Participants from diverse sociodemographic backgrounds were invited for interviews to get maximum population representation (Table 2 Demographic Characteristics of the Participants). A total of five themes and 24 subthemes were found in the qualitative data obtained from participants. The themes were: (1) understanding heart disease, (2) cardiac anxiety, (3) challenges faced by patients, (4) difficulties in behavior change, and (5) patient readiness for home-based cardiac rehabilitation (Table 3 Underpinning Themes, Subthemes, and Codes).
Theme 1: Understanding about Heart Disease
The qualitative findings in this theme emphasize the critical need for improved education and awareness programs targeting heart disease, particularly addressing gaps in knowledge about symptoms, risk factors, and preventive measures. Such initiatives could potentially empower individuals to make informed decisions regarding their heart health and reduce the incidence of heart-related complications (Image 1 Word Cloud of Understanding about Heart Disease).
Subtheme 1.1: Lack of awareness
A lack of understanding was expressed by Participants about their heart condition, attributing it partly to their illiteracy. This suggests a gap in knowledge due to educational limitations, hindering their ability to comprehend the nature of their heart disease. As the participant shared, “I do not have any idea about why it happened to me. I do not know much due to my illiteracy.” P3
Similarly, participant 10 initially misinterpreted the heart problem as a back issue, indicating a lack of awareness regarding the symptoms of heart disease. This misunderstanding highlights the need for better education and awareness about the diverse manifestations of heart ailments. “I initially did not recognize that it was a heart problem. I thought it was my back hurting me because I played football frequently.” P10
On the other hand, a former chain smoker admitted to being unaware of the detrimental effects of smoking on the heart. This reflects a lack of understanding of factors contributing to heart disease, highlighting the necessity for a complete education on the risks associated with smoking. “I was a chain smoker for almost 30 years…I stopped recently…when I used to smoke…I was not aware of the effects of smoking on the heart…” P14
Subtheme 1.2: Misconceptions about heart disease
Findings in this subtheme give emphasis to diverse misconceptions regarding the causes and progression of heart disease, ranging from fatalistic beliefs to skepticism about the influence of risk factors. These misconceptions can significantly impact patients' understanding of their condition and adherence to preventive measures and treatment plans (Image 2 Word Cloud of Misconceptions about heart disease).
A participant expressed a belief that once afflicted with a disease, the body is predisposed to further illnesses. They perceive a progression from one ailment to another, suggesting a fatalistic view that a patient with heart disease cannot fully recover.
“In my view, when the body is diseased with any condition, a person cannot recover fully and keeps progressing for other diseases. When I completed the hepatitis treatment course, I suddenly developed a heart problem and went to previous doctors who treated my hepatitis. I think when you face one disease, the other comes in relation to the first one. A patient with heart disease can never become healthy,” P1.
Similarly, the participant's response challenges the notion that habits or actions directly cause diseases. They reject the idea that lifestyle choices are solely responsible for ailments, implying a more philosophical perspective in which diseases occur irrespective of external factors.
“We keep on saying that this thing is a cause of this disease, but it is not true that whatever we do is not the cause. People link habits and other things with the disease; however, a disease that has to come will come without any cause.” P2
Response by a participant attributes diseases to divine will, emphasizing faith in a higher power over conventional medical explanations. They dismiss the influence of habits or diet on heart health, viewing illness as predetermined by a higher authority.
“Everything cannot have caused some diseases come on their own because we are aging and today will be different from tomorrow…it cannot be same…doctors say that smoking has led to this disease in me, but I do not think so…I think these are just myths that food and habits can cause heart problems…the disease is from ALLAH and he created treatment first and disease after…so we should have faith on HIM about diseases and all the matters of life.” P5
Another participant demonstrates a selective perception of risk factors, attributing heart disease to specific habits while denying the correlation between their own habits and heart health. This selective attribution suggests a lack of awareness or understanding of comprehensive risk factors. “I think those who eat chhalia and smoke cigarettes with it can have effects on their heart…I only eat chhalia...I do not think it has any link with the heart…” P16
Subtheme 1.3: Denying the Causes
The qualitative results suggest a variety of responses among heart patients in denying or questioning the causal link between smoking and heart disease. These responses may be influenced by factors such as personal beliefs, experiences, social norms, and cultural or religious perspectives, emphasizing the importance of considering individual contexts in health interventions and education efforts.
