Challenges to Cardiac Rehabilitation Post Coronary Artery Bypass Grafting: A Qualitative Study in Pune

Background Adherence to cardiac rehabilitation (CR) regimen is crucial in the post-coronary artery bypass grafting (CABG) period. Cardiac rehabilitation involves various lifestyle changes, including diet and exercise, regular follow-up in OPD, and implementing secondary prevention recommendations. This study aims to understand the challenges to CR post-CABG. Methodology Seven in-depth interviews using an interview guide were carried out in the outpatient section of the cardiothoracic vascular surgery (CTVS) department of a tertiary health care facility in Pune, India. A purposive sampling technique was followed. Results The qualitative study revealed that dietary restrictions were difficult to follow, that some patients could not quit smoking even after surgery, and that transportation costs were an issue regarding CR follow-up. The majority of the participants appreciated the importance of regular exercise in their post-surgery life. Conclusion Despite the hurdles, the majority of participants stated that the fact that CABG is a major treatment pushed them to attend routine CR follow-ups and adhere to the CR regimen. A solid CR team was one of the study's strengths, and the team established a routine of telephonic reminders for regular follow-up, which resulted in lower rates of loss to follow-up.


Introduction
Ischaemic heart disease (IHD) affects roughly 126 million people (1,655 per 100,000), or around 1.72% of the world's population. IHD, which has already claimed the lives of nine million people worldwide, affects men more frequently than women. The onset typically begins in a person's fourth decade and intensifies with age [1]. Implementing cardiac rehabilitation (CR) is a valuable and cost-effective technique in improving the effectiveness of post-cardiovascular disease (CVD) care. CR is comprised of a series of activities designed to improve the patient's physical and mental health, lifestyle, reduce risk factors that lead to adaptive behaviours, and maintain optimal daily functioning [2]. Very few qualitative research studies on adherence to CR have been conducted in India. This study was undertaken in Pune, India, to explore the challenges to CR post-coronary artery bypass grafting (CABG).

Materials And Methods
The study was undertaken at a tertiary care hospital in Pimpri-Chinchwad municipal corporation, Pune. The cardio-thoracic vascular surgery (CTVS) department of this hospital provides an in-house comprehensive cardiac rehabilitation program with a strong emphasis on physical activity, diet, and follow-up in the postoperative period after coronary artery bypass graft surgery. A tailored lifestyle modification regimen, home exercises, and counseling are advised as per the respective patient's characteristics.
Using the purposive sampling technique, 12 patients who underwent CABG and presented to the outpatient department of CTVS as a part of their post-surgery follow-up were approached for face-to-face interviews. Institute ethics committee clearance was obtained. Seven participants agreed to an in-depth interview conducted using an interview guide (see Appendix) at a tertiary healthcare hospital in Pune, Maharashtra. Interviews were conducted in Marathi/Hindi for the convenience of the participants and were audio recorded after receiving consent. The interviews were then transcribed and translated into English. Formal introductions included greetings and icebreakers, which were then followed by the main topic of the conversation. Nonverbal cues and indications, including gestures, nodding, and smiling were also recorded. The interview lasted until there was no longer any new information to be obtained. The average time per interview was approximately 30 minutes per participant. The participants were allowed to ask questions or request clarifications after the in-depth interviews, and their concerns were addressed. The note-takers provided verbatim and accurate notes. A thematic analysis was carried out.

Results
An attempt has been made to understand the challenges to CR post-CABG. Out of the seven participants who agreed to the interview, six were males and one was female. The youngest participant was 27 years old. The following seven themes emerged from the interviews (as shown in Table 1

Dietary restrictions
Dietary changes primarily involved the consumption of fewer spicy and fatty foods. The dietary adjustments prohibited participants from eating outside food. The majority of them believed that dietary adjustments were necessary for their health. According to another participant, the improvements can be difficult to implement. One individual claimed that the reminders during routine follow-ups in OPD assisted him in maintaining the dietary changes. Another participant claimed that she has now adapted to the dietary changes after implementing them.

Physical activity -An actual long-term commitment
One of the crucial components in CR involves regular physical activity.
While the majority of the participants started engaging in regular physical activities after CABG, a few believed that their routine daily activities constituted enough physical activity. As Participant 2 stated, "I don't go for long walks, I just walk while I am on the farm." Overall, they all appreciated the importance of regular exercise in their post-surgery life. Others struggled with exercises involving a spirometer. One of them said that he found it challenging in maintaining the long-term exercise regimen.
P1 -"Meri bacchi ki delivery ho gai toh mujhe 2-2 naati sambhalna padta hai, 2 mahine toh hue fookne wali machine band kiya. Ek plastic ka machine to meri naati ne fod diya" [My daughter delivered a few days ago and I have to take care of two grandchildren. So I have stopped doing spirometry exercises for two months.
One of my grandchildren broke that machine. Also, recently I have been unable to walk for five kilometres].
P3 -"Vyayam nahi kela tar nasa tasach rantil, vyayam kela tar nasa moklya rahatil" [Sometimes I forget to do spirometry exercises. If I do physical exercise, it makes my nerves relaxed. I will try to do exercise as long as I can do it, we have to take care of our life].
P4 -"I don't think I will be able to continue exercising for life. I will do it as much as I can tolerate." P6 -"Chalne se khoon patla hota hai, isliye chalna zaroori ha" [Walking helps in thinning of blood, it is very important. I work as a security guard hence I keep walking during my duty hours also], answered one 27year-old participant who underwent CABG in June 2022. He also added further, "I stopped doing spirometry exercises because I completely forgot about it."

