Perspectives of Policymakers on Barriers to and Enablers of the Uptake of Cardiac Rehabilitation in Saudi Arabia: A Qualitative Study

Overview

Journal J Saudi Heart Assoc

Date 2025 Jan 9

PMID 39781229

Authors

Ahmed M Almoghairi

Jane OBrien

Jed Duff

Affiliations

Soon will be listed here.

Abstract

Objectives: This study aimed to identify the barriers to and enablers of secondary prevention care and cardiac rehabilitation (CR) utilization by patients with coronary heart disease (CHD) following percutaneous coronary intervention (PCI) from the perspective of policymakers.

Methods: A qualitative study involving an interpretive descriptive design was conducted through recorded semistructured interviews with key decision-makers in cardiology care in Saudi Arabia. The analysis was guided by the updated Consolidated Framework for Implementation Research (CFIR), which informed the resulting themes.

Results: Interviews were conducted with nine key decision-makers: four directors of major cardiac centers, four heads of cardiac rehabilitation units, and one president of a specialized cardiac society. Data coding identified 16 CFIR constructs as barriers, with seven prioritized by the participants. The most frequently cited barriers included lack of CR facilities, shortage of trained staff, and insufficient knowledge of CR among cardiologists. Seventeen constructs emerged as enablers to aid in overcoming these challenges, with nine receiving high consensus among policymakers. Key enablers included implementing alternative models, such as home-based programs; enhancing cardiologists' understanding of CR benefits; and involving higher authorities for support.

Conclusions: This study highlights the significant barriers to CR utilization and proposes solutions to facilitate the implementation of these programs from the perspective of healthcare leaders. Successful implementation requires improved communication within institutions, collaboration with the broader healthcare system, and engagement with other stakeholders, such as the private sector, to expand access and ensure comprehensive service delivery.

References

Turk-Adawi K, Sarrafzadegan N, Grace S . Global availability of cardiac rehabilitation. Nat Rev Cardiol. 2014; 11(10):586-96. PMC: 4490895. DOI: 10.1038/nrcardio.2014.98. View

Varnfield M, Karunanithi M, Lee C, Honeyman E, Arnold D, Ding H . Smartphone-based home care model improved use of cardiac rehabilitation in postmyocardial infarction patients: results from a randomised controlled trial. Heart. 2014; 100(22):1770-9. DOI: 10.1136/heartjnl-2014-305783. View

Turk-Adawi K, Oldridge N, Tarima S, Stason W, Shepard D . Cardiac rehabilitation enrollment among referred patients: patient and organizational factors. J Cardiopulm Rehabil Prev. 2013; 34(2):114-22. DOI: 10.1097/HCR.0000000000000017. View

Gong X, Zhang W, Ripley-Gonzalez J, Liu Y, Dun Y, Zheng F . Successful Implementation and Development of a Phase II Cardiac Rehabilitation Program: A China-Wide Cross-Sectional Study Tracking In-service Training Clinical Staff. Front Public Health. 2021; 9:639273. PMC: 8009984. DOI: 10.3389/fpubh.2021.639273. View

. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020; 396(10258):1223-1249. PMC: 7566194. DOI: 10.1016/S0140-6736(20)30752-2. View

Shao C, Wang J, Tian J, Tang Y . Coronary Artery Disease: From Mechanism to Clinical Practice. Adv Exp Med Biol. 2020; 1177:1-36. DOI: 10.1007/978-981-15-2517-9_1. View

Van Velthoven M, Cordon C . Sustainable Adoption of Digital Health Innovations: Perspectives From a Stakeholder Workshop. J Med Internet Res. 2019; 21(3):e11922. PMC: 6452285. DOI: 10.2196/11922. View

Shields G, Wells A, Doherty P, Heagerty A, Buck D, Davies L . Cost-effectiveness of cardiac rehabilitation: a systematic review. Heart. 2018; 104(17):1403-1410. PMC: 6109236. DOI: 10.1136/heartjnl-2017-312809. View

Ragupathi L, Stribling J, Yakunina Y, Fuster V, McLaughlin M, Vedanthan R . Availability, Use, and Barriers to Cardiac Rehabilitation in LMIC. Glob Heart. 2017; 12(4):323-334.e10. DOI: 10.1016/j.gheart.2016.09.004. View

10.

Bowry A, Lewey J, Dugani S, Choudhry N . The Burden of Cardiovascular Disease in Low- and Middle-Income Countries: Epidemiology and Management. Can J Cardiol. 2015; 31(9):1151-9. DOI: 10.1016/j.cjca.2015.06.028. View

11.

Buckingham S, Taylor R, Jolly K, Zawada A, Dean S, Cowie A . Home-based versus centre-based cardiac rehabilitation: abridged Cochrane systematic review and meta-analysis. Open Heart. 2016; 3(2):e000463. PMC: 5030549. DOI: 10.1136/openhrt-2016-000463. View

12.

Khushhal A, Alsubaiei M . Barriers to Establishing Outpatient Cardiac Rehabilitation in the Western Region of Saudi Arabia: A Cross-Sectional Study. J Multidiscip Healthc. 2023; 16:653-661. PMC: 10010741. DOI: 10.2147/JMDH.S398687. View

13.

Hennink M, Kaiser B . Sample sizes for saturation in qualitative research: A systematic review of empirical tests. Soc Sci Med. 2021; 292:114523. DOI: 10.1016/j.socscimed.2021.114523. View

14.

Turk-Adawi K, Grace S . Narrative review comparing the benefits of and participation in cardiac rehabilitation in high-, middle- and low-income countries. Heart Lung Circ. 2014; 24(5):510-20. PMC: 4527841. DOI: 10.1016/j.hlc.2014.11.013. View

15.

Roger V, Go A, Lloyd-Jones D, Benjamin E, Berry J, Borden W . Heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation. 2011; 125(1):e2-e220. PMC: 4440543. DOI: 10.1161/CIR.0b013e31823ac046. View

16.

Takroni M, Thow M, Ellis B, Seenan C . Home-Based Versus Outpatient-Based Cardiac Rehabilitation Post-Coronary Artery Bypass Graft Surgery: A Randomized Controlled Trial. J Cardiovasc Nurs. 2022; 37(3):274-280. DOI: 10.1097/JCN.0000000000000763. View

17.

Anderson L, Thompson D, Oldridge N, Zwisler A, Rees K, Martin N . Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2016; (1):CD001800. PMC: 6491180. DOI: 10.1002/14651858.CD001800.pub3. View

18.

Damschroder L, Reardon C, Widerquist M, Lowery J . The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci. 2022; 17(1):75. PMC: 9617234. DOI: 10.1186/s13012-022-01245-0. View

19.

Tsao C, Aday A, Almarzooq Z, Anderson C, Arora P, Avery C . Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation. 2023; 147(8):e93-e621. DOI: 10.1161/CIR.0000000000001123. View

20.

Taylor R, Dalal H, Jolly K, Zawada A, Dean S, Cowie A . Home-based versus centre-based cardiac rehabilitation. Cochrane Database Syst Rev. 2015; (8):CD007130. DOI: 10.1002/14651858.CD007130.pub3. View