Curriculum in Cardiology

A qualitative systematic review of influences onattendance at cardiac rehabilitation programsafter referralAlexander M. Clark, PhD, a Kathryn M. King-Shier, PhD, b David R. Thompson, PhD, c Melisa A. Spaling, MEd, a

Amanda S. Duncan, MA, a James A. Stone, MD, PhD, d,e,f Susan B. Jaglal, PhD, g and Jan E. Angus, PhDh

Alberta, and Ontario, Canada; and Melbourne, Australia

Background Cardiac rehabilitation and secondary prevention programs can prevent heart disease in high-riskpopulations. However, up to half of all patients referred to these programs do not subsequently participate. Although age, sex,and social factors are common predictors of attendance, to increase attendance rates after referral, the complex range offactors and processes influencing attendance needs to be better understood.

Methods A systematic review using qualitative meta-synthesis was conducted. Ten databases were systematicallysearched using 100+ search terms until October 31, 2011. To be included, studies had to contain a qualitative researchcomponent and population-specific primary data pertaining to program attendance after referral for adults older than 18 yearsand be published as full articles in or after 1995.

Results Ninety studies were included (2010 patients, 120 caregivers, 312 professionals). Personal and contextual barriersand facilitators were intricately linked and consistently influenced patients' decisions to attend. The main personal factorsaffecting attendance after referral included patients' knowledge of services, patient identity, perceptions of heart disease, andfinancial or occupational constraints. These were consistently derived from social as opposed to clinical sources. Contextualfactors also influenced patient attendance, including family and, less commonly, health professionals. Regardless of theperceived severity of heart disease, patients could view risk as inherently uncontrollable and any attempts to manage risk as futile.

Conclusions Decisions to attend programs are influenced more by social factors than by health professional advice orclinical information. Interventions to increase patient attendance should involve patients and their families and harness socialmechanisms. (Am Heart J 2012;164:835-845.e2.)

BackgroundWhy are effective health services not used? Cardiac

rehabilitation (CR) and secondary prevention programs

rom the aFaculty of Nursing, University of Alberta, Edmonton, Alberta, Canada, bFacultyf Nursing, University of Calgary, Calgary, Alberta, Canada, cCardiovascular Researchentre, Faculty of Health Sciences, Australian Catholic University, Melbourne, Australia,Cardiac Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada,ardiac Wellness Institute of Calgary, Calgary, Alberta, Canada, fLibin Cardiovascularstitute, Calgary, Alberta, Canada, gDepartment of Physical Therapy, University oforonto, Toronto, Ontario, Canada, and hFaculty of Nursing, University of Toronto,oronto, Ontario, Canada.unding was provided by the Canadian Institutes of Health Research via a Knowledgeynthesis Grant (G118160769).ubmitted April 10, 2012; accepted August 14, 2012.eprint requests: Alexander M. Clark, PhD, Level 5 Edmonton Clinic Health Academy,niversity of Alberta, Edmonton, Alberta, Canada.-mail: alex.clark@ualberta.ca002-8703/$ - see front matter2012, Mosby, Inc. All rights reserved.

FoCd

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http://dx.doi.org/10.1016/j.ahj.2012.08.020

are common across high-income countries, but up to 50%of eligible patients who are referred do not subsequentlyparticipate.1-4 Attendance after referral is essential ifpatients are to benefit from these evidence-based in-terventions. Although modifiable cardiovascular riskremains very high in populations with coronary heartdisease,5,6 patients who participate in programs are up to3 times less likely as those who do not participate to dieand have a stroke or further cardiac event.7 Inequalities inattendance also exacerbate underlying inequalities incoronary heart disease incidence in women, olderpatients, people with low incomes, and ethnicminorities.1,3,4,8

Little research has addressed how to increaseattendance.9-11 Past reviews have identified the mainpredictors of attendance at single time points1,3,4,8 orexamined the processes of referral, attendance, andcompletion together.12 Consequently, understanding ofwhat specifically influences attendance after referral

Figure 1

Process of meta-ethnography.

836 Clark et alAmerican Heart Journal

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remains low. To inform future interventions and increaseservice access, this review examined the factors andprocesses that influence patient decisions to attend CRprograms and similar secondary prevention services.

