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A realist study of the mechanisms of cardiac rehabilitation


  • Alexander M Clark BA PhD RN,

  • Heather K Whelan BSc MSc,

  • Rosaline Barbour PhD,

  • Paul D MacIntyre MB ChB MD

Alexander M. Clark,
Faculty of Nursing,
University of Alberta,
Level 3,
Clinical Sciences Building,
T6G 2G3.


Aim.  The aim of this paper is to report patients’ experiences of cardiac rehabilitation and perceptions of the mechanisms and contexts influencing its long-term effectiveness.

Background.  Cardiac rehabilitation programmes for the secondary prevention of coronary heart disease are common. The effects of these programmes, however, can be inconsistent and little is known of the personal and contextual factors that influence service effectiveness.

Method.  Forty-seven participants with a formal diagnosis of coronary heart disease who had attended a programme of cardiac rehabilitation in Scotland 3 years previously were included in focus groups to discuss their perceptions and experiences (30 males and 17 females). The data were generated in 2002 and analysed using the realist approach of Pawson and Tilley (1997).

Results.  Participants’ accounts indicated that the didactic content of cardiac rehabilitation was not strongly linked to longer-term health behaviour change. The main positive effects of cardiac rehabilitation were related to the effect of participation on mediating social and body-focused mechanisms that were triggered when the rehabilitation setting was perceived to be safe. Social mechanisms identified included social comparisons, camaraderie, and social capital. Body-focused mechanisms included greater knowledge of personal physical boundaries and a greater trust in the heart-diseased body. Collectively, these mechanisms had a positive effect on confidence that was perceived as being imperative to maintain health behaviour change.

Conclusions.  More support is required to promote health behaviour change after the completion of cardiac rehabilitation. Use of community-based exercise services and conventional or web-based support groups for coronary heart disease patients should be encouraged, as these appear to extend the positive health effects of the mechanisms that promote behaviour change. At the completion of cardiac rehabilitation programmes, patients should be referred to safe and appropriate community-based exercise services. Further research is needed to examine the effects on health outcomes of mechanisms and contexts related to cardiac rehabilitation.