Cardiac rehabilitation (CR) is an evidence-based, standard of care for those with coronary artery disease (CAD).1,2 Exercise, risk factor management, patient education, and psychosocial management are internationally-agreed core components of CR.3,4 Current guidelines – including from South America5 – promote this comprehensive structure to achieve cardiovascular risk reduction,6 foster health behaviors,7 reduce disability8 and health-related costs,1 and improve physical activity levels.8 Therefore, CR is a well-established model of secondary prevention care that can mitigate the burden of cardiovascular disease (CVD).1,6

Despite these benefits, CR is only available in 40% of low- and middle-income countries (LMICs),9 which is a group of countries that face a disproportionately heavy burden of CVD with scarce resources and lack of pragmatic guidelines.10 These countries, including Brazil, also report low density and capacity of CR programs to address the high need from this population.11,12,13 Other challenges to achieve CR goals and control cardiac diseases in LMICs include high CR dropout rates (when programs are available),13,14 unavailability of interventions to improve long-term maintenance of heart-health behaviors,14 and no standardization of core components and services,11,12 including the lack of patient education interventions.13

Findings from systematic reviews15,16 and meta-analysis17 have demonstrated the effectiveness of patient education for individuals with CAD in improving disease-related knowledge, self-management behaviors, and health-related quality of life, with potential impact on healthcare costs and recurrence of acute events. A randomized controlled trial (RCT) in Brazil18,19 also showed that comprehensive CR (i.e. exercise plus education) can be delivered in a low- and middle-income setting and is effective. Results of this study could be seen as the first step to establish the standardization of comprehensive CR programs in Brazil. However, other important aspects to improve CR use have yet to be assessed, including the understanding of patients’ perception of CR participation.20

Studies have shown that the knowledge of patients’ perceptions about CR participation can contribute to the understanding of their needs and expectations, which can ultimately refine care, optimize service utilization, and increase short- and long-term treatment adherence.20,21 Moreover, patients’ perception does not often correspond to objective reality or to the perceptions held by providers or administrators regarding care,22,23 which can negatively impact efforts to promote adherence to CR and achieve its goals.

Understanding patients’ perceptions about CR can guide healthcare professionals and administrators on modifications of program elements, which can ultimately improve CR use, adherence of good heart-health behaviors, and promote improvements in clinical outcomes. Thus, the objective of this study was to examine the perception of patients with CAD about their participation in two CR models offered by a public CR service in Brazil.

Early reports indicated that an understanding of the patients’ perceptions of CR is associated with CR use, adherence of recommended heart-health behaviors, and improvements in patients’ clinical outcomes. Cardiac rehabilitation programs are underutilized worldwide11 and, to our knowledge, there are no standardization of comprehensive CR programs in Brazil. The qualitative analysis showed how patients with CAD, who had attended CR, had positive perceptions about this participation two years after discharge from these structured programs. Perceptions were related to the categories of knowledge acquisition, improvement in functionality, and psychosocial well-being. It appeared that the perceived benefits of CR participation were similar between CR models; however, participants in the comprehensive CR program identified extra sub-themes: self-care need and knowledge transfer.

Knowledge acquisition was perceived by participants from both CR models. However, our results suggest that the structured education from the comprehensive CR model made it possible for patients with CAD to reflect on the importance of broader lifestyle goals, including dietary control and appropriate medication use, as these perceptions were only mentioned by participants of the comprehensive protocol. Recent studies have shown that educational interventions designed for patients in CR are associated with adherence to lifestyle recommendations, including a heart-health diet,18,31,32 and medication use.31,33 The identification of these components two years after CR completion suggests that comprehensive CR would have more sustained effects on behavior change post-CR and may be associated with maintenance of long-term health habits, which is a major challenge for CR.34

Another important finding related to the participation in a comprehensive CR program was patients’ ability to recognize their physical, behavioral, and emotional limitations and the importance of behavioral change in secondary prevention, which is essential for self-management. When patients acknowledge the role that lifestyle behaviors play in the course of their disease, it is feasible to say that they can understand their personal control over these behaviors and their active and responsible role in disease control, including drug management, symptom recognition, and risk factor modification.35,36 In this scenario, it is also necessary to highlight the importance of healthcare providers and educators to support and guide patients to translate that knowledge and awareness into action, which was also identified by a previous study.37 Therefore, providing sufficient information is one of the steps for autonomy and accountability in adherence to care, with the role of health professionals as facilitators in the process of effective self-care engagement being crucial so that patients feel confident to self-manage their conditions.36–39

Even without participating in the education classes, the individuals in the exercise CR protocol used non-systematic instructions/information received from physical therapists and information exchange between patients during exercise sessions to change behaviors. The participants in the CR programs value the opportunities for socialization with the multidisciplinary team as well as with other participants as a way of understanding their condition and its possible causes, thereby promoting lifestyle changes.

