The content and characteristics of face-to-face interventions to encourage patients’ enrollment in cardiac rehabilitation; a scoping review

Abstract Purpose To provide an overview of the content and characteristics of face-to-face interventions to encourage enrollment in exercise-based cardiac rehabilitation (CR). Methods Following a published protocol describing the methods, six databases were searched. The search was limited to studies published from January 2000 to December 2021. Two reviewers independently performed study selection and data extraction. Results 5583 studies were identified and 20 studies with a variety of study designs met the inclusion criteria. Eight studies specified important content in face-to-face interventions to be: Education, problem-solving, support of autonomy, exploring reasons for change, emotional and cognitive support while showing understanding. Studies targeting patients’ experiences used motivational interviewing and addressed worries and anticipated difficulties. Intention to attend, CR barriers, practical barriers, exercise self-efficacy, and patients asking questions supported enrollment. Reassurance could lead to nonattendance if patients had a high degree of worry and distress. Conclusion Face-to-face interventions are important to support patients’ enrollment in CR and should integrate a person-centered dialogue exploring reasons for change and providing support to overcome barriers. Focus on the patients’ perspectives, the mechanisms of change, and the evaluation of the intervention to inform implementation should be further explored. Implications for Rehabilitation In-hospital face-to-face interventions support enrollment in cardiac rehabilitation (CR) in patients with ischemic heart disease. This study suggests that individual worries and barriers toward CR should be jointly explored while considering patients’ capacity for making choices as well as their vulnerability. Patients should be encouraged to ask questions. A too strong focus on reassurance and problem-solving can impede enrollment.


Introduction
Patients with ischemic heart disease (IHD) are likely to experience diminished quality of life, readmissions, reduced exercise capacity, and other debilitating symptoms [1].Exercise-based cardiac rehabilitation (CR) improves the quality of life, reduces mortality, reduces the risk of readmission [2], and provides patients with valuable knowledge, feedback, and encouragement from peers and staff [3].Despite these effects and the fact that exercise-based CR is an effective intervention recommended in guidelines [4,5] and a class 1 A recommendation [6,7], less than half of eligible patients participate in CR [8,9].
Patient enrollment in CR depends on multiple and interacting factors.Lower rates of enrollment and participation in CR related to health systems can be addressed through the implementation of systematized referral [10], encouragement to enroll in CR from all hospital healthcare professionals (HCPs) [11] and patient navigators [12], and startup of CR early after discharge [13].Other known barriers are associated with comorbidities, gender, age, depressed mood, lack of support from family and friends, and logistical barriers, i.e., transport to CR, financial resources, and work [14].However, the manifestation of these generic barriers varies depending on the individual patient's experiences, culture, emotions, and various existential concerns [3,15].Individual misconceptions [16], lack of knowledge about the content of CR, a wish to get back to normal, and perceptions of CR being inconsistent with one's own identity can be essential when patients consider their CR participation [3].Furthermore, too much information can be overwhelming and lead to confusion [17].Such individual concerns are possible to target and influence.Encouragement from HCPs providing knowledge about CR are self-evident possibility of promoting CR enrollment [18], and behavior change strategies addressing a persons' perceived barriers also have the potential to support enrollment [19].Additionally, person-centered approaches including considerations of the patients' whole life situation are promising when aiming to support patients in recognizing CR as a meaningful activity considering their heart disease [20].Person-centered approaches are also recommended in global strategies as a key component in high-quality healthcare [21][22][23].Face-to-face interventions providing education and information delivered by trained nurses or allied HCPs have proven to be effective to promote enrollment in CR [10] and are recommended for implementation in the hospital setting [24].However, little research exists on face-to-face interventions targeting patients' individual concerns, barriers, and experiences to promote enrollment in CR [12].Hence, knowledge of structure, characteristics, content, and effectiveness is lacking.To be able to develop, optimize and evaluate interventions, we need to clarify the underlying complex mechanisms of the intervention that affect patients' enrollment in CR [25].
A starting point when developing an evidence-based practice in relation to enrollment in CR, is to gain an overview of studies on face-to-face interventions aiming to encourage enrollment in CR.