Patient 5 expresses a belief in the unpredictable nature of health, suggesting that diseases can arise without clear causes, attributing them to aging and the variability of life. This perspective implies a fatalistic view of health where individuals may perceive illness as an inevitable aspect of life. The response from Patient 7 indicates the perception that denies the association between smoking and heart disease, indicating a refusal to accept personal responsibility for their condition. This denial could stem from a lack of awareness, cognitive dissonance, or a coping mechanism to alleviate guilt or anxiety associated with their smoking habit. “I am still a smoker, and I do not think it was the cause…” P7
Similarly, Patient 8 denies the link between the smoking habit and heart disease, suggesting a disconnect between perceived causality and personal beliefs or experiences. This denial may be influenced by factors such as addiction, social influences, or a desire to maintain a sense of control over their health. “Though people think my smoking habit is the reason, I know it is not…” P8
Additionally, Patient 10 rejects the notion of external causes altogether, attributing all aspects of disease and healing to a higher power (GOD). This perspective reflects a spiritual or religious interpretation of health, where illness is seen as part of a divine plan rather than a consequence of individual behavior or lifestyle choices. “We keep on saying that this has caused this, and this has caused that…I do not believe…all disease and healing is from GOD…nothing else can give you disease or healing…not even smoking…” P10.
Theme 2: Cardiac Anxiety
In this theme, various perspectives have emerged from participants’ data, which include fear of chest pain, fear of death, fear of physical activity, fear of a second heart attack, financial worries, worries about family responsibility, worries about the future, and worries about lifetime medicines.
Subtheme 2.1: Fear of chest pain
The interviews with heart patients revealed a sense of anxiety and fear surrounding their cardiac condition, with concerns centering on the experience of a heart attack, its aftermath, and the potential for recurrence. Participants expressed a lack of understanding about heart attacks prior to experiencing one, indicating a sudden and profound disruption to their lives. Participant P2 recounted, “I did not even know what a heart attack was. After that time, I fear that there is still pain in my chest, sometimes more or less.” This response reflects not only the initial shock of the event but also the persistent worry about the possibility of future chest pains, highlighting an ongoing psychological burden (Image 3 Word Cloud of Fear of chest pain).
Furthermore, participants described how heart disease instills a deep sense of “khoff” or phobia, which permeates their daily lives and inhibits their ability to engage in normal activities. Participant 5 expressed, “Heart disease creates khoff (phobia) in patients when they do some work, and this khoff does not allow a person to live a normal life as other people do.” This sentiment stresses the profound impact of cardiac illness on individuals’ perceptions of their capabilities and quality of life. The fear of triggering symptoms or experiencing further complications leads to a sense of limitation and alienation from activities that were once routine.
Additionally, participants identified specific triggers for their anxiety, notably the physical sensations associated with their condition. Participant 20 described how the act of breathing itself became a source of distress, exacerbating their fear and discomfort: “It was hurting me more when I breathe…which increased my fear…” This quote illustrates how even basic physiological functions can become intertwined with feelings of apprehension, contributing to a heightened state of anxiety.
These qualitative findings highlight the profound emotional impact of cardiac illness on Pakistani patients, underscoring the need for comprehensive support and rehabilitation strategies that address not only physical symptoms but also psychological well-being and coping mechanisms.
Subtheme 2.2: Fear of death
Participants’ narratives illuminate the persistent impact of cardiac anxiety on Pakistani patients, underscoring the urgent need for tailored interventions to address their emotional needs within the context of rehabilitation. One participant distinctly described the initial shock upon receiving the news of their heart condition, reporting a moment of shared vulnerability with a loved one. The mutual tears shed underscored the gravity of the situation, instilling a profound sense of mortality. The participant’s perception of imminent death evoked feelings of helplessness and despair, highlighting the overwhelming psychological burden of their diagnosis (Image 4 Word Cloud of Fear of death).
“…I was crying after hearing the news, and she also started crying and provided me the support that I needed to be brave. I was thinking that I am going to die very soon” P8.
