Heart, Lung and Circulation (2015) 24, 980–987 ORIGINAL ARTICLE

1443-9506/04/$36.00
http://dx.doi.org/10.1016/j.hlc.2015.03.023

Examining Motivations and Barriers for

Attending Maintenance Community-Based
Cardiac Rehabilitation Using the Health-
Belief Model
Hayley Horwood, MPhEd a, Michael J.A. Williams, MD b,c,
Sandra Mandic, PhD a*
a
Active Living Laboratory, School of Physical Education, Sport and Exercise Sciences, University of Otago, Dunedin, New Zealand
b
Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
c
Dunedin Hospital, Dunedin, New Zealand

Received 14 February 2015; received in revised form 26 March 2015; accepted 28 March 2015; online published-ahead-of-print 21 April 2015

Background Reasons for low attendance at maintenance cardiac rehabilitation (CR) programs remain largely unknown.
Using the Health Belief Model as a theoretical framework, this study compared the motivations and barriers
for attending a community-based CR maintenance program in high attenders (HA), low attenders (LA) and
non-attenders (NA) with coronary artery disease (CAD).
Methods Forty-four older adults with CAD (70.5% males; age: 72.7
6.9 years; 11 HA, 16 LA and 17 NA) completed
questionnaires examining reasons for attending CR: perceived threat (symptoms of CAD; the Revised
Illness Perception Questionnaire), perceived benefits (Multi-dimensional Outcomes Expectations for Exer-
cise Scale), perceived barriers (Cardiac Rehabilitation Barriers Scale) and cues to action questionnaire.
Results Sociodemographic characteristics and perceived threat were not different between the groups. Compared to
LA and NA, HA perceived greater social and physical (vs NA only) benefits of participation in maintenance
CR and had fewer barriers to attending (all p<0.05). The CR program newsletter, personal health concerns
and others having heart problems were stronger cues to action for HA versus NA (all p<0.05).
Conclusions Participants perceived greater benefits from attending CR, had fewer barriers and perceived stronger cues
to action compared to non-attenders. Promoting CR maintenance programs should emphasise physical and
social benefits and provide encouragement.
Keywords Cardiac rehabilitation  Attendance  Coronary artery disease  Health-Belief Model  Elderly

and long-term maintenance CR [2]. Despite the proven physi-

Introduction
Cardiac rehabilitation (CR) programs are designed to aid in the
secondary prevention of cardiovascular disease through edu-
cation for cardiac care, supervised exercise sessions and social
support [1]. CR is structured in three phases including in-
hospital CR, outpatient CR (usually 8-12 weeks in duration)
cal and psychological benefits of CR post cardiac event [3],
attendance rates at CR programs remain low worldwide [3]. It
has been estimated that only 2.5% of eligible coronary artery
disease (CAD) patients participate in maintenance CR pro-
grams [4]. Determining the reasons for low attendance to CR
maintenance programs could aid in designing interventions