MethodsBecause this study was focused on the complex factors and

processes that influence attendance rather than preidentifiedpredictors of attendance,3,4 qualitative research studies werethe focus of this review.13 Qualitative research methods havebeen used frequently to understand patient and healthprofessional decision making in complex settings andorganizations, including the provision of primary care14 andcardiac services.15-18

To be included, studies had to contain a primary,qualitative research component either as a dedicated qualita-tive study or in a mixed-methods design. Population-specificdata or themes had to be extractable for attendance afterreferral to secondary prevention services, including CR andsecondary prevention programs or clinics. Studies had tocontain extractable data from adults older than 18 years andpublished as full articles in or after 1995. Databases searcheduntil October 31, 2011 include the following: CSA Sociolog-ical Abstracts, EBSCOhost CINAHL, EBSCOhost GenderStudies, EBSCOhost Health Source Nursing: Academic Edition,EBSCOhost SPORTDiscus, EBSCOhost SocINDEX, Ovid Age-

line, Ovid EMBASE, Ovid MEDLINE, and Ovid PsycINFO. Nolanguage restrictions were used. More than 100 differentsearch terms related to secondary prevention, CR, and healthservices were used across the databases (Supplementary File1). The authors searched reference lists and other reviewsand consulted with colleagues.The meta-ethnographic approach was used to synthesise

study findings (Figure 1).19 This involves studies beingreanalyzed and compared to identify patterns in relation toattendance decisions.19 The title and abstracts of each studywere screened against the inclusion criteria by at least 2reviewers. Full texts of selected articles were then read by 2reviewers who independently extracted findings and ap-praised study quality using the Critical Appraisal SkillsProgram Tool for Qualitative Research.20,21 Studies wereranked as low, moderate, or high quality based on theCritical Appraisal Skills Program tool indicators of rigor (TableI). Articles were not excluded based on their quality rank.110

Differences in study inclusion or assessment were resolvedby consensus.In the review, findings were only included that related to

attendance, defined as “whether eligible patients participatein a secondary prevention service after referral from a healthprofessional.” Financial support was provided via careerawards to A.M.C. by Canadian Institutes of Health Researchand to K.M.K.-S. by Alberta Innovates Health Solutions. S.B.J.holds the Toronto Rehabilitation Institute Chair at theUniversity of Toronto.

Table I. Characteristics of included studies (n = 90)

First author Country Method Sample (% female) Mean age in years Quality (L/M/H)

Allen22 Canada ID HP (NR) NR MAllison23 UK ID Pt (0) NR MAlsen24 Sweden GT Pt (36) 58 MAngus25 Canada Ethnography Pt (100), HP 60 (Pt) HAnnable26 USA ID Pt (50) 65.7 MArndt27 Australia MM Pt (NR) NR MAstin28 UK ID Pt (45), Cg 62 MAustin29 USA Phenomenology Pt (100) NR HBanerjee30 Canada ID Pt (19) 57 MBlake31 UK ID Pt, HP (54) NR MBlasdell32 USA ID Pt (33) NR LCaldwell33 Canada Ethnography Pt (100) NR HChauhan34 UK ID Pt (35) NR MClark15 UK ID HP (NR) NR MClark16 UK MM HP (NR) NR MClark35 UK MM Pt (33) 65 MConnors36 USA ID Pt (30) NR MCooper37 UK ID Pt (35) 56 MCorrigan38 Ireland MM Pt (NR) NR MCrowley39 Ireland MM Pt (8) 62 MDaSilva40 USA GT Pt (100) 77 HDavidson41 Australia MM Pt (100) 61 MDavis42 Canada ID Pt (56) NR MDay43 New Zealand GT Pt (100) NR MDe Angelis44 Australia MM Pt (27) 66.6 LDecker45 USA ID Pt (21) NR LDigiacomo46 Australia ID HP (NR) NR MDoiron-Maillet47 Canada ID Pt (100) NR MDolansky48 USA ID Pt (50) NR MDombroski49 USA MM Pt (100) NR HEastwood50 Australia ID Pt (0) NR MEbbesen51 Canada Case study Pt (100) NR MEsbai52 USA GT Pt (100) 57 MFernandez53 Australia ID HP (NR) NR MFleury54 USA ID Pt (41) 58 MGaldas55 Canada GT Pt (33) NR MGoodman56 UK ID HP (NR) NR MGregory57 UK ID Pt (34) NR MGrewal58 Canada ID Pt (6) 62.6 LGrewal59 Canada ID Pt (6) 62.6 MGurewich60 USA Case study HP (NR) NR MGulanick61 USA ID Pt (42) 61 MHagan62 Australia ID Pt (20) 62 MHaghshenas63 Australia ID HP (80) NR HHiggins64 Australia GT Pt (27) NR LHird65 UK ID Pt (68) NR MHutton66 UK Phenomenology Pt (0) 59 MJackson67 UK ID Pt, Cg (52) NR MJones68 UK ID Pt (33) 63 MJones69 UK ID Pt (NR) 63 MKarner70 Sweden Phenomenography Pt (33) 58 HKeaton71 Sweden Phenomenology Pt (0) NR HKerins72 Ireland MM Pt (NR) NR MKing73 Canada GT Pt (50) NR MKristofferzon74 Sweden ID Pt (51) 65 MLaCharity75 USA ID Pt (100) 65 MLeung76 Canada ID Pt (50) 67.5 MLittle77 UK ID Pt (20) NR MLisk78 USA GT Pt (100) NR MMacInnes79 UK ID Pt (100) 72 MMacintosh80 UK ID HP (NR) NR MMadden81 UK ID Pt, HP (32) NR H

