Behavioral theories and models to enhance compliance in cardiac rehabilitation programs for acute myocardial infarction – A narrative review

AMI is a serious, intense, and progressive cardiac disease that often leads to the appearance of anxiety and depression among patients. A high prevalence of psychological issues has also been reported in previous studies, which frequently results in the reoccurrence of cardiac issues, decreased quality of life, and no interest in physical activities and work life. Cardiac rehabilitation (CR) significantly reduces psychological problems such as anxiety and depression in patients with AMI. Poor quality of life in terms of physical and mental health is often observed in AMI patients with cooccurrence of psychological problems. CR programs not only reduce the prevalence of anxiety and depression but also improve the quality of life (3). In addition, these programs help reduce treatment costs and prevent the reoccurrence of disease as well as adverse effects in cardiac patients.

The global recognition of the advantages of CR has been well-documented. Nevertheless, the introduction and execution of these initiatives are currently in their early stages, characterized by a gradual pace and encountering numerous challenges (3,4). The scarcity of resources in low-income and middle-income countries results in limited access to CR programs. Specifically, in the context of AMI, there have been documented instances of reduced engagement, adherence, and compliance with rehabilitation programs, even within industrialized nations. (5–7). Hence, a comprehensive review was carried out to ascertain potential theories and models that play a vital role in improving compliance with rehabilitation programs in cardiac patients by enhancing their attitudes and behaviours.

Methods

This narrative review summarizes the concept of cardiac rehabilitation, and its significance and highlights various theories and models of behavior change to increase compliance in disease management in the context of acute myocardial infarction. The database search engines (PubMed and Google Scholar) were searched for relevant terms such as behavioral theory, behavioral model, cardiac rehabilitation, cardiac rehabilitation programs, and acute myocardial infarction. Initially, the titles and abstracts of all articles were screened, and suitable articles were then selected based on their relevance to the topic. A total of 345 research articles were screened using the online databases. Subsequently, only those studies were finally included in the review that discussed the impact of theories and models on enhancing patients’ disease conditions through behavior modification.

The concept and development of cardiac rehabilitation

The World Health Organization (WHO) defines cardiac rehabilitation as “the sum of all activities that have a beneficial effect on the disease itself and the patient’s physical, psychological and social functioning, leading to an improved quality of life and a more normal return to social life.” Historically, cardiac rehabilitation programs primarily centered around exercise-based training. However, contemporary CR programs have expanded their scope to encompass health promotion behaviors aimed at managing weight, diet, cholesterol levels, diabetes, blood pressure, and other critical factors contributing to patients’ overall physical and mental well-being. The clinical guidelines and cardiac association recommendations worldwide strongly recommend initiating and implementing CR programs for AMI and heart failure patients (2).

Table 1: Phases and models of cardiac rehabilitation.

Cardiac rehabilitation phases	Description
Phase I	It is an acute phase of hospitalization during which cardiac inpatients receive education and interventions from healthcare professionals, including cardiologists and nurses, who closely supervise them 24/7. This phase is of short duration and only lasts a few days until the patient is stable and no longer immobile.
Phase II	The second phase of rehabilitation lasts from 2 weeks to 12 months post-patient discharge. It is a period of intensive surveillance in which structured exercise routines, educational and psychological interventions, and lifestyle changes such as diet management, sleep management, stress and anxiety management, smoking cessation, and alcohol cessation are provided.
Phase III	The third phase is a long-lasting superficial supervision rehabilitation period which starts right after the second phase either at home or in the community-based CR centers. The digital-based technologies such as telehealth, digital apps, internet-based training, and education, etc. are mostly utilized in this phase.
Cardiac rehabilitation models	Description
Hospital-based initial rehabilitation (Phase I)	The hospital-based initial rehabilitation is the treatment model in which the patients are assessed during their hospital stay and are monitored and guided about the benefits of CR. The early rehabilitation program provides many clinical benefits to the patients, including but not limited to reduced mortality, a decrease in risk factors such as blood pressure and heart rate, etc., and enhanced ventricular functions. The treatment model is best suited for patients with multimorbidity and those requiring intensive care, but it can be expensive for patients paying their treatment costs (8). A study conducted to compare the home- based and hospital-based models reported that the hospital model is far better in improving the quality of life compared to other treatment models (9).
Hospital-based secondary rehabilitation (Phase II)	Secondary hospital-based rehabilitation is designed for outpatients after 2-6 weeks of completion of their necessary treatment and discharge from the hospital. The patients frequently visit the hospital for follow-up guidance and disease management.   However,   these   are   time-consuming, inconvenient, and expensive, especially for old people and  patients dwelling at far distances from hospitals.
Home-based rehabilitation (Phase III)	The home-based CR treatment model has added clinical advantages and is not time and space dependent. Few home- based telerehabilitation programs have successfully improved patients’ cardiac health, cognitive abilities, and mental health by using various technology-driven tools such as remote sensors and virtual exercise machines, etc. for monitoring and management of cardiac patients (10,11). Some studies have shown that home-based cardiac rehabilitation is more convenient and cost-effective for elderly and remote patients, making it a more participation-friendly option (12).
Hybrid community- based rehabilitation (Phase III)	Another treatment model is an individualized community-based service which is more economical and transport-convenient than a hospital-based model (8). Many government-funded community service centers (CSC) are established whose main function is to provide immunization, health education, and rehabilitation to residents. The cardiac rehabilitation provided at a CSC resulted in high participation, low patient withdrawal, and significantly better quality of life and psychological state compared to those provided usual care (13).