*Corresponding author at: School of Physical Education, Sport and Exercise Sciences, University of Otago, PO Box 56, Dunedin, New Zealand.
Tel.: +64-3-479-5415; fax: +64-3-479-8309, Email: sandra.mandic@otago.ac.nz
© 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier
Inc. All rights reserved.
Cardiac Rehabilitation
to improve referral and adherence to such programs[3] and
improve long-term care for cardiac patients.
Based on previous studies, common barriers to attending
CR include sociodemographics factors (such as older age,
female gender, minority ethnicities, low socioeconomic sta-
tus and low education levels) [5–7], low referral rates to CR
programs [5,8–10], lack of perceived need for CR [5,8,11], the
structure of CR [5,7,8,10,11] and presence of other comorbid-
ities [8,10]. Motivators for attending CR include support from
health-professionals, family and other patients [10,12], enjoy-
ment of exercise routines [13] and the perceived benefits from
attending the program (such as a reduction in CAD risk
factors, improved cardiovascular functioning, improved
quality of life and psychological well-being, social support
network, sharing of experiences with like-minded people
and access to medical expertise) [9,10,14]. Previous studies
that examined factors that affect attendance to CR programs
focused mainly on outpatient CR programs [5–8,10–12] with
limited evidence available for maintenance CR programs
[3,13].
The Health-Belief Model is a theoretical framework
designed to examine the reasons behind the initiation and
maintenance of health-behaviours [15], such as attending CR.
This model takes into consideration patients’ beliefs around
their health, the barriers and benefits for a certain health-
behaviour and subsequent actions triggered by the presen-
tation of a cue. The Health Belief Model consist of five key
areas including sociodemographic characteristics, perceived
threat of the illness, perceived benefits and barriers to under-
taking the action, and the cues the patient receives on taking
action [15]. These areas are involved in the patients’ decision
to initiate or maintain a health-behaviour [15].
The Health-Belief Model has been used in previous studies
to determine reasons why cardiac patients participate in CR
programs [16,17]. High perceived benefits, cues to action
(referral from a physician) and sociodemographics factors
have been associated with increased adherence to CR exercise
regimes [16]. However, findings have shown inconsistencies
regarding the role of perceived threat of illness on enrolment
adherence to CR [17]. Using the Health Belief Model as a
theoretical framework, the purpose of this study was to com-
pare the motivations and barriers for attending community-
based CR maintenance programs in high attenders (HA), low
attenders (LA) and non-attenders (NA) with CAD.
Methods
Participants
HA and LA participants were recruited from two local main-
tenance community-based CR programs (the Otago Phoenix
Club and Taieri Fit and Fun Group). NA were recruited from
outpatients CR records from the local hospital. Inclusion
criteria were age 60 years, a documented history of CAD
and a completion of out-patient CR at least six months prior
to the study. Individuals with a cardiac event within the six
months prior to the study were excluded. For HA and LA
981
groups, attendance rates were obtained from the club records
and were calculated as a percentage of available sessions
attended in the last 12 months. Based on the CR registration
status and attendance rates in the previous year participants
were categorised as high-attenders (HA, 60% attendance,
n=11), low-attenders (LA, <60% attendance; n=16), and non-
attenders (NA, completed out-patient CR program but did
not register for (or did not attend) maintenance community-
based CR, n=17). Ethics approval for the study was obtained
from the University of Otago Ethics Committee.
Study Design
In this cross-sectional study, participants completed a paper-
based questionnaire, anthropometry assessment and a seven-
day physical activity assessment using accelerometers.
Outcome Measures and
Measurement Procedures
Demographic Characteristics and
Medical History
Participants self-reported sociodemographic data (age, gen-
der, ethnicity, marital status and education level) and medi-
cal history. Distance from home to CR was calculated using
Google Maps.
Anthropometry and Physical Activity
Height was measured using a stadiometer and weight was
measured using standard scales. Body mass index was cal-
culated from participants’ measured weight (in kilograms)
divided by height squared (in metres). Physical activity was
measured objectively using accelerometers (Actilife GT3X+)
as total energy expenditure over a seven-day period.
Reasons for Attending CR
Reasons for attending the community-based CR maintenance
program were examined using several previously validated
questionnaires that addressed different components of the
Health Belief Model. Perceived threat was assessed using
Symptoms of CAD and the Revised Illness Perception Ques-
tionnaire (IPQ-R) [18]. Perceived benefits were assessed
using a Multi-dimensional Outcomes Expectations for Exer-
cise Scale (MOEES) [19]. Perceived barriers were measured
using Cardiac Rehabilitation Barriers Scale (CRBS) [20]. Pos-
sible triggers for attending the maintenance CR program
were examined using the cues to action questionnaire devel-
oped specifically for this study.
Data Analysis
Differences between the study groups were compared using
Chi-square test for categorical variables and ANOVA with
Tukey post-hoc multiple comparisons for continuous varia-
bles. Data are reported as mean
SD for continuous variables
and frequency (percentage) for categorical variables. P<0.05
was considered statistically significant. Data were analysed
using SPSS Version 19.
982 H. Horwood et al.

distance to CR (Table 1). HA participants had a higher prev-

Results
Demographics and Medical History
Study groups were not different with respect to age, gender,
ethnicity, marital status, education, transportation or
alence of family history of cardiovascular disease, angina and
cardiac valve surgery and were more physically active com-
pared to LA and NA groups (Table 1). There was no signifi-
cant difference between the groups with respect to other
medical conditions.

Table 1 Sociodemographic characteristics and medical history across study groups.