Similarly, another participant expressed the collective apprehension surrounding the cardiac event. The persistent fear spread through the patients and their loved ones, manifesting as a loss of hope in the face of uncertainty. This shared anxiety further intensified the emotional strain experienced by the participant, amplifying feelings of isolation and vulnerability. “Everyone got scared and lost hope of my life, even myself…” P9
The experience of cardiac anxiety was described by participants as deeply visceral, with one individual (P20) likening it to suffocating pressure on their chest. This sensation of impending doom evoked a profound fear of mortality, heightening the psychological distress associated with their condition. The physical manifestation of anxiety underscored the complex relationship between physiological and psychological factors in shaping the participants' lived experiences of cardiac rehabilitation. “I experienced fear, a real fear of death…it was like very heavy pressure on my chest…”. P20
Subtheme 2.3: Fear of Chest Pain during Physical Activity
Participants expressed a sense of fear and threat associated with everyday activities. Participant 1 articulated this sentiment: "I always feel threatened when I walk or do routine activities, even if I cannot walk at my average speed as I used to." This fear suggests a significant psychological barrier to engaging in daily tasks, potentially leading to decreased physical activity.
Several participants highlighted their apprehension towards exercise, particularly walking, due to the fear of experiencing chest pain. Participant 8 vividly described this fear, saying, "After a few weeks, doctors suggested I walk, but walking with heart disease is quite difficult. It is very frightening to have chest pain during the walk, and that is the fear which does not allow to exercise." This fear prevents adherence to recommended exercise regimens, potentially hindering rehabilitation efforts (Image 5 Word Cloud of Fear of Chest Pain during Physical Activity).
Despite recognizing the potential benefits of exercise for their heart health, participants grappled with the fear of recurrent symptoms. Participant 6 acknowledged the benefits of walking but expressed concern about experiencing any symptoms during exercise, stating, "Walking causes me a little shortness of breath, but when I rest, it goes away…it definitely benefits the heart, and doctors should guide us properly because I fear any recurrent symptom associated with the walk…" This uncertainty underscores the delicate balance between recognizing the importance of exercise and managing the fear of adverse events.
On the other hand, participant 4 highlighted a sense of helplessness regarding exercise, fearing that physical activity would exacerbate the condition. They stated, "The heart disease does not allow me to exercise at all…I feel that by doing exercise, I will develop chest pain again due to my diseased heart…" This fear-driven avoidance behavior may contribute to further physical deconditioning and worsen cardiovascular health outcomes.
Furthermore, participants who had experienced a heart attack expressed heightened anxiety about the possibility of recurrence. Participant 11 articulated this fear, stating, "I am concerned that something might occur to me again since I have suffered a heart attack once." This fear not only impacts their psychological well-being but also influences their willingness to engage in activities perceived as risky, including exercise.
Fear stemming from cardiac events penetrated participants' daily lives, influencing their behaviors and interactions. Participant 18 described how slight sensations, such as shortness of breath, induced fear, and hesitation, stating, "The only strange sensation I have is a slight shortness of breath, and because of this, I am afraid to walk." This fear emphasizes the need for tailored interventions addressing cardiac rehabilitation's physical and psychological aspects.
Subtheme 2.4: Financial Worries
Participants worried about their financial stability due to their heart condition. The inability to work or lose their job due to health concerns created significant anxiety. Participant 1 mentioned leaving the job, illustrating how cardiac issues can disrupt employment. Participant 2 highlighted the struggle to manage household expenses and expressed concern about becoming a financial burden on his family. This indicates a critical need for support in managing economic challenges associated with cardiac health issues (Image 6 Word Cloud of Financial Worries).
Participants described experiencing emotional stress and feeling overwhelmed by their family responsibilities. Participant 3 expressed worries about burdening their family due to their health condition, indicating a sense of guilt and responsibility. Participant 15 highlighted the stress of being the sole breadwinner and the pressure of ensuring their children's success. These findings reveal the emotional toll of cardiac illness, particularly in the context of familial obligations and societal expectations.
Subtheme 2.5: Worries about Lifetime Medicines
The experiences shared by heart patients shed light on the impact of cardiac anxiety on their daily lives and the critical need for tailored interventions. Participant 19 expressed a poignant struggle with cardiac anxiety, stating, "After a few weeks of treatment, I started thinking more about it, and this has caused me stress for which I had to take extra medicines." This response shows the psychological toll of living with a cardiac condition, where anxiety becomes a tangible burden requiring additional medication to manage. The participants’ candid admission reflects the extensive fear and uncertainty surrounding their health, highlighting the urgent necessity for comprehensive support beyond medical treatment alone.
Moreover, the participant's acknowledgment of the potential consequences, "I instantly realized that I might not have survived," shows the existential fears intertwined with cardiac ailments. This revelation encapsulates the profound psychological impact of a cardiac event, catalyzing an intensified sense of mortality. Despite this realization, the participants resiliently carry on with their daily lives, demonstrating remarkable adaptability and determination in adversity.