Review questions
The objective of this scoping review was to map and evaluate the content and characteristics of studies that have reported on face-to-face interventions delivered by healthcare professionals to encourage enrollment in exercise-based CR.The research questions addressed in this scoping review were:

Materials and methods
A systematic scoping review method following the Joanne Briggs Institute methodology was used and followed a published protocol [26].However, participants with heart failure (HF) were excluded from this study because the trajectory after hospitalization is distinctly different from the trajectory of patients with IHD.Their heart condition may not yet be stabilized at discharge which is why a referral for CR will only be feasible later on, i.e., when their medication is in place.The study was reported based on the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [27].
Studies were eligible for inclusion if they met the following criteria: 1. Participants were older than 18 years with IHD.This review included intervention-studies with different designs, i.e., randomized, observational, cohort, or qualitative studies.Conference abstracts, opinion papers, or text, i.e., government recommendations were excluded.Studies published in 2000 or later were included to reflect current guideline-recommended management of IHD (e.g., up-to-date surgical-and medical procedures, and CR).Studies in English, Danish, Norwegian, Swedish, and German were included with no restriction regarding country or geographical area.
Based on an initial limited search in PubMed and CINAHL, where relevant key words and search terms used in titles and abstracts were identified, a full search strategy was developed.A research librarian assisted in refining the search strategy and adapting it for the databases PubMed, CINAHL, Cochrane Central Register of Controlled Trials, Embase, PsycINFO, and PEDro with the latest update of the search conducted on 15 June 2023.The search terms related to participants, concepts, and context.Depending on the database, the key words changed slightly.Search strategies for all databases are presented in the Supplementary file.A manual search of reference lists of articles included to be assessed for eligibility was conducted, followed by a search of cited citations in Google Scholar.
The software program Covidence® was used to manage records.After all duplicates were removed, two researchers (BR and BST) independently screened titles and abstracts of the studies.Studies not meeting inclusion criteria were excluded and the remaining studies were retrieved in full text and assessed by BR and BST.Disagreements were solved by discussion between the reviewers.
Data extraction tools were developed by two reviewers (BR and BST) and piloting was refined using the template for intervention description and replication (TIDieR) checklist [28] in conjunction with the CONSORT statement [29].This resulted in the content being detailed into columns with headings in accordance with the TIDieR checklist recommendations, i.e., WHY: rationale, theory, goal, WHAT: intervention procedures, and HOW: modes of delivery.For the review questions related to patient experiences, barriers, and facilitators, meaningful units of text from the studies were extracted, condensed, and systematized in an additional Excel spreadsheet.The findings were mapped and summarized and presented in text and tables.Two reviewers (BR and BST) independently extracted data and discussed the results and continuously updated the data-charting forms in an iterative process.Any disagreements were resolved through consensus.If there was any doubt about the eligibility of a study, authors were contacted.