High Attenders (HA) Low Attenders (LA) Non Attenders (NA) p-value
(n=11) (n=16) (n=17)

Age (years) 69.6
5.1 74.1
8.4 73.4
6.2 0.216

Male gender n(%) 8 (72.7) 11 (68.8) 12 (70.6) 0.975
Ethnicity n(%)
New Zealand European 10 (90.9) 13 (81.3) 16 (94.1)
Māori 0 (0) 1 (6.3) 0 (0)
Other 1 (9.1) 2 (12.5) 1 (5.9) 0.679
Married/living with partner n(%) 8 (72.7) 12 (75.0) 12 (70.6) 0.648
University degree n(%) 2 (18.5) 6 (37.5) 5 (29.4) 0.860
Current drivers licence n(%) 11 (100.0) 15 (93.8) 16 (94.1) 0.704
Access to transportation n(%) 11 (100.0) 16 (100.0) 15 (88.2) 0.189
Distance to CR (km) 5.69
3.65 7.08
4.87 4.75
4.49 0.331
Physical activity total energy 3819
1171*z 2434
1057 2643
1333 0.013
expenditure (kcal/week)
Risk factors n(%)
Hypertension 8 (72.7) 10 (62.5) 12 (70.6) 0.824
Dyslipidaemia 8 (72.7) 11 (68.8) 11 (64.7) 0.904
Smokinga 4 (36.4) 5 (31.3) 4 (23.5) 0.754
Obesityb 3 (27.3) 2 (13.3) 4 (23.5) 0.651
Diabetes 1 (9.1) 2 (12.5) 2 (11.8) 0.961
Family history of coronary artery disease 3 (27.3)*z 2 (12.5) 7 (41.2) 0.040
Total number of risk factors (n) 2.18
1.1 1.93
1.0 1.94
1.0 0.800
Cardiovascular disease n(%)
Myocardial infarction 6 (54.5) 10 (62.5) 14 (82.4) 0.252
Coronary angioplasty/stent 6 (54.5) 9 (56.3) 11 (64.7) 0.831
Coronary artery bypass surgery 8 (72.7) 8 (50.0) 5 (29.4) 0.079
Cardiac valve surgery 4 (36.4)*z 0 (0) 1 (5.9) 0.009
Angina 8 (72.7)*z 5 (31.3) 4 (23.5) 0.025
Heart failure 0 (0) 1 (6.3) 0 (0) 0.408
Peripheral vascular disease 0 (0) 0 (0) 1 (5.9) 0.444
Transient ischaemic attack 2 (18.2) 2 (12.5) 1 (5.9) 0.596
Other cardiovascular disease 1 (9.1) 2 (12.5) 0 (0) 0.342
Stroke 0 (0) 0 (0) 1 (5.9) 0.444
Other medical conditions n(%)
Musculoskeletal problems 6 (54.5) 12 (75.0) 11 (64.7) 0.270
Cancer 3 (27.3) 5 (31.3) 5 (29.4) 0.975
Chronic obstructive pulmonary disorder 0 (0) 1 (6.3) 1 (5.9) 0.704
Asthma 2 (18.2) 0 (0) 3 (17.6) 0.199
Anxiety 2 (18.2) 1 (6.3) 0 (0) 0.175
Depression 2 (18.2) 1 (6.3) 0 (0) 0.175
Other diseases 5 (45.5) 8 (50.0) 5 (29.4) 0.456

*
-p<0.05 for HA versus NA; z-p<0.05 for HA versus LA
a
Includes current smokers and those who quit less than 6 months ago.
b
Determined based on measured height and weight and calculated body mass index of 30.0 kg/m2
Cardiac Rehabilitation 983

Table 2 Perceived threat of coronary artery disease across the study groups.

High Attenders (HA) Low Attenders (LA) Non Attenders (NA) p-value
(n=11) (n=16) (n=17)

Timeline cyclical 10.4
5.1 7.8
3.9 7.9
2.7 0.179

Consequences 15.7
3.2 14.3
5.8 13.4
4.6 0.451
Timeline (acute/chronic) 22.5
7.0 22.1
4.4 23.6
4.2 0.693
Personal control 24.3
4.9 25.0
4.5 25.1
3.2 0.861
Treatment control 18.1
3.5 17.9
3.7 18.4
3.7 0.931

Perceived Threat perform activities of daily living) benefits from participating

There were no statistically significant differences between
the three study groups in perceived threat of attending a
community-based maintenance CR program (Table 2). Over-
all the perception of chronicity was high, perceived cyclical
nature was low, perceived consequences were moderate and
perceived personal control was high (Table 2).
Perceived Benefits
Compared to NA, HA and LA groups perceived greater
psychological (an improved sense of accomplishment), phys-
iological (body functioning) and functional (ability to
in the maintenance community-based CR programs (Table
3). High attenders groups also perceived higher social bene-
fits [social standing (vs LA and NA); at ease with people
(vs LA)]. In addition, LA perceived higher physiological
benefits (muscle strength and cardiovascular functioning)
and psychological benefits (sense of accomplishment) com-
pared to NA (Table 3).
Perceived Barriers
Non-attenders perceived more barriers to attending mainte-
nance community-based CR programs compared to both HA

Table 3 Perceived benefits from attending maintenance community-based CR across the study groups.