(continued on next page)

Clark et al 837American Heart JournalVolume 164, Number 6

Table I. (continued)

First author Country Method Sample (% female) Mean age in years Quality (L/M/H)

McCorry82 Ireland ID Pt (43) 64 MMcGillion83 Canada ID Pt (20) 67 MMcSweeney84 USA MM Pt (100) NR HMcSweeney85 USA ID Pt (100) 58.5 MMitchell86 USA ID Pt (NR) NR MMoore87 USA ID Pt (100) 72 MMurchie88 UK ID HP (89) NR MNorris89 Canada ID Pt (100) 67 MNorthrup-Snyder90 USA ID Pt (100), Cg NR HO'Driscoll91 UK ID Pt, HP (NR) 61 (Pt) LPage92 Australia GT Pt (27) NR MPullen93 UK ID Pt (100) 66 MQuigley94 USA ID Pt (100) 66 HRobertson95 UK Critical theory Pt (0) NR HRolfe96 Canada ID Pt (100) 61.7 MSchou97 Denmark ID Pt (100) 72 MSloots98 Netherlands ID Pt (18), HP 56 (Pt) MThornhill99 Australia GT Pt (50) 60 HThow100 UK MM Pt (45) 67 MTod101 UK ID Pt (20), HP 60 (Pt) MTolmie102 UK MM Pt (48) 74.5 MTraywick103 USA MM Pt (32) 70 HVishram104 UK ID HP (100) NR MWang105 China ID HP (NR) 42.6 MWebster106 UK GT Pt (15) 65 MWebster107 UK ID Pt (29) NR MWhite108 UK ID Pt (27) 57 MWingham109 UK Phenomenology Pt (18) 67 M

L, Low;M, moderate; H, high; ID, interpretive descriptive; HP, health professional(s); NR, not reported; Pt, patient(s);MM, mixed-methods; Cg, lay caregiver(s);GT, grounded theory.

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The authors are solely responsible for the design and conductof this study, all study analyses, the drafting and editing of themanuscript, and its final contents.

ResultsFrom 2264 unique studies screened (Figure 2), 90 studies

contained data onCR attendance (2010patients: 1051male,907 female, 52 not described; mean age 62.1 ± 11.5 years;range 27-90 years; 120 caregivers; 312 professionals). Athird of the studies were conducted in the United Kingdom(n = 31), and study quality was moderate (Table I).