Results
Figure 1 provides the flowchart for the study selection process [30].After removing duplicates, 5583 records were identified.Based on the screening of the title and abstract, 5538 records were excluded.The remaining 49 records were reviewed in full text resulting in the exclusion of 31 records.A search of cited studies in the 49 records retrieved in full text provided nine additional studies of which three were excluded after full text assessment.The corresponding authors of three studies were contacted by email and their replies confirmed the eligibility of the studies [31][32][33].Finally, a total of 24 studies all written in English were included.Twenty-two studies were peer-reviewed publications, two were PhD dissertations [34,35].Eight studies were reported with two publications: a protocol and the actual study [36,37], a pilot study and the full study [38,39], and two PhD theses with a published paper [34,35,40,41].The actual study, the full study, and the published papers [37,[39][40][41] will be used in this review, thus, a total of 20 studies are referred to throughout [11,[31][32][33]37,[39][40][41][42][43][44][45][46][47][48][49][50][51][52][53].
Four of the five randomized studies detailed the intervention's content to a degree that supported replication and identified some active components of change in the intervention [39,40,42,43].These four studies used education [39,40,42,43], and three of the studies additionally described other components i.e., problem-solving [40,43], supporting autonomy [40], exploring reasons for change [40], and emotional and cognitive support [39].Two of the studies were targeting patient experiences: one study using motivational interviewing implemented a compassionate HCPs approach to addressing barriers to CR attendance [40]; one study addressed concerns, worries, and anticipated difficulties [39].The fifth RCT study defined the intervention to be a consultation with an interview providing information about CR [41].The case report study had some detailed description of the theoretical background, the nature of the discussions and some considerations regarding patients' experiences [44].One of the observational prospective studies in the results section determined the nature of the discussion between the HCPs and patients to consist primarily of sharing information about care and showing understanding and agreement [33].
One study examined staff training regarding the benefits of CR prior to the inclusion of the patients [37].The length and frequency of the interventions varied, ranging from a mean of 8:92 min [33] or a 10-min consultation followed by a post-discharge  telephone call [37] to 20 min of basic information followed by three 30-40-min sessions during the hospital stay [43] (see Supplementary Table ).
Factors associated with CR enrollment and their effect on enrollment are presented in Table 3.All quantitative studies reported on how the intervention affected enrollment in CR.Out of six studies with descriptions of the specified content of the intervention, four were RCT studies, one was an observational prospective study, and one was a case report study.The RCT studies investigated processes likely to underlie patients' decision-making regarding CR enrollment using a behavior change strategy [39,40,42,43].Three of the studies found associations [39,40,43].One found a significant increase in intention to attend, and intention had an indirect effect on CR enrollment and adherence; the study found that CR barriers, practical barriers, and exercise self-efficacy predicted enrollment in CR, however, enrollment was not improved [40].A second study detected a small significant increase in perceived personal control; the associations with the increase in CR enrollment was not tested [39].In a third study, the intervention focusing on reassurance and instilling appropriate beliefs with control of the condition increased CR enrollment only for participants with a lower degree of worry and emotional distress, whereas the intervention had detrimental effect on patients who were more worried [43].
Findings in an observational prospective study suggested higher enrollment rates when HCPs provided less reassurance and optimism and when patients asked more questions [33].The analysis indicated that enrollment was higher where HCPs were educated and more aware toward CR.A case report study aiming to improve attendance at CR for Aboriginal Australians found that a higher proportion of patients were referred and participated in CR after the implementation of a model of care [44].
Out of 11 studies with no specific description of the components of the face-to-face intervention, seven studies investigated referral processes in combination with a discussion of CR.The prospective study testing four different referral strategies (reported in three studies) found that automatic referral combined with a personal discussion was more effective than an automatic referral or personal discussion delivered separately [32], particularly in women [52].HCP endorsement of CR was reported to be associated with higher CR enrollment, however, it was perceived to be lower by patients with lower income, shorter education, lower subjective social status, and participants who were retired [11].Four studies implementing an automatic referral process found an increase in referral and enrollment [45,46,48,50].The retrospective study found that participation in CR increased significantly after reducing the number of hospital visits and reinforcing the role of the CR liaison nurse [47].A cohort study aiming to increase awareness of CR, determined that the intervention increased knowledge about CR particularly among patients with shorter educations and below average income [37].The association with CR enrollment was not investigated.The randomized study testing four interventions found that the hospital bedside consultation was the most important determinant of enrollment in CR [34].In the survey study, enrollment in CR was higher when the advice to attend CR was provided by a nurse [31].
From the three qualitative studies, 13 meaning units related to the research questions were extracted, which provided insight into the patients' perspectives.The analysis revealed that HCPs endorsement along with the provision of knowledge facilitated enrollment in CR.Particularly receiving support from HCPs to overcome barriers [49], being provided with knowledge about CR health benefits, and becoming aware of the support from CR deliverers when participating in the CR program [51,53] were emphasized.Feeling reassured that cardiac condition after surgery was good could lead to nonattendance.
Patients' satisfaction with the intervention was highlighted in one study to be essential, however, a description of how data were collected was lacking [42].Reasons for nonparticipation were reported in one study, however, methods for data collection were not reported [37].

Discussion
This review mapped and evaluated the current evidence on face-to-face interventions to encourage enrollment in CR.Twenty studies using a variety of methods were included, and we found some important knowledge gaps.Surprisingly, the complex nature of the interventions was given little attention.
The majority of studies concerned the implementation of referral strategies combined with an unspecified personal discussion or the increase of patients' awareness toward benefits of CR.These studies were primarily older (data collected 2010 or earlier) or were from a low-resource settings [50].These findings confirm evidence demonstrating that healthcare system factors such as referral to CR in combination with a HCP conversation, and awareness of CR among HCPs have a major impact on patients' enrollment in CR [3,10,12,55].Further, our findings support earlier research showing that automatized referral has the potential to reduce gender inequality and support greater enrollment among women [56].To produce new knowledge and credible outcomes regarding how and whether face-to-face interventions can ensure enrollment in CR, well-implemented referral procedures are a basic prerequisite [7,57,58].If referral procedures including awareness of CR benefits among staff are lacking, it seems appropriate to secure implementation of referral procedures to improve CR uptake prior to embarking on other investigations.However, we acknowledge that this may only be applicable and ethical in high-income countries.In low-resource settings, CR programs may be unavailable [50] and therefore, referral interventions could be unethical to implement.Still, even in high-income countries, where hospital referral for CR is automatized and CR programs are established in the primary healthcare setting, enrollment and completion rates remain low and below national quality standards [59].
Endorsement from HCPs is evidenced to be crucial for patients to understand the importance of CR participation [12].Our findings confirm previous research indicating that this may be particularly crucial when communicating with patients with lower socio-economic status and shorter education [10].
Face-to-face interventions to encourage enrollment in CR are to be considered complex interventions [25].Eight studies included in this scoping review provided specifications of the content and characteristics of the intervention, which may inform the development of complex interventions in future studies [33,39,40,42,43,49,51,53]. The complexity in these studies is related to a) the patients' individual experiences of their situation and the importance they ascribe to health and well-being issues; b) contextual factors such as the flexibility needed in the delivery of the intervention; specific skills that may be requested by the providers of the intervention; and the interaction with the context  that can determine the generation of enrollment, and c) the causal chain between the intervention and the outcomes [25].