Theme 3: Challenges Faced by Patients
These qualitative findings showed the multifaceted challenges faced by heart patients, including financial constraints, access to healthcare services, and emotional stress related to familial responsibilities. Addressing these challenges requires comprehensive support systems considering medical needs and socioeconomic and emotional well-being.
Subtheme 3.1: Challenges Faced during Follow-up
Response from Participant 1 highlighted the challenge of managing follow-up appointments and prescribed medications while being the family's sole breadwinner. This participant expressed difficulty attending follow-up visits due to prioritizing work and providing for the family. This suggests that financial constraints and the need to fulfill familial responsibilities often take precedence over health-related commitments (Image 7 Word Cloud of Challenges Faced during Follow-up).
"They asked me to take medicines as prescribed and to come for follow-ups regularly. Now, if one person alone is earning, how can he manage to come for follow-ups? Therefore, it becomes difficult to attend…in the initial days, the person actively follows the instructions and does hospital visits frequently when required…but…after some time, the priorities change. Other family responsibilities do not allow that person to stay without earning." - P1
Participant 4 reported difficulty accessing healthcare services, particularly regarding travel expenses and the time required to reach the same hospital. This suggests that patients may face barriers in seeking timely medical assistance or continuing treatment due to logistical constraints such as travel distance and associated costs. "Even if they develop any symptoms after the treatment, they cannot come to the same doctor or hospital due to the travel expenses and time required to reach the same hospital again" - P4.
Participant 15 expressed feeling stressed due to being the sole provider for the family. This participant highlighted the emotional burden of balancing work, health, and familial responsibilities. The stress was particularly linked to concerns about their children's future success and well-being, indicating the complex interplay between health challenges and broader life circumstances.
"Yes, I feel stressed because you are a single-earning family member. It is hard to stay home and rest. My children are my biggest stress, which I do not think will be reduced until I see them succeeding in my life" - P15
Subtheme 3.2: Resistance from Family toward Physical Activity
Responses received from participants (4 & 5) both express frustration over their families' reluctance to allow them to engage in physical activity. “My family does not allow me to walk much due to my heart problem.” P4 “… my family does not allow me to do routine work.” P5. This overprotectiveness stems from a genuine concern for their health, but it may inadvertently restrict their ability to maintain an active lifestyle recommended for heart patients (Image 8 Word Cloud of Resistance from Family toward Physical Activity).
Similarly, Patient 6 describes feeling constrained by their family's insistence on accompanying them for walks, even in safe environments like parks. This restriction on autonomy can lead to feelings of frustration and dependence, impacting the patient's mental well-being. “My family takes care of mine, and they do not allow me to go outside alone, even for a walk… Doctors told me to walk at home or nearby parks, so I do it for 5 to 10 minutes, and then my family do not allow me…” P6
Patient 10 highlights the conflict between the family's desire to rest and the patient's need for rehabilitation and a gradual return to normal activities. This conflict can lead to misunderstandings and disagreements within the family dynamic, affecting the patient's overall well-being and recovery trajectory. “When I was discharged from the hospital, It was a difficult phase for me because my family was not allowing me to do routine life activities, and they wanted me just to rest and rest…” P10
Subtheme 3.3: Challenges in quitting smoking
Response from Participant 5 highlights a unique aspect of their smoking habit, where it becomes almost medicinal. They associate smoking with alleviating symptoms related to digestion. Despite recognizing the harmful effects, they feel reliant on smoking to maintain normal digestion, likening it to necessary medication. “You know if for any reason I do not smoke, I developed symptoms related to digestion, so I need to take it before and after meals to keep my digestion normal… maybe it affects other persons, but to me, it is just like medicine.” P5
Likewise, Participant 9 expresses the struggle of quitting smoking despite the awareness of its dangers. He acknowledged the success stories of others who have quit solely through willpower but find it difficult to himself. He relies on faith for strength, indicating a spiritual aspect to his coping mechanism. Participant further points out a common issue where smokers initially enjoy the habit without realizing its detrimental effects. (Image 9 Word Cloud of Challenges in quitting smoking). He emphasizes the importance of awareness, drawing from personal experience of pain and suffering caused by smoking, suggesting that many smokers may not fully comprehend the extent of harm until they experience it firsthand. The emotional toll of smoking is evident in P9's statement about how it "destroys your inner completely." This implies not only physical harm but also a profound impact on one's emotional and psychological well-being, suggesting that quitting involves more than just overcoming physical addiction.