Personal barriers to attendanceLow insight and knowledge into servicesNumerous studies identified that a lack of

personal insight or knowledge regarding the natureof programs was a common barrier to atten-dance.48,50,53,56,58,59,61,65,73,83,84,92,99,101,107 Patientsperceived that programs would not be beneficialgenerally47,82 or for people “like them”23,93and reportedreceiving little information from health professionals onwhat programs consisted of37,45,50,58,59,84,90or programbenefits 51,58,59 and little encouragement to at-tend.47,58,59,82 The language used to describe CR

services was found to be vague.29,82 Understandably,health professionals reported that patients conveyedlittle interest in programs.22

Beliefs about heart diseaseIn a number of studies, patients perceived heart disease

as defying any attempts to reduce risk. Thus, attempts atrisk reduction were perceived by patients to be futile. Forexample, risk of acute myocardial infarction was per-ceived to be unpredictable,24,82 inevitable,24,84,85,101,102

and uncontrollable, irrespective of whether the underly-ing heart condition was seen to be of low101 or highseverity.33 Likewise, participants expressed a low senseof control over their future health.24,54,82,93

Negative views of services/health systemNegative general views of health services and systems

impacted decisions to attend. Professionals within thehealth system were seen to disrespect patients,33 provideinsufficient time for consultations,84 give very narrow38

or mixed messages about recovery,56 and have inade-quate resources for patient support46,101 and poor32 orculturally insensitive communication.30,34,46,63Atten-dance could be restricted because no services wereavailable locally.103,105

Figure 2

Flow of included studies.

Clark et al 839American Heart JournalVolume 164, Number 6

Attendance was also curtailed when services were seento be unresponsive to the needs of particular populationssuch as older adults16,92,102 or ethnic minorities,34,46,63

when long wait times existed after referral,60 or whenservices were seen as gymnasium-like “men's clubs.”90

Patients could be “apprehensive” about returning to thehospital for programs,31 yet community-based servicescould be perceived as an unsafe alternative.35

Self and identityAspects of identity also influenced decisions to attend

when patients saw themselves as different from the typeof people who should participate in services.23,93 Basedon this sense of identity, patients viewed services as beingnot needed,36,58,59,72,92 unlikely to benefit,66,68,71,81,93,102

for “old people,”48,82,92 or conflicting with their priori-ties.41At times, patients engaged in avoidance strategiesto downplay the need to attend24,36,53,84,106and reportedthat their activities of daily life were already healthy interms of physical activity.82,102 Other health-relatedfactors reported to curtail attendance were anxi-ety,24,93,97 pain,48,97,102 recovery from surgery,51 orother illnesses.26,31,68,72,82,96,97,102

Financial and work constraintsParticipation in services had extensive financial rami-

fications, especially when incomes were low or employ-ment was uncertain.25,55,86Costs could be immediate15,96

but mostly resulted from competing occupationaldemands.25,31,37,38,43,53,58,59,62,65,68,69,72,74,75,81,84,86,91-

Flexible home-based programming or support from socialservices70 was rarely offered.81

Demands on womenWomen struggled to meet the financial and social

costs of participation.43,75,96 Women's lives involvednumerous domestic and family demands that reducedcapacity to prioritize attendance.43,94,96,97,104 Meetingthe needs of partners and children41,96 or preparingmeals for family members43 was perceived as a higherpriority than attendance at CR. Women with heartdisease reported receiving little support from theirwider communities76,97 and significant others toattend.89

Personal facilitators of attendanceHeart disease as controllableA high sense of control over heart disease

was common ly a s soc i a t ed wi th a t t en -dance24,26,27,55,58,59,76,93,95,97,102,108 and was rein-forced by experiences of controlling other diseases,56

the sense of mastery33 or security associated withparticipating in programs,26,30,75,88,93 and self-reliancein the face of the demands created by heartdisease.24,44,54,95

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Positive views of servicesService benefits perceived to increase attendance

included reducing stress,76,78,79,86 improving gener-al health, 39,76,97,100,108 and increasing confi-dence.30,35,39,93,95 Cardiac rehabilitation services wereseen as the best place in which to attain recovery.68,69,102

Contextual barriers to attendanceLong distances to servicesLong travel distances to CR programs were cited as a

common barrier to attendance,58,59,64,65,80,92,99,109 par-ticularly from rural settings33,53 or when transport linkswere poor.55,65

Lack of support from familyFamily members curtailed attendance through both

active and passive actions. Families were seen tooverprotect the patient24 or “take charge” of risk factorreduction.28,53,57,61,68,89,101 Families also constrainedattendance due to demands on patients for caregiv-ing67,85 or similar familial commitments.65,91