High Attenders (HA) Low Attenders (LA) Non Attenders p-value

(NA)
(n=11) (n=16) (n=17)

Psychological benefits
Sense of accomplishment 4.6
0.5* 4.5
0.5y 3.8
0.2 0.007
Mental alertness 4.5
0.5 4.2
0.8 3.7
0.9 0.065
Psychological state 4.3
0.5 4.1
0.8 3.6
1.1 0.095
Improved mood 4.6
0.5 4.0
1.2 3.8
1.2 0.171
Stress management 4.2
0.8 4.1
0.9 3.6
1.1 0.222
Social benefits
Social standing 4.3
0.8*,z 3.2
1.2 3.2
1.0 0.022
At ease with people 4.3
0.7z 3.4
1.0 3.5
0.9 0.036
Acceptance by others 4.0
0.6 3.7
1.0 3.3
0.9 0.129
Companionship 4.4
0.7 3.8
0.9 3.7
1.1 0.151
Physiological benefits
Muscle strength 4.6
0.5 4.7
0.5y 3.9
0.9 0.008
Body functioning 4.7
0.5*
4.6
0.5y 4.0
1.0 0.019
Cardiovascular system functioning 4.6
0.5 4.7
0.5y 4.1
0.8 0.021
Strengthen bones 4.3
0.8 4.1
0.9 3.8
0.9 0.301
Functional benefits
Ability to perform activities of daily living 4.6
0.5* 4.6
0.5y 3.8
1.3 0.010
Aid in weight control 4.4
0.5 4.1
0.9 3.5
1.1 0.056

*
p < 0.05 for HA versus NA;
z
p < 0.05 for HA versus LA;
y
p < 0.05 for LA versus NA
984 H. Horwood et al.

Table 4 Perceived barriers to attending maintenance community-based CR across the study groups.

High Attenders (HA) Low Attenders (LA) Non Attenders (NA) p-value
(n=11) (n=16) (n=17)

Transport and weather

Transport 1.6
1.2 1.2
0.4 2.1
1.5 0.072
Travel 2.9
1.7 3.8
1.4y 2.2
1.2 0.012
Distance 1.6
1.2 1.4
0.8 2.2
1.4 0.123
Weather 2.3
1.6 1.9
1.3 1.7
1.2 0.541
Personal preference
Already exercise 1.8
1.4* 1.6
0.8y 3.9
1.2 <0.001
Manage on my own health 1.9
1.4* 1.6
0.7y 3.3
1.2 <0.001
Don’t like group 1.8
1.3* 1.5
0.7y 3.1
1.2 <0.001
Don’t need cardiac rehabilitation 1.6
1.2* 1.3
0.6y 2.7
1.3 0.001
Referral
No referral 1.6
1.2 1.4
0.7 2.2
1.3 0.091
Too long to get referred 1.6
1.2 1.2
0.4 1.9
1.1 0.091
Doctor felt it was unnecessary 1.6
1.2 1.2
0.4 1.8
1.0 0.133
Didn’t know about cardiac rehabilitation 1.6
1.2 1.3
0.8 1.6
1.1 0.716
Physical issues
Other health problems 2.9
1.4 2.0
1.4 2.4
1.5 0.299
Exercise is painful 1.7
1.4 1.4
0.6 1.9
1.2 0.336
Too old 1.6
1.2 1.3
.06 1.7
0.9 0.390
No energy 2.1
1.5 1.8
1.0 1.1
1.2 0.710
Social influences
Others with heart problems don’t go 1.8
1.4 1.4
0.7 1.9
1.1 0.446
Costs too much 1.6
1.2 1.2
0.4 1.5
0.9 0.430
Time constraints 1.8
1.4 2.1
1.4 2.5
1.6 0.445
Work responsibilities 1.6
1.2 2.3
1.7 2.0
1.4 0.567
Family responsibilities 2.0
1.3 1.9
1.2 1.8
1.3 0.937