“Yes, I smoke; I am facing difficulty when it comes to stopping smoking…I know some people already stopped it and shared that they did nothing, but the only thing was their will…I am also praying that Allah may give me the strength to avoid smoking for my remaining life…initially, people enjoy it, but unfortunately, they do not realize how dangerous it is…ask me because I know the pain and suffering I experienced…so it destroys your inner completely.” P9
Subtheme 3.3: Challenges in Managing Diet
The qualitative results also illustrate the challenges heart patients face in managing their diet, particularly in the context of financial constraints and social pressures. Participants express their struggles with financial limitations, making it difficult to afford specific dietary requirements. For instance, P4 mentions having to eat whatever is available at home due to financial constraints. “So I take what I can afford… frequently I had to eat whatever is made at home because I cannot afford two different dishes at a time…” P4. Meanwhile, P9 highlights the inflationary pressures that make healthy food options increasingly unaffordable.
Similarly, P12 emphasized the financial strain of managing medical expenses and basic household needs. Despite facing financial hardships, the participants acknowledge that they can barely sustain their family's livelihood, let alone afford a healthy diet. Furthermore, the participant experiences social isolation due to dietary restrictions imposed by heart conditions. He feels disconnected from family gatherings where food plays a significant role. The pressure to conform to social norms regarding food consumption exacerbates his feelings of isolation and discomfort. The participant's reluctance to attend family gatherings stems from the fear of being judged or treated rudely for not adhering to dietary recommendations. This highlights the social stigma and lack of understanding surrounding dietary restrictions in the participant's social circle (Image 10 Word Cloud of Challenges in Managing Diet).
Subtheme 3.4: Challenges with Medicine Compliance
Participants express difficulties in purchasing medications due to financial constraints. When participants cannot afford to buy medicines, they skip doses. The limited availability of medicines at hospitals contributes to the problem (Image 11 Word Cloud of Challenges with Medicine Compliance).
“I often do not have money to buy medicines, so I miss the dose. When I get money from a pension, then I buy and spend money. I face difficulty in getting medicines; the hospital provides only a few medicines, such as disprin, but other expensive medicines we purchase from outside.” P2
Furthermore, Patients feel doctors should consider their financial situation before prescribing multiple medications. There is a lack of understanding or communication between doctors and patients regarding the necessity and duration of medication intake. Patients express concerns about the duration of medication intake and seek doctor clarification.
“I have financial issues; doctors should understand our condition…they write so many medications without knowing that even if we have resources to buy it or not…they just do their duty to prescribe medicines…due to unaffordability, I miss my doses frequently and when I have money I buy and take it…” P4
Affordability issues directly affect medication compliance. Patients try to manage their conditions through dietary adjustments when they cannot afford medications. Compliance is easier when medicines are available, but affordability issues hinder adherence.
“When I have medicines, I take them, but when I do not have them, how can I make sure it complains…compliance can be done when I have medicines in hand, but when I do not have resources to buy medicines, here comes the affordability issues…when I know I have affordability issues, I tried to manage my diet so that I do not harm myself…” P4
Theme 4: Difficulties for Behaviour Change
The qualitative results highlight the multifaceted nature of the challenges faced by heart patients in adopting healthier behaviors and emphasize the need for personalized approaches to support behavior change efforts.
Subtheme 4.1: Persistent unhealthy behavior
The response by a participant, "I am taking medicine for my heart problem, and I smoke as well." - P5 reflects a reluctance to change behavior despite being aware of the risks associated with smoking, which is detrimental to heart health. The patient's acknowledgment of taking medication for their heart condition juxtaposed with their continued smoking suggests a barrier to behavior change, possibly due to addiction or other factors.
Similarly, The statement "I did not do anything to change my lifestyle…because I do not need to…" - P7 illustrates a sense of satisfaction and denial regarding the need for lifestyle changes despite a heart condition. The patient's lack of action to improve their lifestyle suggests a belief that their current habits are sufficient or that the severity of their condition is not recognized. This attitude presents a significant barrier to behavior change, as there is a lack of motivation or acknowledgment of the necessity for change.
Subtheme 4.2: Unable to Quit Smoking Habit
The Qualitative results shed light on the multifaceted nature of difficulties faced by heart patients in adopting behavior change, particularly concerning smoking cessation. The findings underscore the importance of personalized interventions and support systems to address individuals' unique barriers toward healthier behaviors (Image 12 Word Cloud of Unable to quit smoking habit).
