Barriers to Participation in Cardiac Rehabilitation Among Patients with Coronary Heart Disease After Reperfusion Therapy: A Scoping Review

Figures & data

Figure 1 PRISMA flow diagram.

Notes: Adapted from Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. Creative Commons.³¹

Table 1 Characteristics of Study

Ref	Design	Country	Age (Mean±SD)	Sample	Findings			JBI
					Barrier to Low Participation	PR, Types of CR, and Phase of CR	PR Measuring Tool
(Higgins et al, 2008)^Citation33	Prospective cohort study	Australia	65.7±9.8	170 Female (20.6%) Male (79.4%)	Travel time (OR 0.86, 95% CI 0.75–0.99) (p=0.039)	72%, Directly at the hospital, N/I	Contact	9/11
(Khadanga et al, 2022)^Citation34	Prospective observational study.	USA	68.3±12	378 Female (31%) Male (69%)	Electronic referral (OR 8.79, 95% CI 4.18–18.45) (p<0.001) Surgical diagnosis (OR 5.95, 95% CI 2.44–14.50) (p<0.001) Non/former smoker (OR 2.86, 95% CI 1.38–5.92) (p<0.001) Strength of physician recommendation (OR 1.68, 95% CI1.34–2.11) (p<0.001)	46.29%, N/I, N/I	Form	10/11
(Bolivar et al, 2022)^Citation35	Cross-sectional study	USA	54±13	149 Female (24.8%) Male (75.2%)	Social environment (smokers) (OR 0.40, 95% CI 0.17–0.93) (p=0.038)	32%, N/I, N/I	N/I	6/8
(Winnige et al, 2021)^Citation10	Prospective observational study.	Czech Republic	59.5±8.8	186 Female (24.1%) Male (75.9%)	Transportation problems (p<0.05)* Distance and Travel (p<0.001)* Work/time conflicts (p<0.05)* Comorbidities (p<0.05)*	29.8%, Directly at the hospital, Phase I–III	Self-report	9/11
(Shanmugasegaram et al, 2013)^Citation16	Cross-sectional study	Canada	65.4	1807 Female (25%) Male (75%)	Gender (Men) participated more (p<0.05)* Rural (p<0.05)* Low economic status (p<0.01)*	51.9%, Directly at the hospital, N/I	Survey	8/8
(De Vos et al, 2012)^Citation22	Descriptive study	Belgia	65	226 Female (27%) Male (73%)	The distance, the cost of rehabilitation, the belief that they can handle matters independently, and the lack of time.	77%, Directly at the hospital, N/I	N/I	6/8
(Cao et al, 2021)^Citation36	Prospective longitudinal survey	China	60	283 Female (42%) Male (58%)	Age (SE 0.057, B 0.77, 95% CI 0.69–0.86) (p<0.001) Perception of Shared Decision-Making (SE 0.13, B: 1.14, 95% CI: 1.02–1.27) (p<0.05) Knowledge about Risk factors (SE 0.07, B 1.14, 95% CI 1.02–1.27) (p<0.001) Predisposing factors (SE 0.56, B 6.54, 95% CI 2.16–19.7) (p<0.001) Treatment (SE 0.80, B 9.04, 95% CI 1.87–43.6) (p<0.001) Self-Management Behavior Life management (SE 0.07, B 1.90, 95% CI 1.03–1.38) (p<0.05) Emotional management (SE 0.11, B 1.31, 95% CI1.05–1.65) (p<0.05)	64.66%, Home and exercise-based CR, Fase I and II	Questionnaire	8/11
(Foster et al, 2021)^Citation11	Cross-sectional study	United Kingdom	68.9	295 Female (24.1%) Male (75.9%)	Perceived need/healthcare factors (OR 0.02, 95% CI 0.01–0.06) (p<0.001) Lack of willpower (OR 0.42, 95% CI 0.18–0.97) (p=0.043) Self-efficacy to overcome barriers (OR 1.29, 95% CI 1.05–1.59) (p=0.016)	53%, Directly at the hospital, N/I	Form	7/8
(Viana et al, 2018)^Citation37	Cohort Study	Portugal	63.5 ± 12.9	197 Female (15.2%) Male (84.7%)	Travel time to the CR centre (OR 0.18, 95% CI 0.04–0.92) (p<0.001) Health insurance coverage (p<0.001)	67.7%, Directly at the hospital, N/I	N/I	8/11
(Parashar, 2012)^Citation38	Prospective study	USA	60.41±11.9	2361 Female (25.3%) Male (74.7%)	Uninsured patients (OR 0.39, 95% CI 0.21–0.71) (p<0.001) Hypertension (OR 0.58, 95% CI 0.43–0.78) (p<0.001) Peripheral arterial disease (OR 0.43, 95% CI 0.22–0.85) (p=0.004) Previous PCI (OR 0.55, 95% CI 0.36–0.83) (p<0.001) High school education (OR 1.38, 95% CI 1.04–1.84) (p=0.002) Higher physical function (OR 1.19, 95% CI 1.02–1.39) (p<0.001) Economic burden (OR 0.56, 95% CI 0.38–0.81) (p<0.001)	48.3%, Directly at the hospital, N/I	Self-report	10/11
