mainly assessed as factors associated with nonparticipation in CR. Moreover, we found differences between the factors associated with nonparticipation in and dropout from CR programs. Article II aimed to synthesize the evidence about barriers reported by women with cardiovascular diseases affecting their nonparticipation in and/or dropping out from CR programs. For this purpose, a systematic review of studies that evaluated the barriers perceived by women with cardiovascular diseases associated with their nonparticipation in and/or dropping out from CR programs was carried out. Studies were identified through electronic databases, reference lists were checked, and experts were consulted. Methodological quality was assessed and outcomes were extracted in duplicate. Twenty-four studies (17 descriptive, six qualitative, and one randomized controlled trial) were included in the systematic review. Barriers were grouped into five broad categories: intrapersonal barriers (self-reported health, health beliefs, lack of time, motivation, and religious reasons); interpersonal barriers (lack of family/social support and work conflicts); logistical barriers (transport, distance, and availability of personal/community resources); CR program barriers (services offered, group format, exercise component, and CR sessions); and health system barriers (lack of referral, cost, negative experiences with the health system, and language). Differences between the barriers related to nonparticipation in and dropout from CR programs were found. Article III aimed to describe the barriers women faced regarding dropout from CR programs. For this purpose, a qualitative study that described the reasons for women’s dropout from CR from the perspective of both women and cardiovascular professionals was conducted with semi-structured interviews and a focus group. Five general themes were identified that illustrated reasons for dropout from CR among women: intrapersonal reasons (self-reported health, self-reported mental health, health beliefs); interpersonal reasons (family caregiver role, work conflicts); logistical reasons (transport distance); CR program characteristics (perception of the objective of CR, exercise component, inconvenient timing, CR equipment); and health system reasons (financial assistance for transport, long waiting list). Cardiovascular professionals identified similar barriers to CR completion in women. Chapter 3 reports a general discussion based on the three articles. Overall, non-adherence process is complex. The results of this thesis show that women are at higher risk for CR non-adherence, facing barriers that might influence both nonparticipation in and dropout from CR. In addition, strengths and limitations of the present dissertation are provided. Finally, Chapter 4 provides conclusions, future research lines and practical implications to address the problem of non-adherence to CR programs in women. Health system policies should contemplate gender-specific issues in CR. The results of this thesis will enable policy makers to design specific strategies to maximize participation and completion of CR in women. The articles included in this dissertation have either been published, in press or in review to high impact international journals indexed in Journal of Citation Reports first quartile. They have been included in this dissertation in their published or submitted form.