Patient 5 expresses skepticism toward the link between smoking and heart disease. Despite medical advice attributing their condition to smoking, they refuse to accept it, citing examples of other patients who have heart disease despite never smoking. This denial may pose a significant barrier to behavior change, as the patient fails to acknowledge the role of smoking cessation in improving their health. “Doctors say that smoking has led to this disease in me, but I do not think so…because there are many patients who have heart disease but they never smoke a single cigarette in their life…now I am on medicine, and I feel good with them…but I still smoke because I cannot quit it.” P5
Both patients 5 and 15 highlight the immense challenge they face in attempting to quit smoking. Patient 15 acknowledges smoking as their biggest concern and expresses frustration over their inability to quit. Despite their efforts, such as reducing cigarette consumption, they find themselves trapped in a cycle of relapse and increased consumption. This struggle underscores the complexity of behavior change, particularly in the context of addictive behaviors like smoking.
“I am unable to quit smoking, and that is the biggest concern for me…I am still struggling with my smoking…If I reduce smoking cigarettes one day, I take more on the next day…it is not helping me out really…” P15
Subtheme 4.3: Unconvinced by behavior change
The responses shared by participants show the challenges they faced in implementing behavior changes recommended by healthcare professionals. Despite their efforts to comply with medical advice, participants express dissatisfaction and a lack of perceived benefits, which may impact their motivation and adherence to future recommendations.
Participants expressed frustration despite quitting smoking, indicating that their condition has not improved. Despite adhering to medical advice, they perceive no positive changes in their health status. This suggests a disconnection between their expectations and the outcomes of behavior change efforts. “I never feel relieved after stopping smoking. I used to smoke not more than 4 to 5 cigarettes a day. I was told to quit smoking, but it has not benefited me. P2
Another participant elaborates on their attempt to quit smoking, indicating that despite reducing their cigarette consumption, they have not experienced any relief. This sentiment reflects a perception of the ineffectiveness of behavior change efforts, leading to potential disillusionment with medical recommendations. “Doctors say that do not smoke a cigarette. I stopped smoking a cigarette a long ago. I feel my condition is the same as when I used to and now when I stopped it. P2
Subtheme 4.4: Unchanged dietary habits
Qualitative findings uncovered the complex interplay of familial, cultural, social, and personal factors contributing to heart patients' difficulties in making dietary behavior changes. These insights can inform the development of tailored interventions to support patients adopting healthier lifestyles.
Many patients express adherence to their family's dietary habits, indicating a challenge in altering their eating patterns. Responses such as "we all eat the same food cooked in a house" and "nothing unusual, same food which all members used to eat" (P2, P3) emphasize the influence of familial food practices on individual behavior.
On the contrary, some patients find deviating from their established dietary routines challenging. Despite being advised to make changes, they struggle to do so. For instance, one patient admits, "I have not changed my dietary plan at all" (P5), suggesting a resistance to modifying their eating habits.
Additionally, several patients confess to difficulty resisting certain types of food, particularly sweets. Despite being aware of their health condition, they find it hard to control their cravings. Patient 11 admits, "Truly speaking, I cannot avoid sweet things…I think I am addicted to sweets…" illustrating the struggle with unhealthy food cravings.
Cultural and social factors play a significant role in shaping dietary behaviors. Patients mention factors such as joint family setups and familial caregiving influencing their dietary choices. Patient 20 reflects on the continuity of familial food practices post-recovery, stating, "In our house, it is a joint family, and we all eat the same food…after one week, the same food started for me as well…" (P20). Some patients express limitations in their ability to afford or demand special dietary requirements. Patient 13 mentions, "I take whatever is made at home. I never demanded something special because I know what I can afford," indicating financial constraints as a barrier to behavior change.
Theme 5: Patient Readiness for Home-based Cardiac Rehabilitation
The findings from qualitative interviews suggest that heart patients exhibit varying levels of readiness for behavior change, which are influenced by factors such as personal motivation, external support, and access to resources. Healthcare interventions promoting behavior change should consider these individual differences and provide tailored support to help patients effectively modify their lifestyles and improve their cardiac health.
Subtheme 5.1: Readiness for Behavior Change
A response from P12 reflects a realization of the need for change after experiencing a heart attack. The patient acknowledges that their previous lifestyle was unhealthy and understands the importance of modifying their habits to prevent another heart attack (Image 13 Word Cloud of Readiness for Behavior Change).