Contextual facilitators to attendanceThe family and social networksFamilies could also facilitate attendance97 by providing

social support,67 transportation to centers,33,40,52,55,96

accompanying the patient to the program,30,77,93,98

providing information on services,24,67 communicatingwith health professionals,96 or making exercise nor-mal.24,67 Encouragement to participate in programs fromprevious attending patients was also cited to promoteattendance.30,34 A sense of camaraderie between pa-tients in CR programs existed and could sustainattendance over time.26,35,39,55,96

Health professionalsAttendance could be increased by health professionals

via telephone calls made to patients before the com-mencement of services42,44,57-59 and through offeringchoices around services81,99or information that waspatient specific24,84,96,98 and attentive to noncardiacconditions.96At times, patients wished to learn aboutCR services during hospitalization and from a physi-cian58,59 rather than a nurse.81,82 However, only onestudy specifically noted that cardiologists were animportant source of information,42 although physicianencouragement in general was identified as a strongfactor in motivating attendance,30,49,87 especially forwomen.96

DiscussionDecisions to attend CR programs were strongly

influenced by patients' psychosocial factors, context,

and other occupational and personal commitments,including social comparisons, perceived benefits andcontrol, occupational demands and constraints, distanceto settings, and families. The influence of such a widerange of factors is common in acute111-116and chronicstages of heart disease,117,118 but medical reasons for lowattendance (such as symptoms and comorbidities) wereinvoked far less often as reasons for nonattendance. Also,the degree to which programs were seen to potentially oractually affect life expectancy was small, althoughpositive changes in health behaviours can improvemortality, morbidity, and quality of life.119,120

Research and practiceThere is strong evidence from clinical trials that

patients who are unable to participate in hospital-basedprograms can have equally positive outcomes fromspecially tailored programs as patients who attendhospital-based programs.121-124 In preference to pro-viding hospital-based programs outside traditional workhours, more types of programs that allow remoteaccess via the Web, e-mail, or telephone could beavailable to ensure that time and distance do not act asbarriers to attendance.Given the relatively high influence of psychosocial

factors on decisions to attend CR and the likelihood offuture financial constraints on health systems, evidence-informed interventions are needed to increase access toCR. However, a recent Cochrane review identified thatonly 3 such interventions exist.125 Moreover, currentinterventions address predictors of attendance but notthe actual factors that influence attendance,126,127

evaluate new types of programs rather than interventionsto promote access,126 and tend to include narrow groupsof patients post–myocardial infarction.127-129 Interven-tions are thus needed that supplement programs topromote CR attendance and draw on evidence, as isdetailed here, on the social and contextual factors thatactually influence attendance130,131 in representativepatient groups.Evidence from this review indicates that future in-

terventions to promote attendance in CR should considerthe following:

1. Provide accurate and personalized feedback to eachpatient on the suitability of services to the individualand quantify the likely benefits of CR to risk reductionbased on individual needs, cardiovascular risk, andcapabilities. Comparisons could be made to thesimilarity of size of benefits available from commonmedicines such as statins.

2. Foster patients' sense of individual control over theircardiovascular health.

3. Engage both patients and families132 in ascertaining layviews of the causes of heart disease and the nature and

Clark et al 841American Heart JournalVolume 164, Number 6

benefits of CR and respond to views and beliefs thatimply negative service experiences or incongruence ofCR services with patient identity and needs.133

4. Such interventions will require health professionalsfrom multidisciplinary teams to adapt their support tothe individual—for example, using principles of adultlearning132,134—and consider how patient sex andfamily roles are likely to affect attendance decisionsand involve family members in discussing how tosupport patient attendance.

5. Promising innovative mechanisms to support theseinterventions include “decision-aids” to ensure that allelements have been raised or addressed with patientsand their families.135-137 Other patients appear to beparticularly suitable but often underutilized advocatesfor promoting service attendance and could comple-ment support provided by health professionals.62

This peer support could not only use face-to-facesupport but also harness social media and Web-basedonline forums.