The significance of cardiac rehabilitation

Cardiac rehabilitation is a preventive treatment program aimed at preventing vascular disease recurrence. The main goal of the program is to provide a tailored approach that is specifically designed to address the unique needs of each patient. Using this approach, the program can effectively identify the risk factors associated with cardiovascular disease and implement preventive measures to help reduce the likelihood of developing the disease. It uses a comprehensive model of five core interventions to provide personalized care for patients with cardiovascular disease in the acute, recovery, and maintenance phases and throughout life, which includes pharmacological intervention, exercise intervention, nutritional intervention, psychological intervention (including sleep management) and smoking and alcohol cessation (6,7,14).

Clinical significance: Cardiac rehabilitation has been found to be effective in controlling cardiac symptoms, stabilizing or reversing the atherosclerotic process, reducing the physical and psychological effects of heart disease, and lowering the risk of sudden death. Research indicates that CR improves cardiovascular outcomes and overall health, reducing the incidence of recurrent myocardial infarction (15,16). Moreover, previous studies have demonstrated that CR can enhance medication adherence, increase exercise tolerance, improve cardiovascular risk factors such as blood pressure, lipid profile, blood glucose, and smoking, and improve psychological well-being. In addition, patients who underwent cardiac rehabilitation for a considerable time period had a reduced risk of cardiac mortality (17–20).

Economic influences: Studies conducted in Latin America have shown that cardiac rehabilitation is a cost-effective intervention and significantly reduces the high expenses associated with passive treatments (2). By adopting cardiac rehabilitation, individuals and healthcare organizations can save a considerable amount of money which makes CR a valuable contributor towards a healthier and more prosperous patient lifestyle.

Social influences: Anxiety and depression are frequently observed psychological symptoms in patients suffering from AMI. Cardiac rehabilitation programs have been shown to significantly reduce social and psychological symptoms like anxiety, depression, and general disinterest in daily routines (3). These programs help patients improve their quality of life, lifestyle, and psychological well-being.

Table 2: Significance of cardiac rehabilitation programs for AMI patients.

Type of significance	Examples
Clinical significance	Control cardiac symptoms, stabilize or reverse atherosclerosis, lower risk of sudden death, lower risk of reoccurrence of myocardial infarction, enhance medication adherence, increase exercise stamina, reduce cardiovascular risk factors such as smoking, blood pressure, lipid profile, diabetes, etc. Some studies indicated the positive influence of CR on AMI patients (15,16). A meta-analysis also indicated reductions in mortality associated with cardiovascular diseases, reoccurrence of cardiac incidents, and rehospitalizations in CR patients (21).
Economic significance	CR programs are cost-effective, reduce the high costs of passive treatment, and save long-term costs by preventing disease reoccurrence. A systematic review conducted to evaluate the cost-effectiveness of rehabilitation programs proved the economic significance of cardiac rehabilitation interventions compared to usual medical care. The exercise- based intervention proved to be much more economical compared to telehealth and other CR interventions (22).
Social significance	Improved quality of life, and reduced psychological effects of cardiac disease such as anxiety and depression experienced during and after treatment. A Cochrane review indicated significant improvements in quality-adjusted life years of AMI patients undergoing exercise-based randomized trials (23). Furthermore, a meta-analysis has shown that CR interventions significantly reduce anxiety and depression among AMI patients, resulting in a momentous impact on their lifestyle and overall quality of life (3).