“I think my lifestyle was not good. I have a heart attack this time, and if I will change my habits, I will definitely get another one. So, I need to modify unhealthy activities which I know about and need to find out and overcome the roots of anxiety and stress in my personal life…” P12
Similarly, the P7's response indicates that enthusiasm for lifestyle changes may diminish over time. This suggests that initial motivation may wane as patients continue their recovery journey, highlighting the need for ongoing support and motivation. “I think in the initial months, I was more enthusiastic to bring change in my lifestyle than now…” P7
On the other hand, P14's and P15’s thoughts reveal their proactive approach to changing behavior. This demonstrates a readiness to engage in behavior change and a willingness to seek professional assistance.
“I have changed a lot for the diet and consulted a nutritionist for it…I want to avoid things now which I was able to previously, but there is proper guidance to me what should I do…” P14
“Initially, when I was discharged home, I was very keen to manage myself quickly…” P15
Subtheme 5.2: Patients Preference for Mode of Follow-up
In this subtheme, the data from participants suggest that patient preferences for follow-up care after heart-related issues are diverse and influenced by factors such as accessibility, satisfaction with care, trust in healthcare providers, and individual circumstances. Providing options and considering patient needs and preferences could improve patient satisfaction and adherence to follow-up protocols (Image 14 Word Cloud of Patients Preference for Mode of Follow-up).
Many patients express a desire for options for follow-up care. They appreciate being given choices rather than being dictated to a single follow-up mode. For instance, Patient 2 mentioned feeling dissatisfied because they were not offered options initially. “Give me options, and then I can tell you…mmmm….ok obviously the one with telephone…I was not offered such; I was just told to take medicine and come after 15 days for a checkup…no options were given at that time…” P2
Some patients prefer telephonic consultations, particularly those who face challenges in physically attending clinics due to distance or other constraints. Patient 5 expresses a balanced view, suggesting that both in-clinic visits and telephonic consults have merits, but telephonic consults would be preferable if feasible. “I would say both because sometimes you can go and sometimes it is difficult…but if possible, then patients would prefer telephonic consults after a few in clinics.” P5
Furthermore, patients emphasize the importance of considering individual circumstances when determining the mode of follow-up. Patient 6 highlights the diversity of patient locations and situations, suggesting that choices should accommodate varying needs, including those of rural patients. “I think it should be given a choice to patients because many live far away from the hospital and even come from rural areas for checkups, and many live near the hospital or in the same city.” P6
While telephonic consultations are appreciated for convenience, some patients still find in-person hospital visits more satisfactory. Patient 7 articulates this sentiment, noting that direct interaction with healthcare professionals provides reassurance and guidance, especially regarding post-heart attack lifestyle adjustments.
“Hospital visits are more satisfactory than any other method…but the telephone is also good for guidance about exercise and food, but tell me, who will do calls? If patients do it, then it is not good. If hospitals do it, then it is good…patients after heart attacks want information from their doctors about whether they should eat and what not…, whether they should walk or not, and how much they should walk, but unfortunately, there is very little given by the hospital upon asking…” P7
On the contrary, patients shared the financial and logistical burdens associated with hospital visits, particularly for those traveling from distant locations. Patient 8 emphasizes the economic implications of in-person visits, suggesting that telephonic check-ups would alleviate these challenges.
“I think telephonic checkup is good because who needs to come from far areas just as I come from Sahiwal, and if check on call, it will be easy for patients; otherwise, patients like me have to lose one day's wage and spend travel fare as well.” P8
Many patients strongly trust their doctors' recommendations regarding follow-up care. Patient 14 highlights the influential role of healthcare providers in shaping patients' decisions, indicating that patients are likely to adhere to the mode of follow-up suggested by their doctors.
“The patient would follow what doctors suggest…they consider the doctors' decision as the ultimate one…there is no choice if the doctor says you must come…likewise if they say call checkup is possible, then the patient will follow this instruction…” P14
Subtheme 5.3: Patients' views of the benefits of telephonic guidance
Qualitative data suggests that Participants perceive telephonic guidance as a convenient, cost-effective, and beneficial alternative to traditional in-person consultations, particularly for addressing lifestyle changes and misconceptions about post-heart attack care. The data also showed patients' trust in their doctors' recommendations and their willingness to adhere to guidance provided remotely. A participant stated, "Patients will pray for all of you if this service takes place. It will be very helpful and feasible for patients." P1. It highlights the convenience aspect of telephonic guidance, which would alleviate the need for frequent hospital visits. It also acknowledges the positive impact on the patient's family, as hospital visits disrupt their routines (Image 15 Word Cloud of Patients' views of the benefits of telephonic guidance).