(Zhang et al, 2022)^Citation7	Retrospective study	China	59.89±9.30	391 Female (29.0%) Male (71.0%)	Support Life Club (OR 27.38, 95% CI 10.2–73.6) (p<0.000).	72.5%, Directly at the hospital, Phase II	Diaries	8/11
(Kim et al, 2021)^Citation39	Prospective survey	Korea	63±50.3	173 Female (23.7%) Male (76.3%)	Symptom experience (OR 3.46, 95% CI 1.45–8.27) (p=0.004) Higher perceived socioeconomic status (OR 2.90, 95% CI 1.28–6.58) (p<0.001) Perceived susceptibility (OR 1.22, 95% CI 1.08–1.39) (p<0.001) Perceived benefits (OR 1.09, 95% CI 1.02–1.17) (p<0.001) Perceived severity (OR 1.04, 95% CI 1.00–1.08) (p=0.007)	42.6%, Directly at the hospital, N/I	N/I	8/11
(Olsen et al, 2018)^Citation23	Observational Cohort Study	Norway	63.1±10.2	9.013 Female (24.7%) Male (75.3%)	Sex (OR 0.72, 95% CI 0.62–0.83) (p<0.001) Age >70 years (OR 0.31, 95% CI 0.26–0.37) (p<0.001) Prior MI/CABG (OR 0.47, 95% CI 0.32–0.70) (p<0.001) Educational level (OR 1.50, 95% CI 1.32–1.71) (p<0.001) BMI >25 (OR 19.0, 95% CI 1.05–1.36) (p=0.009)	20–31%, Directly at the hospital, N/I	Form	9/11
(Poh et al, 2015)^Citation13	Prospective Observational Study	Singapore	54.8±9.7	795 Female (9.2%) Male (90.8%)	Work (37.5%), no reason (26.7%), prefer self-exercise (20.1%), no time (5.5%), foreigner (5.2%), miscellaneous (5.0%).	12.3%, Directly at the hospital, Phase II	N/I	9/11
(Harrison & Wardle, 2005)^Citation40	Cross-sectional study	United Kingdom	67.34± 10.95	313 Female (31.4%) Male (68.6%%)	Age (OR 1.90, 95% CI 1.01–3.56) (p=0.020) Gender (OR 0.48, 95% CI 0.22–1.03) (p=0.020). Major reported barrier: Access to CR service, including public transport, parking and the time and location of classes, geographical access, and living in an urban or rural electoral ward	75.4%, Directly at the hospital, Phase II and III	N/I	6/8
(Grace et al, 2009)^Citation27	Prospective Study	Canada	65.9±11.2	1.273 Female (28.5%) Male (71.5%)	Older age (p<0.001)* Already exercising at home (p<0.001)* Confidence in the ability to self-Manage their condition (p=0.003)* Perception of exercise (p<0.001)* Knowledge about CR (p<0.001)* Lack of physician encouragement (p<0.001)* Comorbidities (p<0.001)* The perception that CR would not improve their health (p<0.001)*	43%, Directly at the hospital, N/I	Survey	8/11
(Park et al, 2021)^Citation9	Cross-sectional study	Korea	N/I	72 hospitals Tertiary medical centre (54%) Secondary medical centre (46%)	Lack of staff (59%) and space (33%)	77%, Directly at the hospital, N/I	N/I	6/8
(Kim et al, 2022)^Citation19	Cross-sectional study	Korea	N/I	132 hospitals Hospitals with CRP (35.6%) Hospitals without CRP (64.4%)	Patients’ transportation (p<0.000)* Cost (p=0.003)* Problem related to equipment (p<0.000)* Space (p<0.000)* Workforce (p<0.000)* Budget (p<0.000)*	80.5%, Directly at the hospital, N/I	N/I	6/8
(Sze et al, 2019)^Citation26	Prospective study was	Malaysia	55.82±10.31	380 Female (15.2%) Male (84.7%)	Male (p<0.001)* Travel time (p<0.000)* Able to drive (p=0.009)*	37.11%, Directly at the hospital, Phase II	N/I	8/11
(Worcester et al, 2004)^Citation41	Prospective study was	Australia	N/I	808 Female (30.3%) Male (69.7%)	Smoking status (p<0.001)** Hypertension (p=0.004)** Diabetes Mellitus (p=0.003)**	49.6%, Directly at the hospital, N/I	Attendance record program	9/11
(Suaya et al, 2007)^Citation28	Cohort study	US	N/I	267.427 Female (44.1%) Male (55.9%)	Income and economic status, higher educational level, and travel time.	31%, Directly at the hospital, Phase II	N/I	10/11
(Beauchamp et al, 2013)^Citation42	Retrospective cohort study	Australia	60.9±10.1	544 Female (26.9%) Male (73.1%)	Aged >70 years (p<0.001)* Male more participated (p=0.044)* Diabetes Mellitus (p=0.012)*	52%, Directly at the hospital, N/I	N/I	9/11
(Lemstra et al, 2013)^Citation43	Retrospective cohort study	Canada	N/I	9.490 (N/I)	Economic status (OR 1.58, 95% CI 1.39–1.71)	12.7%, Directly at the hospital, N/I	N/I	8/11

