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Abstract

Young and middle-aged patients with coronary heart disease who have undergone percutaneous coronary intervention often find it difficult to participate in secondary cardiac rehabilitation. This study examines patient experiences in cardiac rehabilitation using health empowerment theory as a framework. Purposive sampling was used to collect data through semi-structured interviews, which were analysed using Colaizzi’s phenomenological approach. Five themes emerged from the data: (1) Personal growth, (2) Self-acceptance, (3) Life Purpose and motivation, (4) Social support, and (5) Utilisation of social services. The findings are consistent with all dimensions of health empowerment theory. The results of the study emphasise the importance of individualised empowerment and highlight the need to address the requirements for cardiac rehabilitation benefits, providing a new perspective for improving cardiac rehabilitation intervention programmes.

Keywords

coronary heart disease cardiac rehabilitation percutaneous coronary intervention health empowerment theory young and middle-aged

What do we already know about this topic?

Although the incidence of coronary heart disease is higher in young and middle-aged people, the participation and compliance rates for stage II cardiac rehabilitation in this group are relatively low.

How does your research contribute to the field?

Adopting a health empowerment theory perspective, this paper conducts in-depth research into the factors affecting the cardiac rehabilitation of young and middle-aged patients with coronary heart disease. It also provides a basis for improving cardiac rehabilitation intervention strategies.

What are your research’s implications towards theory, practice, or policy?

Research can confirm or refute existing theories, and contribute to their development. Medical professionals are recommended to adopt individualised empowerment strategies, tailoring cardiac rehabilitation intervention strategies according to patients’ preferences and needs, in order to improve participation and compliance.

Introduction

According to the Global Burden of Disease Study, coronary heart disease (CHD) remains the world’s leading cause of death,¹ posing a serious threat to human health. Among this group, the risk of CHD is particularly high in young and middle-aged people.^2,3 This means that the number of young and middle-aged patients undergoing percutaneous coronary intervention (PCI) and surviving the disease is increasing year on year. However, given the large number of patients, a complete treatment system should consider not only the surgical stage but also the postoperative rehabilitation stage to manage symptoms and prognosis.

Several studies have confirmed that cardiac rehabilitation (CR) can reduce hospitalisations related to coronary heart disease, as well as all-cause hospitalisation and mortality rates.^4
-6 It is therefore highly recommended in guidelines such as the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guidelines for managing patients with chronic coronary artery disease, and the 2024 ESC guidelines for managing chronic coronary syndromes.^7
-9 CR is typically categorised into 3 stages: Stage I, in-hospital rehabilitation; Stage II, outpatient rehabilitation; and Stage III, out-of-hospital long-term rehabilitation. Since the average hospital stay for Chinese patients is 7 days, stage II is the core stage of recovery for patients with coronary heart disease, as it is both a continuation of stage I and the basis of stage III.¹⁰ However, previous data show that patients’ participation in stage II cardiac rehabilitation is poor. Therefore, it is necessary to further explore the factors influencing the participation of young and middle-aged patients with CHD in cardiac rehabilitation.^11,12

The health empowerment theory was proposed by Professor Shearer in 2009.¹³ This theory posits that individuals can achieve health management goals by effectively integrating and applying personal and social resources, and by promoting behavioural changes in 5 areas: personal growth, self-acceptance, purpose of life, social support and social service utilisation. Among these aspects, personal growth refers to individuals’ self-growth and improvement by mastering health knowledge and skills. Self-acceptance refers to individuals’ ability to fully accept themselves and maintain a positive attitude towards life while acknowledging their strengths and weaknesses. Purpose of life refers to having life or health goals and feeling that life is meaningful. Social support refers to establishing good relationships with others and understanding the importance of giving and receiving in interpersonal relationships. Social service utilisation refers to having the ability to effectively use the material resources needed (eg, for managing health needs) and access the necessary services, as well as having the skills to promote problem solving.^14
-16 This theory has been widely used in the field of chronic diseases, such as cardiovascular disease and cancer, both at home and abroad.^17,18 It emphasises helping individuals to actively manage their diseases, thereby promoting behavioural change and ultimately achieving the desired health outcomes. Selecting health empowerment theory can help to identify the drivers and obstacles in the cardiac rehabilitation process. Through research findings, more effective cardiac rehabilitation intervention plans can be formulated to ensure the feasibility of intervention strategies.

In China, existing literature mainly focuses on quantitative research and the exploration of the psychological, spiritual and social factors affecting patient behaviour is limited and lacks theoretical support. Furthermore, many intervention programmes fail to explore patient needs, preferences and subjective experiences of CR in depth, which may result in low participation and adherence rates. Improving participation and adherence requires empowering patients and guaranteeing their right to advocate for interventions, as well as commitment from healthcare providers to make decisions with patients. Based on the theoretical framework of health empowerment, this qualitative study analyses the real feelings of young and middle-aged patients with CHD in 5 areas: personal growth, self-acceptance, life goals, social support, and utilisation of social services. This will provide valuable insights into improving CR interventions, participation rates, and adherence.