Take on addiction -A stubborn habit
Smoking and alcohol intake are known to contribute to coronary artery disease (CAD). The majority of participants had quit smoking and alcohol. One of the participants responded that he could not quit smoking and his family did not understand that he had urges to smoke to clear his bowels. Another participant accepted the fact that his habit of smoking led him to the hospital and because of this, he had no choice but to give up the smoking habit.
P1 -"I used to smoke earlier. This habit landed me over here. Now, however, I've quit following the surgery." P4 -"I have not quit smoking. I also take alcohol. I have urges to smoke. I can't go to the washroom in the morning without smoking. My family doesn't understand this. They keep shouting at me to quit smoking." P5 -"I used to be a heavy drinker and smoker, but I have stopped smoking now. But I occasionally take alcohol." P6 -"I used to be a heavy alcoholic. Now I have stopped." "Itna bada operation hone ke baad kaise mann karega?" [After undergoing such a major surgery, how would I feel to drink?].

Follow-up for cardiac rehabilitation
An important part of CR involves visits to the cardiac OPD and consultation with cardiovascular surgeons. Sometimes, the patient has to travel long distances to reach the tertiary health care centres and may find this burdensome. One individual responded that using private transportation was expensive, hence he had to switch to the public transport system so as not to miss follow-ups in the OPD. Another participant mentioned that meeting with the doctor for follow-ups makes him happy, hence, the transportation cost was not a barrier for him.
P2 -"I have to spend nearly 13,000 to 14,000 INR if I use a private vehicle for transportation. Now I have started using public transport to attend Cardiac Rehabilitation follow-ups." P4 -"I don't feel that follow-ups are a burden. In fact, I feel happy to meet the doctor, so that I can share my problems." P6 -"I have no problems in regular follow-ups." "Abhi itna bada operation hua toh kaun bhoolega, apni jaan ki fikar to sabko hai" [One cannot forget such a big surgery, everyone worries about their life].

Need for a cardiac rehabilitation group
Respondents pointed out that they valued the social aspect of CR. One of the most significant benefits of participating in the group-based CR programme was the opportunity to engage and converse with individuals who have undergone the same surgery, and thus, can relate to their concerns and problems.
P1 -"Ek doosre ko share kiya toh unko dilasa, mil jaega, atmabal baddjaega. Aur kuch seekne ko milega" [If we keep sharing with each other, it will help motivate us and we can learn from each other].

Financial constraints
In our study, most of the respondents were able to manage their healthcare finances. One participant mentioned that the medication had been expensive for him, while another claimed that in order to cover the costs, his spouse had to start working. Another participant mentioned that he resumed working again to relieve his family of the financial load caused by the cost of medicines.
P2 -"Zyada paisa dawa goli mein lag rahe hai, sugar aur BP ka takleef hai, heart ka goli hai, ek tube toh Rs 150 ka aata tha" [Most of the money is spent on medication, I have diabetes, BP and heart problem. One ointment cost around 150 INR].
P2 -"I have stopped going to work after surgery, now my wife goes for work." P3 -"Doosre ke khande pe nahi reh sakta, main goli ko, 2 paisa khud se kama kar" [I don't want to be a burden on anyone to buy my medications, hence I have started working again].

Emotions surrounding CABG
Open-heart surgery is an ordeal that threatens several aspects of the patients' and their families' lives. The incapacity of the patients to perform their prior duties and responsibilities within the family or community can create fear and anxiety. One participant felt fearful and restless occasionally. Another young participant responded although there was stress initially, he had made peace.