Notes: *t-test with Significant at p<0.05, **Chi-Square test with Significant at p<0.05.

Abbreviations: PR, Participation Rate; OR, Odd Ratio; CI, Confidence Interval; SE, Standard Error; N/I, Not Information; BMI, Body Mass Index; PCI, Percutaneous Coronary Intervention; CR, Cardiac Rehabilitation; CABG, Coronary Artery Bypass Graft.

Table 2 Categories of Participation in Cardiac Rehabilitation

Categories	References
Participation Rate
Low Categories (≤50%)	Bolivar et al, 2022;^Citation35 Grace et al, 2009;^Citation27 Khadanga et al, 2022;^Citation34 Kim et al, 2021;^Citation39 Lemstra et al, 2013;^Citation43 Olsen et al, 2018;^Citation23 Parashar et al, 2012;^Citation38 Poh et al, 2015;^Citation13 Suaya et al, 2007;^Citation28 Sze et al, 2019;^Citation26 Winnige et al, 2021;^Citation10 Worcester et al, 2004^Citation41
Moderate Categories (51–75%)	Beauchamp et al, 2013;^Citation42 Cao et al, 2021;^Citation36 Foster et al, 2021;^Citation11 Higgins et al, 2008;^Citation33 Shanmugasegaram et al, 2013;^Citation16 Viana et al, 2018;^Citation37 Zhang et al, 2022^Citation7
High Categories (>75%)	Harrison & Wardle, 2005;^Citation40 Kim et al, 2022;^Citation19 Park et al, 2021;^Citation9 De Vos et al, 2012^Citation22
Types of CR
Directly at the hospital	Beauchamp et al, 2013;^Citation42 Foster et al, 2021;^Citation11 Grace et al, 2009;^Citation27 Harrison & Wardle, 2005;^Citation40 Higgins et al, 2008;^Citation33 Kim et al, 2022;^Citation19 Kim et al, 2021;^Citation39 Lemstra et al, 2013;^Citation43 Olsen et al, 2018;^Citation23 Parashar et al, 2012;^Citation38 Park et al, 2021;^Citation9 Poh et al, 2015;^Citation13 Shanmugasegaram et al, 2013;^Citation16 Suaya et al, 2007;^Citation28 Sze et al, 2019;^Citation26 Viana et al, 2018;^Citation37 Winnige et al, 2021;^Citation10 Worcester et al, 2004;^Citation41 Zhang et al, 2022^Citation7
Home and Exercised-based	Cao et al, 2021^Citation36
No Information	Bolivar et al, 2022;^Citation35 Khadanga et al, 2022^Citation34
Phase of CR
Phase I, II	Cao et al, 2021^Citation36
Phase II	Poh et al, 2015;^Citation13 Suaya et al, 2007;^Citation28 Sze et al, 2019;^Citation26 Zhang et al, 2022^Citation7
Phase I, II, III	Winnige et al, 2021^Citation10
Phase II, III	Harrison & Wardle, 2005^Citation40
No Information	Beauchamp et al, 2013;^Citation42 Bolivar et al, 2022;^Citation35 Foster et al, 2021;^Citation11 Grace et al, 2009;^Citation27 Higgins et al, 2008;^Citation33 Khadanga et al, 2022;^Citation34 Kim et al, 2022;^Citation19 Kim et al, 2021;^Citation39 Lemstra et al, 2013;^Citation43 Olsen et al, 2018;^Citation23 Parashar et al, 2012;^Citation38 Park et al, 2021;^Citation9 Shanmugasegaram et al, 2013;^Citation16 Viana et al, 2018;^Citation37 De Vos et al, 2012;^Citation22 Worcester et al, 2004^Citation41