Similarly, patients express a desire for guidance on lifestyle changes, such as diet and exercise, indicating that telephonic guidance could address these concerns and promote healthier habits. “This is good if patients can receive guidance about food and exercise because if tell you my experience, I was very concerned about these two…”P3
Furthermore, another patient response emphasizes the time and cost savings associated with telephonic guidance. Patients appreciate the convenience of not traveling to the hospital and believe they would be more likely to adhere to instructions if they could receive guidance remotely. Patients trust their HCPs' recommendations and are willing to follow instructions given via telephonic guidance, perceiving it as being for their benefit.“doctors always think for patients' benefit, so if they tell patients to follow instructions on the phone instead of coming to hospital, patients will happily follow because doctors suggested…”P18
Subtheme 5.4: Readiness about home-based exercise
The qualitative results highlight the importance of trust in medical advice, the convenience of home-based exercise, the need for external support and monitoring, and the significance of addressing patients' fears and providing proper guidance for exercise programs tailored to their needs and concerns (Image 16 Word Cloud of Readiness about home-based exercise).
The response from Participant 1 indicates a high level of trust in doctors' recommendations. Patients are inclined to follow the advice given by medical professionals, especially if it involves activities they can perform at home. This trust stems from the belief that doctors have patients' best interests in mind and that following their instructions would lead to better health outcomes. “Look….whatever doctors suggest patients follow its 80% of the information. If they do something for us and guide us to do something at our home, then who will not follow?”P1
Furthermore, the response from P5 emphasizes the potential benefits of external monitoring and support for exercise routines. Patients recognize the importance of accountability and supervision in maintaining a consistent exercise regimen. They are open to the idea of being monitored or supervised, acknowledging that it could help them stay on track with their health goals. “if someone traces you for your exercise, it would be good because it is very important for heart patients; otherwise, they must go into trouble if they do not change their behavior towards health. If I was asked, I must have accepted it.” P5
On the other hand, participants reveal a sense of fear and apprehension about exercising independently. Patients express reluctance to engage in exercise without proper guidance and training. They fear the potential consequences of incorrect or inadequate exercise, especially in relation to their heart condition. This stresses the importance of comprehensive guidance and education from healthcare providers to address patients' concerns and build confidence in their ability to exercise safely. “I think exercise is something which I would fear doing on my own…yes, if they train me in front of them first and then they keep check on me, I would be happy to do it…” P6
Subtheme 5.5: Resources for education Patients expect
The qualitative data suggest that participants Expect education resources that include visual aids, written guidance in simple language, and accessibility through mobile devices. Comprehensive materials catering to these preferences can improve patient understanding, compliance, and overall health outcomes. "I would say it should be written on paper in easy language and sent on mobile so that the other option should be available if the paper is misplaced."
Participants' responses conveyed the importance of comprehensive health education for heart patients, including medication management, lifestyle modifications, and exercise guidance. Patients desire clear instructions and support from healthcare providers to navigate their condition and improve their overall well-being. (Image 17 Word Cloud of Resources for education Patients expect).
Data showed participants' willingness to change their lifestyle if instructed to do so by doctors. However, it also reflects a sense of frustration when healthcare providers only emphasize medication without guiding lifestyle changes. “You know, when doctors suggest a lifestyle change, then definitely one will change, but if they told you nothing except “keep taking medicines” then why would one do…” P9
Subtheme 5.6: Suggestion to include family members as well
The participants emphasized the importance of involving family members in their healthcare journey, particularly when patients face challenges such as illiteracy or technical limitations. They expressed a desire for healthcare practices and technologies to be accessible to the patients and their family members, who can provide crucial support.
The responses from participants highlight the importance of simplicity and accessibility in healthcare instructions. Patients, especially those who are illiterate, feel that healthcare guidance should be understandable to themselves and their family members. They view family members as potential allies in adhering to medical advice, indicating a desire for inclusive healthcare practices. “It could be anything which patients can follow, and an illiterate like me can also follow….If a person is illiterate, then it should be something that family members can understand and help the patient follow with that.”