LimitationsThis review used a recognized approach to qualitative

synthesis19 to harness and synthesize relevant data fromqualitative studies of diverse populations. As with allreviews, it is constrained by the quality and scope ofexisting published studies.21 Across the included studies,there was limited analysis of the influence of sex, age, orethnic group membership. Study quality was moderateoverall and mostly confined to high-income countrieswith well-funded health care systems. Attendance wasexplored predominantly in relation to traditional hospital-based CR programs; as such, the factors that mayinfluence participation in other types of programs (eg,community-based programs) should be addressed infuture research. Similarly, studies contained few data onfacilitators of attendance but, instead, more narrowly,focused on “barriers” to attendance. To reduce thepossibility of bias in study selection and synthesis, thereview used detailed and comprehensive search andselection criteria and involved multiple reviewers. Thesynthesis followed the stages for qualitative systematicreview recommended by members of the Cochranecollaboration.138

ConclusionAttendance in CR is influenced by a range of

psychosocial, familial, and contextual factors. Futureinterventions to promote higher access should includefamily members and foster patients' sense of control ofcardiovascular risk, harness similarities rather thandifferences with patients who participate, and harnessfamily members to support rather than curtail atten-dance. Peer support of both patients and families may be

a particularly promising and efficient means to facilitatethese aims.

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Clark et al 845.e1American Heart JournalVolume 164, Number 6

Appendix

Supplementary File I. Sample search strategy

MEDLINE

001

heart diseases/ or myocardial ischemia/ or acutecoronary syndrome/ or angina pectoris/ or exp angina,unstable/ or coronary disease/ or coronary aneurysm/or coronary artery disease/ or coronary occlusion/ orcoronary stenosis/ or coronary thrombosis/ ormyocardial farction/

63031

002

(coronary artery disease* or atherosclerotic heartdisease* or Arteriosclerotic heart disease*).ti,ab.

14734

003

(Acute coronary syndrome* or angina or heart attack ormyocardial infarct* or heart infarct*).ti,ab.

38816

004

((Ischem* or ischaem*) adj3 (heart or cardio* ormyocard* or coronary)).ti,ab.

14608

005

((coronary or heart) adj3 (aneurysm* or occlusion* orstenosis or thrombosis)).ti,ab.

4818

006

1 or 2 or 3 or 4 or 5 87417 007 exp Exercise Therapy/ 7936 008 risk reduction behavior/ or disease management/ 6206 009 secondary prevent*.ti,ab. 3556 010 (rh or th).fs. 297011 011 exp Patient Education as Topic/ 15683 012 exp health education/ 24971 013 (exercise training or exercise program*).ti,ab. 4715 014 ((educat* or rehabilit* or prevent* or manag*) adj3

(program* or clinic$1)).ti,ab.

23142

015

(manag* adj3 (illness or disease)).ti,ab. 7670 016 recurrence/ or (recur* adj3 prevent*).ti,ab. 31782 017 7 or 8 or 9 or 10 or 12 or 11 or 13 or 14 or 15 or 16 371137 018 6 and 17 21631 019 px.fs. 179033 020 Patient Acceptance of Health Care/ or Patient

Compliance/ or Patient Participation/ or PatientSatisfaction/ or Refusal to Participate/

38842

021

exp Decision Making/ 31884 022 intention/ or decision making/ or choice behavior/ 24610 023 Motivation/ 11420 024 attitude/ or attitude to health/ or Health Knowledge,

Attitudes, Practice/

43111

025

(factor* or barrier* or decision* or motivat* or incentive*or intention or choice or attitude* or utili* orunderutili*).ti,ab.

870320

026

exp Compliance/ 661 027 (compliance or noncompliance or participat* or

nonparticipa* or nonadherence or adherence).ti,ab.

128297

028

exp Life Style/ or lifestyle.ti,ab. or exp Health Behavior/ 51364 029 exp Adaptation, Psychological/ or exp Personality/ or

exp Cultural Characteristics/

73190

030

exp Social Support/ or support*.ti,ab. 278251 031 or/19-30 1289300 032 18 and 31 7599 033 (CR or cardiopulmonary rehabilitation).ti,ab. 1032 034 32 or 33 8121 035 limit 34 to yr = 1995-2008 3554 036 exp qualitative research/ 7502 037 exp Nursing Methodology Research/ 5179 038 exp anthropology, cultural/ 26152 039 exp focus groups/ 6042 040 exp tape recording/ 2203 041 exp Video Recording/ 6704

Supplementary File I. (continued)

MEDLINE

042

qualitative.mp. 39203 043 (ethnol$ or ethnog$ or ethnonurs$ or emic or

etic).mp.