Abbreviation: CR, Cardiac Rehabilitation.

Table 3 A Barrier to Low Participation in Cardiac Rehabilitation

Categories	Subcategories	References
Individual Barriers	Age	Beauchamp et al, 2013;^Citation42 Cao et al, 2021;^Citation36 Grace et al, 2009;^Citation27 Harrison & Wardle, 2005;^Citation40 Olsen et al, 2018^Citation23
	Gender	Beauchamp et al, 2013;^Citation42 Harrison & Wardle, 2005;^Citation40 Olsen et al, 2018;^Citation23 Shanmugasegaram et al, 2013;^Citation16 Sze et al, 2019^Citation26
	Health Perceptions and Beliefs	Cao et al, 2021;^Citation36 Foster et al, 2021;^Citation11 Grace et al, 2009;^Citation27 Kim et al, 2021^Citation39
	Lack of time	Poh et al, 2015;^Citation13 De Vos et al, 2012;^Citation22 Winnige et al, 2021^Citation10
	Work conflict	Poh et al, 2015;^Citation13 Winnige et al, 2021^Citation10
	Knowledge	Cao et al, 2021;^Citation38 Grace et al, 2009^Citation27
	Self-management behaviour	Cao et al, 2021;^Citation36 Grace et al, 2009;^Citation27 Poh et al, 2015;^Citation13 De Vos et al, 2012^Citation22
	Educational level	Olsen et al, 2018;^Citation23 Parashar et al, 2012;^Citation38 Suaya et al, 2007^Citation28
	Lack of motivation	Foster et al, 2021^Citation11
	BMI	Olsen et al, 2018^Citation23
Health History	Prior revascularization	Olsen et al, 2018;^Citation23 Parashar et al, 2012^Citation38
	Surgical diagnosis	Khadanga et al, 2022^Citation34
	Comorbidities	Beauchamp et al, 2013;^Citation42 Grace et al, 2009;^Citation27 Parashar et al, 2012;^Citation38 Winnige et al, 2021;^Citation10 Worcester et al, 2004^Citation41
	Physical status	Kim et al, 2021;^Citation39 Parashar, 2012^Citation38
Environmental Barriers	Social environment (smokers)	Bolivar et al, 2022;^Citation35 Khadanga et al, 2022;^Citation34 Worcester et al, 2004^Citation41
	Living in the rural	Harrison & Wardle, 2005;^Citation40 Shanmugasegaram et al, 2013^Citation16
	Lack of support	Foster et al, 2021;^Citation11 Grace et al, 2009;^Citation27 Khadanga et al, 2022;^Citation34 Zhang et al, 2022^Citation7
Logistical Barriers	Distance or travel time	Harrison & Wardle, 2005;^Citation40 Higgins et al, 2008;^Citation33 Suaya et al, 2007;^Citation28 Sze et al, 2019;^Citation26 Viana et al, 2018;^Citation37 De Vos et al, 2012;^Citation22 Winnige et al, 2021^Citation10
	Transportation	Harrison & Wardle, 2005;^Citation40 Kim et al, 2022;^Citation19 Sze et al, 2019;^Citation26 Winnige et al, 2021^Citation10
Health System Barriers	Cost and economic status	Kim et al, 2022;^Citation19 Kim et al, 2021;^Citation39 Lemstra et al, 2013;^Citation43 Parashar et al, 2012;^Citation38 Shanmugasegaram et al, 2013;^Citation16 Suaya et al, 2007;^Citation28 De Vos et al, 2012^Citation22
	Patient referral	Khadanga et al, 2022;^Citation34 Kim et al, 2022^Citation19
	Health insurance coverage	Parashar et al, 2012;^Citation38 Viana et al, 2018^Citation37
	Equipment, space and staff	Kim et al, 2022;^Citation19 Park et al, 2021^Citation9

Abbreviation: BMI, Body Mass Index.

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