Community-based exercise training for people with chronic respiratory and chronic cardiac disease: a mixed-methods evaluation

Figures & data

Table 1 Participant characteristics

Characteristic	All participants, n=32	Participants interviewed, n=15
Age, years	72 (10)	73 (6)
Gender, male:female	11:21	5:10
Current smokers, n	3	1
BMI, kg/m^2	29 (7)	30 (7)
Primary diagnosis, n
Asthma	5	2
Bronchiectasis	3	3
COPD	15	6
Congestive cardiac failure	2	1
Hypertrophic obstructive cardiomyopathy	1	1
Interstitial pulmonary fibrosis	1	–
Lung cancer	1	–
Postpartum cardiomyopathy	1	–
Pulmonary hypertension	3	2
Pulmonary function*
FEV1 (L)	1.42 (0.44)	1.58 (0.50)
FEV1 (% predicted)	61 (20)	67 (22)

Notes: Data are presented as mean (SD) unless otherwise stated.

* n=25 for “all participants” and n=11 for “participants interviewed”. “–” indicates not applicable.

Abbreviations: n, number; BMI, body mass index; FEV₁, forced expiratory volume in 1 second; SD, standard deviation.

Figure 1 Participant flow.

Table 2 Quantitative outcomes

Outcome measure	n	Baseline	Follow-up	Change	P-value
6-minute walk distance, m	22	408 (77)	440 (77)	32 (11 to 53)	0.005
St George’s Respiratory Questionnaire#	17
Total score		44 (19)	40 (20)	−4 (−10 to 1)	0.09
Symptoms score		56 (18)	53 (23)	−3 (−12 to 5)	0.40
Activity score		59 (19)	52 (22)	−6 (−12 to −1)	0.03
Impact score		32 (23)	26 (19)	−6 (−13 to 1)	0.08
Minnesota Living with Heart Failure Questionnaire#	4
Total score		54 (25)	41 (22)	−12 (−33 to 8)	0.16
mMRC dyspnea scale#	22	3.2 (1.1)	2.7 (1.1)	−0.5 (−0.9 to −0.1)	0.008
HAD scale#	21
Anxiety score		6.5 (4.6)	6.1 (5.0)	−0.3 (−1.8 to 1.2)	0.65
Depression score		5.8 (4.4)	4.8 (3.5)	−1.0 (−2.3 to 0.3)	0.13

Notes: Data are presented as mean (SD) or mean (95% CI), unless otherwise stated.

# Lower score equates to better outcome. n denotes the sample size.

Abbreviations: mMRC, modified Medical Research Council; HAD, Hospital Anxiety and Depression; SD, standard deviation; CI, confidence interval.

Table 3 Major themes and quotes from interviews

Major themes	Participant quotes	Physiotherapist quotes
Community venue and environment facilitated a positive rehabilitation experience	“It has got a better atmosphere than the one at the hospital” (Male, 77 years) “I think the equipment and the area and being outside the hospital is better for people” (Female, 68 years) “It is a very nice atmosphere to work in. So you are not just shut up in a blank wall, you can look out over the park and see what is going on outside, and it is lovely … they also have televisions up on the wall and that sort of thing … it is a very nice environment” (Female, 68 years) “Yes there is a lot of choice, what you can do. So I think it is very good, because it can be very basic for those who are very ill and weak. They can do it on a very low level, or you can do it on a more intense level. The variety is very good. I did things that I have never done before” (Female, 68 years)	“It is good to get out of the hospital setting and see the real-world setting and seeing these people exercising in the community in that way” (Physiotherapist 1) “They were probably doing more exercise than they might do at one of the hospital venues that is setup for older people … rather than only having a few options for them … flexibility to be able to vary people’s programs, try different things with them” (Physiotherapist 1)
Convenience of accessing the community venue	“Easier parking, easier access, it was closer” (Male, 77 years) “(Main reason for choosing community venue was) proximity and parking availability with no cost” (Female, 71 years) “You just cannot park anywhere over at the hospital, unless you go to the parking area and that is really expensive” (Female, 85 years) “I would not have done two days (at the hospital), I probably would have done one. It is a great program, but when it is at the hospital it is just so difficult” (Female, 72 years)	“The fact they could just park outside and have a short walk in, they were more confident, they were not getting anxious about the parking, because some of them do get quite anxious, just the idea of I have got to park, then I have got to walk, but they knew what was going to happen at the community venue” (Physiotherapist 2) “They were less fatigued when they got there” (Physiotherapist 3) “The whole concept of access to the facility was a thing that made them attend more” (Physiotherapist 2)
Normalizing and transference of behaviors	“Because it is a ‘gym’ gym, most of the other people there were young rather than a hospital environment” (Female, 68 years) “There were other people using the gym, younger people. Really fitness fanatics … we sort of fitted in quite well … the venue was absolutely perfect” (Female, 72 years)	“They got to see some other people their own age who were just coming to use the gym independently, so they could see other older people exercising” (Physiotherapist 3) “It was not as institutionalized. It made the patients feel more that they were training as opposed to doing some treatment … it makes them feel like they are less sick” (Physiotherapist 2) “What I really enjoyed about it … it is real life. In our society people go to the gym. So it is a sort of fostering that within them and giving them the opportunity to go outside a hospital setting into a community setting … so they are not so institutionalized by coming back in and doing their program at the hospital” (Physiotherapist 1) “They were more confident to actually be in a gym environment because they have come to a community gym. The fact that we had that little interaction sort of helped other people see, maybe I can come here with my family … one patient is a little bit more confident now so he is looking to get his son to go to another gym so they can go together and he feels confident enough now to be able to do that, whereas before I do not know whether he would have been as confident going to the hospital gym … it is a clinical setting” (Physiotherapist 2)
Barriers to post-program exercise	“Honestly and truly, you do not do the same things when you have not got to do them … whereas if I have got to do it myself I think ‘Oh, I do not think I will go for a walk today’” (Female, 72 years) “I would not keep on doing, I would not you know keep on going to the gym. I think I am too old. Old to be coming to the gym all the time” (Female, 85 years) “I think it is expensive to join the club. But I would not do that, because I am not interested in going to the gym all the time” (Female, 85 years)	“They are not able to get motivated to go to the gym and do their own program, even though they know it very well … they are able to set up their equipment, get on and off the equipment by themselves, use it correctly. It was just that motivation of getting to the gym” (Physiotherapist 2) “(Main barriers to joining the gym) cost and the commitment … they are not able to commit to the amount of sessions that they deemed to be getting value for money and also the motivation to come to the gym” (Physiotherapist 2) “The main thing is cost … they have other things that they might prioritize and they might think that joining a gym is a luxury compared to say health care costs … so cost I think is probably the main barrier for a lot of the people that go to the pulmonary rehab program because the majority of them are elderly or on a pension” (Physiotherapist 1)