Discussion
CABG surgery improves a patient's survival rate, reduces the risk of angina, and increases their capacity for physical activities. On the other hand, CABG patients can also remain at high risk of coronary artery disease. Following surgery, secondary preventive measures such as self-management and cardiac rehabilitation are required to increase longevity and reduce future heart issues and the need for additional procedures. Selfmanagement is an essential component of healing and that includes adopting or improving heart-healthy behaviours such as improving the quality of nutrition and increasing physical activity. Cardiac rehabilitation involves a variety of changes in lifestyle, especially through diet and exercise, regular follow-ups in the OPD, and implementing secondary preventive measures and recommendations. Participation in these programs is linked to a 20% reduction rate in cardiovascular mortality and morbidity, and consequently fewer medical expenses [3].
The utilisation and implementation of cardiac rehabilitation is limited by difficulties faced at both the provider and patient levels, which have been adequately described in Western literature [4].
Cardiac rehabilitation (CR) is underutilised, especially in regions with limited resources.
Ragupathi et al. found in their study that affordability, transportation challenges, primarily long distances to CR centres, a reluctance to participate in CR, and competing demands on patients' time were all difficulties faced by patients [5].
Rashidi et al. discovered facilitators and impediments to treatment plan adherence among cardiovascular disease patients. Facilitators found were physical activity, support and mentorship, lifestyle modification, and the perceived benefits of medication. A perceived lack of support, reservations about taking medication, and a lack of engagement in exercise and lifestyle improvements were recognised as obstacles [6]. Overall, participants' views of CR were favourable. The findings of this research support existing cardiac rehabilitation studies.

Dietary modifications
One of the integral parts of CR involves dietary modifications. It requires the consumption of a wellbalanced meal with moderation in spices and restrictions of fat intake. In our study, most of the participants adjusted well to the new dietary requirements. Only one of them struggled in adapting to it.
Kalantarzadeh et al. observed in their qualitative study that participants' preference for unhealthy cultural behaviours and beliefs were one of the barriers impacting treatment recommendations and lifestyle adjustments [7].
The qualitative study by Fix and Bokhour revealed that adhering to food restrictions was challenging [8]. This is consistent with the findings of our study.

Exercise
It was found that most of the participants were aware of the importance of exercise in their rehabilitation program while a few of them reported some reluctance in continuing the exercise regimens for life.
Back et al. found that patients who wished to live in the present would find it challenging to participate in an exercise-based rehabilitation programme. These patients did not value their participation in exercise-based CR as they wished to avoid worrying about the future. They also discovered that informants with physically demanding jobs viewed exercise as part of the job and did not believe that additional exercise in their leisure time was necessary [9].
A study by Mcintosh et al. found that fear of exercise acted as a barrier for cardiac rehabilitation therapy [10].
A study by Supervia et al. identified that one of the barriers in cardiac rehabilitation is anxiety in relation to exercise apart from finding transportation as a barrier [11].
Similar findings were reported by Pourhabib et al. People who attributed lifestyle factors to their heart illnesses were more inclined to continue with behavioural adjustments [12].

Addiction
Cigarette smoking is a predisposing factor for cardiovascular diseases. Few participants in our study couldn't quit smoking, in line with the findings of the qualitative study by Kalantarzadeh et al. [7].

Support from CR team
In contrast to Kalantarzadeh et al.'s findings that concluded failure to offer follow-up assistance and continued contact with healthcare professionals after discharge were among the hurdles to treatment plan adherence [7], our study indicated that the CR team provided excellent healthcare service support.
Our findings were consistent with those of Rashidi et al., which also identified social support from health professionals and/or family as a crucial element in promoting treatment plan adherence [6].
Our results concurred with those of Nascimento et al. where participants thought that involvement in CR had long-term beneficial effects on their disease-related knowledge, increased functional gains, and enhanced psychosocial well-being [13]. Our results are consistent with those of the study conducted by McIntosh et al. [10].

Financial constraints and barriers to regular follow-ups
Financial burden remains one of the challenges for regular follow-ups in the CR programme.
It was found that cost of medication was one of the barriers to rehabilitation, which was similar to Kalantarzadeh et al.'s study [7].
Servio et al. found in their study that in comparison to non-participants, CR participants considered longer travelling distance, comorbidities, wait periods, and a lack of programme follow-up as barriers (the travel/work conflict subscale was significantly higher in this group) [14]. These findings were not reported by our participants during the in-depth interviews.
A study by Rangel-Cubillos et al. found that expenses associated with transportation were a significant barrier to participation in CR. They identified transportation cost as one of the greatest barriers of CR [15]. This finding was identical to our findings.
The results of this study demonstrated that challenges for cardiovascular patients to adhere to CR are complex and unlikely to be resolved by a single, focused intervention. Acknowledging patients' limits, recognising the difficulties of altering lifestyles and beliefs and understanding the constraints of sociocultural contexts can help policymakers, healthcare providers, especially nurses, establish tailored care plans and treatments suitable to the patients. Additionally, individuals with CVD should adhere to their CR regimen for an improved quality of life.

Conclusions
The study revealed that it was challenging for cardiovascular patients to adhere to dietary restrictions. Controlling addictions was another issue, and transportation costs presented a challenge for CR follow-ups. However, the majority of the participants believed that, despite the challenges, CABG was a major procedure that motivated them to attend routine CR follow-ups and adhere to the CR regimen. All participants seemed satisfied when asked about the CR team's behaviour, readiness to help, and motivation provided by them to continue following the CR regimens (diet, physical activity, follow-ups, etc.).
One of the strengths of this study was the presence of a good CR team with a protocol of telephonic reminders regarding follow-ups which led to a minimal drop-out rate.