Theories and models of cardiac rehabilitation

Participation in post-myocardial infarction management CR programs has been reported under par levels (28.0%) in the United Kingdom (UK) compared to other cardiovascular diseases, especially old age people, women, and patients with comorbid conditions. The UK Cardiac Rehabilitation Audit Report of 2019 found that 50% of patients had comorbidities, which strongly impacted compliance and participation in CR programs (24). Despite being a crucial cause of death in most European countries and the availability of best practices for cardiac rehabilitation, these countries still face challenges with regard to the active participation of cardiovascular patients in rehabilitation programs (7). Developing countries are at more risk of disability and mortality due to the non- existence or minimal existence of CR programs compared to high-income countries. One rehabilitation center exists for every 3.4 cardiac patients in developed countries even then patient participation is a challenging issue due to patient’s lack of interest. The clinicians’ lack of education and patients’ unwillingness due to lack of motivation, low awareness, and inconvenience in terms of time, travel, and costs are key barriers to the uptake of CR programs (2). The CR program may not work well or produce significant beneficial results because of insufficient involvement and lack of interest and motivation of patients in the program (25,26). Several theories and models suggest a positive change in behavior toward active participation in rehabilitation and posttreatment management programs.

Transtheoretical Model (TTM)s

The Transtheoretical Model (TTM) proposes that behavioral change is not an instant event but rather a gradual process. It emphasizes the importance of an individual’s decision-making ability and suggests that varying strategies should be used to help individuals develop and sustain healthy habits throughout their lives. The TTM model was utilized to evaluate the willingness of cardiac patients to modify their health behaviors concerning exercise routine, eating habits, and mental relaxation. It was found that a considerable number of patients were not willing to change their behaviors. However, those with a higher risk of cardiovascular illness were observed to be more willing to change (27).

The utilization of TTM for behavior change in women with osteoporosis has yielded promising results. Specifically, the implementation of this model has led to statistically significant improvements in self-efficacy, nutrition, walking distance, and overall process of change. These findings are particularly noteworthy given the challenges associated with promoting behavior change in individuals with osteoporosis. The TTM model is a valuable tool for healthcare providers seeking to improve outcomes in this population and warrants further investigation (28). An intervention study carried out on patients with chronic obstructive pulmonary disease (COPD) based on the TTM has shown notable improvement in compliance with rehabilitation, pulmonary function, and overall quality of life. The study’s outcome highlights the effectiveness of the TTM as a framework for enhancing COPD treatment outcomes, thereby improving the quality of life for COPD patients. The study results suggest that the TTM could be a valuable tool in enhancing the quality of care for COPD patients, by facilitating the adoption of healthy behaviors and improving patient outcomes (29). Similarly, a study was conducted to assess the effectiveness of TTM in the self-management of colorectal ostomy patients. The study found that the intervention group exhibited significant improvements in disease self-management compared to the control group. This highlights the potential of TTM in improving patient outcomes in this population (30).

Information motivation behavior skill (IMB) model

The IMB model is an intervention model that focuses on providing information, motivation, and behavioral skills to encourage certain behaviors. This model is scientifically rigorous and has found extensive application in the medical domain. The IMB model has been utilized in patient education for various medical conditions and has demonstrated significant benefits in enhancing patients’ lifestyles, quality of life, and treatment adherence.

Researchers conducted a study to evaluate the effectiveness of a mobile application in the exercise- based cardiac rehabilitation of patients with coronary artery disease. The study found that patients who received information based on the IMB model endorsed by the application showed significant improvement in exercise tolerance and adherence to the rehabilitation program, resulting in superior outcomes. This study highlights the enormous potential of mobile technologies in the field of cardiac rehabilitation (31). Adherence also improved due to IMB model-based intervention in a quasi- experimental study conducted on cardiovascular patients (32). The study conducted on Iranian patients who had undergone coronary artery bypass grafting also reported a significant increase in adherence to the intervention (33). Similarly, a telephonic intervention led by nurses aimed at motivating AMI patients to participate in rehabilitation resulted in higher attendance and low dropout rates for secondary sessions, proving to be a cost-effective strategy for behavioral change (34). The IMB model constructs have demonstrated a significant association with the health behaviors of South Korean women aimed at preventing metabolic syndrome. It is imperative to note that interventions based on the IMB model should be implemented to promote positive health behaviors (35).

