A quantitative and qualitative analysis of non-participation in cardiac rehabilitation: The role of psychological burden and experienced barriers

Background
Participation in cardiac rehabilitation (CR) remains low. The cumulative role of psychological factors in non-participation is insufficiently understood. Conceptual and mechanistic overlap suggests an accumulation of dysregulated psychobiological domains, which may result in an exposure-response relation with CR non-participation. The current study investigated the presence of such relationship between psychological burden and CR non-participation. Patient-reported reasons for non-participation were also investigated.

Methods
Data from 1600 participants (Mage = 64.9 ± 9.6 years, 21.1% women) with coronary heart disease were used. A Psychological burden index was created as a count of depression, anxiety, work-related stress, social stress, Type D personality, and hostility. Logistic regression models examined whether an exposure-response association was present. Patient-reported reasons for non-participation were analyzed using inductive coding, and the role of psychological burden was explored.

Results
The Psychological burden index was associated with increased CR participation (OR = 0.89, 95%CI: 0.82–0.97). Sensitivity analyses revealed that higher psychological burden was associated with enrollment in the psychosocial support module, explaining the increased CR participation. Analysis of patient-reported reasons showed that higher psychological burden was associated with non-participation due to medical reasons (OR = 1.15, 95% CI: 0.97–1.36, p < .10). Lower psychological burden was associated with reasons relating to patients' exercise capacity, motivation level, and deemed necessity.

Conclusion
Higher psychological burden was associated with increased participation in CR, which was partly explained by participation in the psychosocial support module. Patient-reported reasons for non-participation included medical reasons when psychological burden was high. Reducing implicit biases and individualizing the CR program could help improve CR participation.