*
p<0.05 for HA versus NA; zp<0.05 for HA versus LA; yp<0.05 for LA versus NA

and LA, including personal preferences (already undertaking
own exercise, managing their own health, not liking group
situations, and perceiving no need for CR). Only the LA
group perceived travel as a barrier to attending CR (Table 4).
Cues to Action
Worry about health was a more significant cue to action for
both the HA and LA groups compared to NA. The HA group
also had higher desire to prevent another heart attack com-
pared to NA. Peer influence (others having heart problems)
was a stronger cue in the HA group compared to both the LA
and NA groups. Family was a stronger cue to action in LA
compared to NA (Table 5).
Discussion
The key finding of the present study was that high attenders
and low attenders perceived more physical and social ben-
efits and fewer barriers to attending community-based CR
compared to non-attenders (Figure 1). Therefore, emphasis-
ing physical and social benefits of attending CR, addressing
modifiable barriers and providing encouragement should
be used for promoting participation and encouraging atten-
dance to the maintenance CR programs. This study adds to
the existing extensive knowledge related to poor attendance
of outpatient CR programs by providing novel information
regarding the reasons for attendance and non-attendance of
maintenance CR programs. Currently, a very small percent-
age of eligible CAD patients participate in maintenance CR
programs [4]. In addition, there is a paucity of information
regarding maintenance CR programs despite findings that
such programs are associated with health benefits and facil-
itate management of cardiovascular risk factors [21–24].
In individuals with cardiovascular disease participating
in community-based maintenance CR programs, session
attendance was positively correlated with peak oxygen con-
sumption and first-year attendance was strongly correlated
with attendance in subsequent years [24]. Therefore, under-
standing the reasons for attendance and non-attendance of
maintenance CR programs is essential for promoting long-
term exercise adherence in graduates of outpatient CR pro-
grams and facilitating their transition to maintenance CR
programs.
Cardiac Rehabilitation 985

Table 5 Cues to action to attending maintenance community-based CR across the study groups.

High Attenders (HA) Low Attenders (LA) Non Attenders (NA) p-value
(n=11) (n=16) (n=17)

Health concerns
Worry about health 3.8
0.9* 3.8
0.9y 3.1
0.2 0.014
Do not want another heart attack 4.1
0.9*
3.6
0.9 3.2
0.5 0.015
Symptoms of coronary artery disease 3.7
1.0 3.5
0.9 3.1
0.2 0.064
Family history 3.1
1.2 3.5
0.7 3.1
0.3 0.281
Social influence
Others having heart problems 3.8
0.9*,z 3.2
0.5 3.1
0.5 0.021
Newsletters 4.0
1.0* 3.3
1.0 3.1
0.3 0.024
Family 3.9
0.9 4.1
0.8y 3.4
0.7 0.045
Friends 3.8
0.9 3.9
1.2 3.2
0.5 0.067
Promotional material
Doctor 3.7
0.9 3.6
1.0 3.4
0.9 0.578
TV advertisements 3.0
1.3 3.3
0.6 3.2
0.5 0.735
Education about heart health 4.2
1.6 4.0
1.7 4.3
1.5 0.872

*
p<0.05 for HA versus NA;
z
p<0.05 for HA versus LA;
y
p<0.05 for LA versus NA.

Figure 1 The results of the current study presented within the Health-Belief Model framework.