Self-determination theory (SDT)

The theory of self-determination is based on people’s psychological growth and development of motivation. Of the several motivation theories, SDT is widely used in the field of cardiac rehabilitation and believes that the satisfaction of basic psychological needs and independent motivation is related to enthusiasm for performance.

The studies conducted in the United States of America (USA) examined the effect of SDT-based interventions on exercise behavior in patients with CR. Patients who had higher levels of psychological need satisfaction and self-determined motivation demonstrated a greater propensity for autonomous exercise (36,37). Another study evaluated the impact of psychological well-being of patients with exercise behaviour. The findings suggest that there is a significant relationship between exercise behavior, psychological well-being, and self-determined motivation and, therefore, addressing the psychological needs and promoting the self-determined motivation of CR patients during rehabilitation programs can lead to better outcomes (38). A recent study investigated how autonomy support, psychological needs satisfaction, and motivation contribute to physical activity in young adults with physical disabilities. The findings upheld the self-determination theory process model, revealing that when autonomy support is present, it leads to higher needs satisfaction, which in turn is associated with greater motivation and self-efficacy for physical activity (39).

The PRECEDE-PROCEED model

The PRECEDE-PROCEED model has been well-validated for its effectiveness in reducing depression and improving the quality of life. Healthcare professionals can evaluate health factors more comprehensively by using this model, leading to a more effective implementation of intervention strategies. An intervention study was conducted among patients who underwent CABG surgery, with the aim of improving their sleep quality based on the constructs of the PRECEDE- PROCEED model. The study successfully demonstrated a significant improvement in the quality of sleep among the patients (40). During the COVID-19 pandemic, a study was conducted on patients undergoing CR. The study endorsed the implementation of model-based interventions that aim to improve patients’ knowledge and behavior toward physical exercise (41). The model was also used to relieve depression and improve the quality of life in elderly patients with congestive heart disease. The educational intervention was developed based on the PRECEDE-PROCEED model which showed significant improvements in depressive symptoms and life quality of the elderly patients (42).

Family-Centered Empowerment Model (FCEM)

The Family-Centered Empowerment Model improves the quality of life of chronic illness patients by engaging and empowering family members/caregivers and providing them with the necessary knowledge and skills to manage their patients effectively. It is a highly effective model that enhances the quality of life for patients and their families. Additionally, it serves as a useful intervention model for healthcare providers, enabling them to cater to the healthcare needs of their patients in a better manner (43).

A clinical study confirmed that the model effectively improved the mental health of patients suffering from myocardial infarction. The study assessed psychological factors such as anxiety levels, perceived stress, and quality of life, both physically and mentally, using the model-based approach. The intervention group resulted in significant improvements in anxiety and stress symptoms, as well as overall health levels (44). Similarly, another intervention study improved the physical and mental health of myocardial infarction patients undergoing FCEM model-based cardiac rehabilitation. The study found that patients who underwent FCEM model-based cardiac rehabilitation experienced significant improvements in exercise tolerance, perceived stress, and state of anxiety compared to the control group (45).

Omaha System Theory

The Omaha System presents health problems to patients and develops care plans based on their condition, making clinical practice more standardized and quantitative. The system has been shown to improve the quality of care in both children and adults with cardiovascular problems (46). A study conducted has confirmed the feasibility of the Omaha system in patients after percutaneous coronary intervention (PCI). The implementation of this system has improved the quality of life of patients and their behavior toward medication compliance. After receiving sustained care for nine months, patients showed significant improvement in their adherence to medication, and the incidence of adverse events was considerably reduced (47). The implementation of the Omaha system-based nursing intervention for one year in stroke patients in China has also resulted in improvements in their ability to perform daily activities, overall quality of life, and a reduction in the number of falls (48).

Table 3: Theories/Models based studies to evaluate patients’ behavior change during rehabilitation.