2285

044

(leininger$ or noblit).mp. orhare.ti,ab. 412 045 (field note$ or field record$ or fieldnote$ or field

stud$).mp.

3347

046

(participant$ adj3 observ$).mp. 1869 047 (nonparticipant$ adj3 observ$).mp. 10 048 (non participant$ adj3 observ$).mp. 110 049 (hermeneutic$ or phenomenolog$ or lived experience

$).mp.

6134

050

(heidegger$ or husserl$ or merleau-pont$).mp. 204 051 (colaizzi$ or giorgi$).mp. 232 052 (ricoeur or spiegelberg$).mp. 43 053 (vankaam$ or van manen).mp. 36 054 (Grounded adj5 theor$).mp. 2361 055 (constantcompar$ or theoretical sampl$ or triangulat

$).ti,ab.

2091

056

(glaser and strauss).mp. 14 057 (contentanalys$ or thematic analys$ or narrative

analys$).mp.

5910

058

(unstructuredcategor$ or structured categor$).mp. 4 059 (unstructured interview$ or semi-structured interview

$).mp.

4674

060

(maximum variation or snowball).mp. 507 061 (audiorecord$ or taperecord$ or videorecord$ or

videotap$).mp.

3279

062

((audio or tape or video$) adj5 record$).mp. 9425 063 ((audio$ or video$ or tape$) adj5 interview$).mp. 1565 064 (metasynthes$ or meta-synthes$ or metasummar$ or

meta-summar$ or metastud$ or meta-stud$).ti,ab.

164

065

(meta-ethnog$ or metaethnog$ or meta-narrat$ ormetanarrat$ or meta-interpret$ or metainterpret$).mp.

73

066

(qualitative adj5 meta-analy$).mp. 60 067 (qualitative adj5 metaanaly$).mp. 0 068 purposive sampl$.mp. 1092 069 action research.mp. 752 070 focus group$.mp. 9454 071 (exp interview/ or exp interview as topic/) and px.fs. 672 072 or/36-71 97954 073 35 and 72 117 074 (mixed method* or multi-method* or multiple research

method* or multiple method* or multimethod* or mixedmodel* or mixed research).tw.

6215

075

((qualitative or qual) and (quantitative or quan) and(nested or blend* or concurrent or complementary orexpansion or initiation or holistic or transformative orembedded or iterative or triangulat*)).tw.

816

076

((quantitative or quan) and (phenomenolog* or ethno*or (grounded adj3 theor*) or hermeneutic* or livedexperience* or content analys* or thematic or theme* ornarrative* or interview* or focus group* or actionresearch)).tw.

3281

077

(triangulat* adj15 (method* or data or concurrent orsequential or simultaneous or design*)).tw.

585

078

(qualitative adj5 quantitative adj5 (combin* or mixed ormix or integrat* or method* or analys*)).tw.

2989

079

exp qualitative research/ and quantitative.tw. 660 080 or/74-79 12173 081 (qualitative and quantitative).tw. 12033 082 exp Nursing Research/ or exp Health Services

Research/ or exp Rehabilitation/

72248

083

(px or nu or rh or ed or og or es or eh).fs. 338759

845.e2 Clark et alAmerican Heart Journal

December 2012

Supplementary File I. (continued)

MEDLINE

084

(nurs* or educat* or rehabilitat* or psych* or social orsocio* or service* or interview* or questionnaire* orsurvey*).af.

885702

085

or/82-84 932046 086 81 and 85 4646 087 80 or 86 13688 088 (clinical trial* or evaluation studies or randomized

controlled trial).pt.

198199

089

(randomized or (clinical adj3 trial*) or (controlled adj3trial*)).mp.

259049

090

88 or 89 329925 091 qualitative.mp. 39203 092 90 and 91 3395 093 ((qualitative or quantitative) adj5 nested).tw. 133 094 87 or 92 or 93 16330 095 35 and 94 28 096 73 or 95 127 097 limit 96 to updaterange = "medc(20110916134040-

20110902170230], medl(20110916134040-20110919135137],prem(20110916134040-20110923122444]"