In the present study, perceived benefits from attending
maintenance community-based CR included physical bene-
fits (improved muscle strength, improved body functioning
and cardiovascular system functioning), functional benefits
(ability to perform activities of daily living) and social
benefits (sense of accomplishment, social standing and being
at ease with people). These findings are consistent with
previous studies that reported both psychosocial and physi-
cal benefits gained from attending maintenance community-
based CR programs by individuals with cardiovascular
986
disease [10,25]. Interestingly, the HA group perceived a
larger gain of social benefits compared to the LA group.
Therefore, both physical and social benefits should be
emphasised by health professionals when encouraging
patients to enrol and attend community-based CR mainte-
nance programs.
Compared to HA and LA, NA perceived more personal
barriers to attending maintenance community-based CR
(already exercising, being able to manage their own health,
not liking the group situations, not perceiving need for CR).
These findings suggest that individuals who do not enrol in
CR maintenance programs likely perceive no need to partici-
pate and/or do not like the format of such programs [11].
This novel finding also suggests that if non-attenders are
undertaking their own exercise routine they may be satisfac-
torily managing their own cardiac health. This possibility is
supported by the data in the present study showing similar
levels of measured physical activity total energy expenditure
in the LA and NA groups. Active individuals are more likely
to attend CR programs [3] which is consistent with our
findings of higher measured physical activity total energy
expenditure in the HA group.
Worrying about health, not wanting another heart attack,
others having heart problems, club newsletters and encour-
agement from family were the cues to action that had an
effect on attendance at maintenance community-based CR.
Worrying about their health and not wanting another heart
attack showed that patients were aware of the benefits of
attending maintenance community-based CR programs sug-
gesting that education about cardiovascular disease appears
to be effective [5,12]. Interestingly, the doctor’s advice was
not perceived as motivation for attending maintenance CR
programs even though doctors can be a trigger for attending
outpatient CR programs [12]. The social aspect of the club’s
newsletters as a cue to action is a novel finding and may aid
in creating a sense of community and increasing the support
network to encourage attendance at maintenance commu-
nity-based CR programs [26]. Therefore CR program’s news-
letters could be used as promotional material that advocates
both physical and social benefits of participation in such
programs.
Perceived threat did not appear to influence the decision
to attend maintenance community-based CR among par-
ticipants in the current study. Although perceived threat of
illness appeared to have a positive correlation on exercise
intention and action in the study by Tulloch et al. [27], its
effect on exercise behaviour was small compared to other
factors. Both the current study and Tulloch et al. [27],
suggests that either patients are unaware of the severity
of their illness or perceived threat is not as relevant to
attendance at community-based CR maintenance pro-
grams. Future research needs to examine whether per-
ceived disease severity influences patients’ decision to
participate in CR.
The present findings suggest that individuals who attend
community-based CR maintenance programs perceived the
need for it. However it is still important to ensure that
H. Horwood et al.
individuals who choose not to participate in the maintenance
CR program have readily available access to a medical sup-
port and advice regarding secondary prevention of cardiac
events [28]. This could be achieved by providing an online
community with advice on cardiac health maintenance [29].
Based on findings from the current study, distributing the
program’s newsletter to patients in in-hospital and out-patient
CR programs may facilitate transition to the maintenance
phase of CR by instilling a sense of community. Creating a
sense of community through peer support has already been
shown to be an effective trigger for encouraging attendance
to other community-based CR programs [26]. A wider distri-
bution of the CR maintenance program newsletters may
support patients who wish to be a part of a maintenance
community-based CR program but cannot participate due
to travel issues or other reasons.
With regard to clinical implications, these findings suggest
that interventions for promoting participation and encour-
aging attendance to the maintenance CR programs should
emphasise physical, functional and social benefits of partici-
pation, address modifiable barriers and provide encourage-
ment. A program newsletter could be used to highlight the
benefits of participation, create a social community and
improve social support, encourage regular program atten-
dance and promote physical activity outside of scheduled
supervised exercise sessions.
This study has several limitations including a cross-
sectional study design and a small sample size which limit
generalisability of the findings. In addition, medical history
data was self-reported and data on medications were not
collected. Furthermore, only participants from the local com-
munity in Dunedin, New Zealand, were recruited. Therefore,
issues related to distance to CR, transportation and cost may
have been more prominent if participants were recruited
from the wider CR catchment area or a different geographical
region. Finally, high physical activity level observed in all
three study groups may limit generalisation of these findings
to cardiac patients regularly seen in a clinical practice.
Conclusions
Older adults with CAD participating in community-based
CR maintenance programs, and in particular high-attenders,
perceived greater benefits from attending CR, had fewer
barriers and perceived stronger cues to action compared to
non-attenders. In contrast, non-attenders perceived fewer
benefits, had less personal preference to attend CR and
received less cues for action from their environment. There-
fore, emphasising physical and social benefits of attending
CR, addressing modifiable barriers and providing encour-
agement should be used for promoting participation and
encouraging attendance to the maintenance CR programs.
Future intervention studies should examine the effects of
online support programs and CR program newsletters to
improve access to and attendance at maintenance CR
programs.
Cardiac Rehabilitation
Declaration of Interest
The authors report no declarations of interest.
Funding
None
Acknowledgments
The authors would like to acknowledge Leanne Barclay and
Dianne Body for their assistance with participant recruit-
ment, both cardiac clubs (The Otago Phoenix Club and Taieri
Fit and Fun Group) for supporting this project, and all study
participants for their time and effort.
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