Author (Year)	Country	Model/theory used	Disease	Study outcome
N. F. Eshah (2019) (27)	Jordan	Trans Theoretical Model	Ischemic Heart Disease	Patients with a higher risk of cardiovascular illness were willing to change their behavior.
Jeihooni et al (2018) (28)	Iran	Trans Theoretical Model	Osteoporosis	Improvements in self-efficacy, nutrition, walking distance, and overall process of change.
Chen et al. (2018) (29)	China	Trans Theoretical Model	COPD	Improved pulmonary functions, improved compliance, and better quality of life.
Wen et al. (2019) (30)	China	Trans Theoretical Model	Ostomy	Improvements in self-management of disease and process of change.
Shi et al (2022) (31)	China	IMB Model	Cardiac patients who received PCI	Improvement in exercise tolerance and medication adherence.
Zahmatkeshan et al. (2021) (32)	Iran	IMB Model	Cardiovascular patients	Increase in medication and treatment adherence.
Zarani et al. (2010) (33)	Iran	IMB Model	CABG	Improvement in psychological factors improved medication adherence in the intervention group.
Li et al. (2022) (49)	China	IMB Model	CHD	Improved cardiopulmonary function, increased physical fitness, and self-efficacy among patients.
Kim et al. (2023) (35)	South Korea	IMB Model	Metabolic syndrome	The IMB model components were considered crucial for developing interventions to influence health behaviors in effective disease management.
Russel et al (2009) (36)	USA	Self-determination theory	Cardiovascular disease	An increase in self-determined motivation in the intervention group resulted in improved participation in exercise routines.
Russel et al (2010) (37)	USA	Self-determination theory	Cardiovascular disease	Increased attendance in CR and improvements in exercise frequency and duration were observed after the model-based intervention.
Rahman et al. (2015) (38)	UK	Self-determination theory	Cardiovascular disease	The model-based intervention significantly improved psychological well-being which ultimately improved health behaviors among patients.
Saebu et al. (2013) (39)	Norway	Self-determination theory	Physical disability	The model-based intervention significantly increased patients’’ self-efficacy and motivation for physical activity.
Ranjbaran et al. (2015) (40)	Iran	The PRECEDE- PROCEED model	Sleep quality in CABG patients	Significant improvements were observed in the quality of sleep after the intervention.
Vanzella et al. (2022) (41)	Canada	The PRECEDE- PROCEED model	Cardiovascular disease	Endorsement of the implementation of model-based interventions that aim to

				improve patients’ knowledge and behavior towards physical exercise.
Wang et al. (2017) (42)	China	The PRECEDE- PROCEED model	Chronic heart failure	The model-based intervention effectively relieved depressive symptoms and improved the quality of life in the intervention group.
Raei et al. (2022) (44)	Iran	Family-Centered Empowerment Model	Myocardial infarction	Decreased stress and anxiety levels in the intervention group.
Vahedian-Azimi et al. (2016) (45)	Iran	Family-Centered Empowerment Model	Myocardial infarction	Improved physical and mental health.
Yin et al. (2022) (47)	China	Omaha System Theory	CHD	Increased medication adherence and reduced adverse effects in the intervention group.
Fang et al. (2022) (48)	China	Omaha System Theory	Stroke	Improvements in performing daily activities and a reduction in the number of falls.

COPD= Chronic obstructive pulmonary disease, PCI= Percutaneous coronary intervention, CABG= Coronary artery bypass graft, CHD= Coronary heart disease, IMB Model= Information motivation behavior skill model

Conclusion and Future Perspectives

There is a growing concern regarding the low adoption and inadequate compliance with cardiac rehabilitation programs globally. This issue has been a persistent challenge for healthcare providers and policymakers alike, as it has significant implications for the long-term health outcomes of patients with cardiovascular diseases. The success of rehabilitation programs, particularly in countries where the recovery rate of cardiac diseases, especially AMI, is lower than in developed countries, depends on the comprehensive understanding and professional knowledge of healthcare providers, as well as the positive behavior and motivation of patients. Therefore, it is imperative for the healthcare community to improve cardiac rehabilitation guidance for patients by offering comprehensive, scientific, model-based effective approaches, leading to greater heart recovery and associated benefits. The implementation of theory and model-based interventions has the potential to provide patients with increased adaptability, enhanced motivation, and improved adherence to rehabilitation. In the future, the integration of theories, and models with developing technologies, new devices, and information technologies may facilitate patients’ engagement in cardiac rehabilitation by addressing various challenges and barriers.

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