The impact of knowledge and beliefs on adherence to cardiac rehabilitation programs in patients with heart failure: A systematic review

Background: Heart failure is a global health problem which affects a large percentage of the older population. Cardiac rehabilitation programs have been implemented to aid patients in successfully managing their heart condition. However, non-adherence to cardiac rehabilitation programs is common in this group of patients. This results in higher morbidity and mortality rates, rehospitalisation and ultimately higher healthcare costs. There is a need to have a better understanding of the impact that knowledge and beliefs have on patients’ adherence levels, so that healthcare providers can implement appropriate strategies to promote their adherence. Objectives: This review aimed to establish the best evidence regarding the impact of knowledge and beliefs on adherence to cardiac rehabilitation programs in patients with heart failure; and to make recommendations for healthcare practice and future research. Inclusion criteria: Participants; Patients above the age of 18, who had been diagnosed with heart failure and had been admitted to a cardiac rehabilitation program in inpatient or outpatient settings. Types of intervention(s): This review considered studies that evaluated the impact of heart failure patients’ knowledge and beliefs of their disease, medication, diet, exercise and other lifestyle change recommendations, on their adherence to cardiac rehabilitation programs. Types of outcomes: Heart failure patients’ knowledge, beliefs and adherence toward their medication regime, low-sodium diet, exercise, and other lifestyle change recommendations. Types of studies: Quantitative study designs published in the English language, up to December 2010 were considered for inclusion.Search strategy: Using a three-step search strategy, the following databases were assessed: CINAHL, PubMed, SCOPUS, Web of Science, OvidSP, MDConsult, ScienceDirect, Sociological Abstracts, Mosby’s Nursing Consult, Mednar and TRIP. Methodological quality: Two independent reviewers assessed each paper for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute. Data extraction: Information was extracted by two independent reviewers, from each paper using the standardised data extraction tool from the Joanna Briggs Institute. Data synthesis: The findings are presented in narrative form, as statistical pooling was not possible, due to the different instruments used in measuring the outcomes. Results: Twelve quantitative studies were included in this review (one RCT, one pre-test/post-test single group study, and ten descriptive studies). The present findings suggest that the relationship between knowledge and adherence is unclear. However, patient beliefs on medication, symptom monitoring, illness and control were found to have stronger associations of adherence to cardiac rehabilitation programs. Implications for practice: Healthcare institutions need to provide adequate support for patients with heart failure; individualise adherence-enhancing interventions to cater for varying patient needs; and work on empowering patients. Implications for research: Future quantitative research should be undertaken to investigate the relationship between knowledge and beliefs, determine their combined effect on adherence and examine the effectiveness of strategies used to improve patient knowledge and beliefs. Quantitative and qualitative studies could also be conducted to ascertain the factors correlated with patient knowledge, beliefs, and adherence