Relating to patients' individual experiences
Patients' preferences, needs, and values are essential for person-centered approaches and are key when delivering healthcare [60], and both HCPs' scientific knowledge and patients' experiential knowledge should be drawn upon [61].Our findings show that more information is needed on how patients' experiences and knowledge of living with cardiac disease can be used in interventions aiming to encourage enrollment in CR.In two studies targeting patients' information needs [42] and illness beliefs [43], the intervention seemed to be characterized by an expert-advice approach.The interventions were focusing on providing information and education to achieve compliance [42] and instill appropriate beliefs [43].Without descriptions of how the patients' experiences are taken into account in the interventions, there is a risk of being paternalistic, which is non-compliant with person-centered care [62].From an existential perspective, illness such as IHD disturbs peoplés relationship with the world; life style changes and participation in CR must be considered in relation to being an integrated part of a whole life worth living [17].When patients' knowledge and opinions are drawn upon, it provides an opportunity for the patient to understand what is being talked about as meaningful in relation to one's own life [63].According to results from this scoping review, a person-centered approach when talking with patients about CR is supported when patients are encouraged to ask questions; by jointly exploring personal barriers to CR; and by sharing knowledge with a focus on patients' perspectives.
However, in addition to respectful and compassionate interactions, person-centered approaches also depend on embedding them in broader units of care such as the inter-professional team and among significant others; and within the organization in which the intervention is delivered [60].No fixed procedures or strict guidance can secure the delivery of person-centered care.Rather, the focus should be on providing key concepts, overall guidance, and possibilities for a person-centered practice as well as knowledge on how the attributes of person-centered practices are accomplished [60].
We draw attention to patients' vulnerability toward worries.Our findings showed that targeting problem-focused regulation and perceptions of control was beneficial for patients who had lower degrees of worry, whereas effects were detrimental for patients who were more worried [64].Further, emphasizing reassurance and optimism in the discussions about CR and lifestyle may mean that patients decline to enroll [33,53].These findings indicate that while it is important to honor patients' autonomy and respect their choices, at the same time, it is important to acknowledge and meet the patients in their vulnerabilities.When people fall ill and become patients and they experience the limitations of being human, i.e., being fragile they may feel unmet when HCPs emphasize their agency of increased empowerment without acknowledging their vulnerability [65].

Context
Economic, organizational, and cultural considerations are lacking in the studies.In developing and evaluating complex interventions, the context is a core element because interaction with the context can determine the implementation, the outcomes, and the adaptation of the intervention in a real-world setting [25,66].Knowledge on constraints and enablers on delivery of the intervention is crucial to avoid research waste [67] and important for decision-makers, who consider using the intervention in a real-world practice such as specific cardiac care units [25,66].Nurses and/or allied healthcare providers are highlighted as deliverers superior in delivering the intervention [57] and intervention studies using specific behavior change strategies or/and applying a person-centered care approach are particularly dependent on staff competencies and their flexibility in delivering the intervention [68].We still lack knowledge on whether and how ordinary cardiac care unit staff will be able to adopt the interventions.Training seems to be a prerequisite for supporting the knowledge, skills, and confidence of HCPs as well as their willingness to use person-centered behavior change approaches in their daily practice [69,70] the results were for the whole group of patients (see table 1).c the result was also significant for patients with coronary artery bypass graft and percutaneous coronary intervention (p > 0.001) (personal communication with the author).intend to influence participants' behavior, are time-consuming.
Considering that hospital stays tend to be short and effective [71], an assessment of whether the intervention is transferable into routine practice is called for.We suggest considerations on sustainability when developing the study's program theory and we recommend the use of process evaluation.Process evaluation can determine the quality of the implementation (i.e., what is implemented and how) and the effect context has on outcomes and implementation (i.e., understanding how interventions work in practice).A diversity of methodological approaches can be useful to capture the complexity of the intervention, including a person-centered approach [72].For example, a mixed methods research approach including qualitative research may identify and describe the complexity of and generate hypotheses about factors that affect the results of implementation efforts.