The information received was perceived as beneficial in different ways by patients with CAD, such as a tool for maintenance of physical activity and healthy eating habits, which resulted in perception of weight loss. Exercise is a core component of CR and while exercise adherence rates among CR participants are usually met during the program, studies have shown that exercise after CR completion is not maintained, with only one-third of patients engaging in regular exercise when assessed 6 months following CR completion.40 The constructs related to exercise maintenance after CR perceived by participants in this study included the following: the importance of social support; factors related to self-regulation, i.e. establishing a routine/habit; creating action plans and goals; and self-monitoring, as well as recognizing and associating health benefits. These results are similar to the ones provided by previous studies.41,42

Patient education is a core component of CR programs and refers to activities that raise an individual's awareness, giving the individual the health knowledge required to decide what is best for their health.16 This study provides contemporary data on the education experience of patients with CAD following a comprehensive CR program. This is particularly important given the challenge to include this core component in programs: education interventions require training of healthcare providers to become health educators, resources (for both providers and patients), and perform content and cultural adaptation to individual needs.4 In the present study, participants in the comprehensive CR program recognized the application of learning in their daily routine and the usefulness of the book to reinforce learning. Another study similarly found that educational sessions were informative, empowering, and necessary for women to maintain healthy lifestyle changes, including performing a safe home or community center exercise program.43 The fact that patients remain aware of the need to continue taking care of themselves two years after the end of CR and continuing with the behavioral changes implemented in their daily lives reinforces that the education offered was effective.24

An interesting fact indicated by those in the comprehensive CR program was the knowledge transfer to family and friends. Respondents perceived the need to share resources and knowledge to motivate others to feel better, adopt prevention strategies, and adopt lifestyle changes, thus acting as multiplier agents. This involvement in disease control by patients is essential, especially in LMICs where health resources are scarce.4,44

One of the objectives of CR is the maintenance/recovery of functional capacity45 and reintegration and optimization of participation in society,46 which contributes to return to previous activities.42 A range of personal, environmental, and social factors may limit this ability to perform activities; therefore, one of the goals of CR programs should be to maximize functional capacity and provide ways to facilitate reintegration.46 In this context, respondents from both protocols perceived they made improvements in functionality, which improved social participation, self-esteem, and well-being. These observed factors are consistent with the literature, that identifies CR as a source of empowerment for patients to return to active living.43

Fear, anxiety, and depression are common symptoms among cardiac patients – especially the ones with a recent cardiac event47 and recovering from cardiac surgery.48 Participants in our study perceived a decrease in their fear to return to regular daily activities. This was an important finding because studies have shown that cardiac patients usually experience both fear of having a new event and a desire to perform normal daily activities.49 In this context, CR was perceived as a safe environment in which participants became physically active and encouraged to resume their usual tasks. These results were also identified in previous studies.21,50 In addition, participants perceived the exercise component of their program as the responsible factor for tangible improvements in health and well-being, which was also identified in previous studies and considered as a reassuring factor for practicing more exercise and returning to the previous level of physical activity.44

Participants also perceived CR participation and the continuous practice of physical exercise during and after this intervention as positive factors affecting their psychosocial well-being. Examples of psychological benefits associated with the practice of exercise included the pleasure associated with the CR sessions, the well-being feeling after exercise, and the confidence to resume daily activities. These factors are associated with recovery of patients’ self-esteem and improvements of their social relations, which are also considered facilitators in maintaining active behavior.47,51 As recognized by the patients in the present study, CR decreased negative emotions associated with their cardiac history and increased their sense of control.52

This study has several limitations. Therefore, we recommend caution when interpreting the results. The chief limitation is related to selection bias, because results are from a sample of patients who attended CR programs at one site, which is not the reality of most cardiac patients in LMICs.13,14 Moreover, those who accepted to participate may be those who had a better experience. Thus, these findings may be limited in their generalizability. However, the results appear consistent with those from other studies, supporting the validity of the results. Another limitation is the fact that patients’ perceptions are not necessarily isolated from their beliefs; therefore, it is suggested that future studies also focus on patients’ beliefs about CR and their condition. Finally, although the interpretation and discussion of the themes generated would appear to support long-term perceptions of these patients, these results remain speculative until replication in a larger sample of patients with CAD. New qualitative studies with different groups of patients attending CR programs (e.g. stroke, diabetes, and hypertensive patients) should be conducted, to assess the unique experiences of these participants.

This study suggested that patients from two different CR modes (exercise and comprehensive) perceived in the long term that the CR participation positively impacted their disease-related knowledge, promoted functional gains, and improved psychosocial well-being. Structured educational interventions seemed to be associated with an increase in participants’ perception about CR in addition to an increase in physical exercise performance, which could contribute to long-term maintenance of heart-health behaviour and better outcomes.

None to declare