Table 4 Minor themes and quotes from interviews

Minor themes	Participant quotes	Physiotherapist quotes
Perceived fitness benefits	“Mainly the walking machine, because I was having difficulty walking up hills … and that has improved my fitness level quite considerably. So I was very pleased from that point of view … I can lift a lot heavier things now … it has improved my fitness, my lifting capability, my walking capability” (Female, 68 years) “The best part was getting fit so that I can walk up stairs without being breathless” (Female, 72 years) “There was tangible improvement … yeah, I thought the actual rate of progress was visible and it gave me a lot of satisfaction” (Female, 77 years) “Well I think it was showing that you can do a little bit more than you thought you could, you know. Like I do more now than I would have ever done before. I would not have done any of those sorts of things before other than walking” (Female, 72 years)
Interaction facilitated adherence to the exercise training program	“It is very difficult to do it by yourself at home … they push you more, you just do a bit extra, a bit extra, you know” (Male, 68 years) “Even though it is a sort of work, it is still social and you are still mixing with other people, and they are people that are like you” (Female, 72 years) “It gave you encouragement, that we were all trying our best to achieve something and, you know, it was sort of nice to have people to talk to, and after eight weeks, 16 sessions, you get to know people and encourage them and they encourage you” (Female, 68 years) “I found the interaction with people who had severe illnesses and were very much incapacitated, that it was very good for me to see how far I had come. The group interaction was very warm and very supportive” (Female, 77 years)
Physiotherapists importance and role	“You had the people to show you what to do and to encourage you to get started. So that has given me the opportunity to think well now I can do that myself because I know what to do” (Female, 68 years) “If I have the physios with me I am confident, but on my own I am not so confident. I actually enjoyed the exercises, but I think I enjoyed the exercises because I knew I was being monitored. I do not know if I could go and do it on my own because I would be a bit anxious” (Female, 68 years) “Yeah, I was in a pretty bad way and I needed to improve, but I did not feel I could go to a commercial gym, I needed the physios there to monitor me and support me” (Female, 77 years)	“We do not want them to be so dependent on us once they finish the program. Hopefully we have taught them the skills to continue exercising on their own or joining a group outside of the hospital setting … the main thing is empowering the person who has completed to continue on by themselves” (Physiotherapist 1) “With a lot of these people right at the end of the program … it was more just checking them at the start, how are you going, upping them as they needed to and some people would just be increasing themselves” (Physiotherapist 2) “We were able to encourage them to be really independent, so hopefully that will translate to them being able to do that themselves” (Physiotherapist 3)

Table S1 Satisfaction survey

Please tick the relevant column for your answer to each statement below	Strongly Agree agree	Neutral	Disagree	Strongly disagree
The exercise program has helped me manage my lung or heart condition more effectively
The exercise program was enjoyable
The exercise program has improved my fitness
The exercise program has improved my breathing when performing activities
The exercise program has improved my ability to exercise independently
I found the education booklet I received helpful
I would recommend this exercise program to others with a lung or heart condition
The venue of the exercise program was convenient for me (eg, transport/parking was easy)
I would like to continue the exercise program at this site
Overall, I am satisfied with the quality of service I received in delivering the exercise program