Mechanisms of change
The active elements of an intervention using education to influence patients' behavior need to be specific to be understood and evaluated [25].We found some information regarding specific precursors to CR enrollment and suggest that patients' intention to attend, perceived necessity, exercise concerns, CR barriers, and exercise self-efficacy should be targeted in future behavioral interventions to promote CR enrollment.Further, it seems relevant to evaluate whether HCPs' reassurance as well as their facilitation of patients' asking questions about lifestyle are related to enrollment.However, the mechanisms by which face-to-face interventions result in increasing enrollment in CR and the interaction with the context that can determine the generation of outcomes still remain to be clarified.The intervention should not be viewed as isolated activities, but also as a result of educating and preparing patients, staff, and systems, where emphasis can be put on either; empowerment, patient education, communication, staff training, the service system, decision making, the delivery, development, and/or the consequences [73].A challenge exists in measuring person-centeredness, however, an evaluation must be consistent with the core attributes of person-centeredness [60].Quantitative measures used to evaluate interventions designed to further patients' engagement in their healthcare may not capture patients' perception of their involvement [74].Hence, qualitative research may generate a better understanding of person-centeredness and give valuable explanatory insight into interventions [75].

Strengths and limitations
A strength of the study is the comprehensive systematic search and inclusion of a broad range of study designs.Further, we follow the recommendation of acknowledged methodology for scoping reviews.The strength of the interpretative analysis of qualitative data is that a team member checked the summarized findings and strengthened the credibility.
A limitation is the low number of included studies providing details on intervention content.However, considering the comprehensive systematic search strategy aiming to identify a broad range of study designs, we are confident that we have identified the main body of literature on interventions to support enrollment in CR.Further, only studies published from the year of 2000 onwards were included, thus, we may have excluded eligible studies.However, the findings we produced may be more relevant to current cardiac care practices.Studies in other languages than English, Danish, Norwegian, Swedish, and German were excluded, and therefore, we may have missed out on literature from large geographical areas, i.e., from Latin America and Asian countries.

Conclusion
This scoping review identified 20 studies of heterogeneous content and study designs on face-to-face interventions aiming to support enrollment in CR.Face-to-face interventions are important to support patients' enrollment in CR and should integrate a person-centered dialogue to jointly explore reasons for change and barriers to CR.In patients who are more worried reassurance and problem-solving can impede enrollment.Implementation requires HCPs' knowledge and competences in conducting person-centred dialogues on CR and considerations of contemporary short and effective hospital procedures.We suggest that future studies integrate process evaluation including of person-centeredness into the evaluation the intervention to ensure successful long-term implementation in the organization.

1 .
What is the extent, range, and nature of literature on face-to-face interventions to encourage enrollment in CR for adults with IHD? 2. What are the content and characteristics of the interventions?a.What factors considered to influence enrollment is targeted?b.How are patients' experiences taken into account?c.What outcomes are evaluated?d.What similarities and/or differences across the interventions exist?

Figure 1 .
Figure 1.Flow diagram of study selection.

From:
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al.The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.BMJ 2021;372:n71.doi: 10.1136/bmj.n71.For more information, visit: http://www.prisma-statement.org/ examine how women decided whether or not to participate in outpatient CR.Discussion about CR with hCP.Provision of educational material about CR. a Methods b Findings c Description requested and delivered by first author by e-mail.abbreviations: aCs: acute coronary syndrome; CabG: coronary artery bypass graft surgery; CCU: coronary care unit; CR: cardiac rehabilitation; hCP: healthcare providers.
Studies were excluded if they focused on adults that had already enrolled in CR and if the intervention only took place outside the hospital setting.
2. Participants were offered or were planned to be offered referral to CR after surgery or medical treatment, i.e., supervised or unsupervised inpatient, outpatient, community-or home-based program that included exercise-based training and could include psychosocial and/or educational interventions.3. HCPs were providing face-to-face interventions including online face-to-face interventions to encourage enrollment in CR.The interventions could be combined with other follow-up strategies, i.e., home visits or telephone calls.
abbreviations: int: intervention; Ctr: control; aCs: acute coronary syndrome; CabG: coronary artery bypass graft; PCi: percutaneous coronary intervention; hF: heart failure; Mi: myocardial infarction; CR: Cardiac rehabilitation.a Results were based on responses from the 22 women who were offered or requested participation in CR.

Table 3 .
Factors associated with CR enrollment and their effect on enrollment.
. Further, interventions in this scoping review, which abbreviations: CR: cardiac rehabilitation; na: trait negative affectivity; oR: odds ratio.a the results also covered patients with Mi and PCi (personal communication with the author) b