Method

Study Design

This descriptive qualitative study forms part of the research group’s comprehensive, large-scale scientific research project. The aim is to gain a thorough understanding of the real-world experiences of young and middle-aged patients with CHD in Phase II cardiac rehabilitation. The study will also provide valuable insights for developing CR interventions that improve patient participation and adherence.

Participants

From January to March 2025, young and middle-aged CHD patients from the cardiovascular medicine outpatient clinic of a tertiary hospital in Zhangjiakou City were selected as the research subjects. Purposive sampling was employed, taking into account factors such as age, educational attainment and comorbidities. The inclusion criteria were: Patients who met the diagnostic criteria for coronary heart disease in the 2018 edition of the ‘Guidelines for the Diagnosis and Treatment of Stable Coronary Heart Disease’¹⁹; patients who underwent PCI after coronary angiography; patients aged 18 to 59 years; and patients who voluntarily participated and signed the informed consent form. Exclusion criteria included patients with communication or cognitive impairments, patients unwilling to participate in interviews and patients who withdrew from the study for some reason. The study was conducted in accordance with the Declaration of Helsinki. During the recruitment process, one person refused to participate in the study because he refused to cooperate with the recording. In September 2024, when preparing the key R&D plan project in Zhangjiakou City, the necessary ethical approval materials were submitted and a provisional ethics approval number was obtained. After the project was filed in December 2024, the approval materials were revised and improved. Finally, the official ethics approval number (K2024195) was obtained. Saturation was derived from the encoding and analysis of the interview transcript of the 13th participant. No new topics or codes were generated in this process, and existing topics were enriched, indicating that the information had reached saturation standards. Consequently, we stopped recruiting new participants.

Interview Guide

Professor Shearer, an American nursing expert, developed a framework for health empowerment interventions to guide behaviour change and help individuals achieve health management goals. Combining this framework with the research content of the research group, this study defines personal growth as patients acquiring rehabilitation knowledge and mastering rehabilitation skills to achieve self-improvement and growth. Self-acceptance is defined as the patient’s acceptance of living with an illness and maintaining positive attitude towards life. Purpose of life is defined as the establishment and achievement of personal goals based on one’s preferences and needs. Social support is defined as assistance obtained from various sources, including family, friends, and institutions like hospitals. Social service utilisation is defined as the material resources needed by patients (eg, medical insurance or rehabilitation services) and access to the necessary services (eg, medical facilities or personnel) and skills to facilitate problem solving. The research team used the health empowerment theoretical framework to guide the development of the interview outline, consulting with experts in cardiology, cardiac rehabilitation and nursing to develop a first draft of the interview guide. Subsequently, two research team members (DXJ and JWX) conducted pilot interviews with 2 participants who met the inclusion criteria, in order to test the applicability of the interview guidelines. Based on participant feedback, additional questions on the topic of social service utilisation were added to the interview guide. See Table 1 for the full interview guide.

Table 1.

Questions Based on the Components of the Health Empowerment Theory.

Theoretical constructs	Questions
Personal growth	How much do you know about cardiac rehabilitation, and what knowledge or skills does it give you?
Self-acceptance	How do you view the state of living with illness, both positive and negative?
Purpose of life	What are your thoughts on life goals or health goals, can you talk about them specifically?
Social support	What individuals or institutions influence your persistence in cardiac rehabilitation?
Social service utilisation	What social services are available to you, including medical institutions or health insurance? What else do you need from a healthcare provider during cardiac rehabilitation?

Data Collection

Semi-structured interviews were conducted in the cardiac rehabilitation room and recorded using a voice recorder. The interviewers were 2 supervising nurses, who have both worked in clinical nursing for 15 years. One of the nurses is a woman with a master’s degree. The other is a man with a bachelor’s degree. Both nurses have extensive experience and have completed training in qualitative research courses. Neither nurse has any clinical relationship with the participants. Prior to the interview, they familiarised themselves with the participants’ medical histories via the medical record management system, facilitating the establishment of trusting nurse-patient relationships. Before the interview began, the interviewer explained the research background and purpose, privacy protection and participant rights, and the fact that the interview would be fully recorded, to each participant individually. After obtaining consent, the participants signed the informed consent form and completed the general questionnaire. Considering the patients’ actual conditions and psychological states, repeated interviews were not arranged in this study and the interview time was kept between 30 and 50 min. Only the interviewer and the participant were present during the interview. Based on the interview outline, the interviewer encouraged participants to openly share their real-life experiences and feelings about participating in CR. They ensured that the questions remained neutral and did not influence the responses. Additionally, the interviewer took note of non-verbal cues, such as the participants’ tone, expressions and movements, in the manuscript.

Data Processing

In order to protect participants’ information and data from leakage, the researchers anonymised the interview recordings and notes in order to prevent unauthorised viewing.

Data Analysis

The researchers analysed the data using the Colaizzi analysis method.²⁰ Data were derived from original interview recordings and note-taking manuscripts. Within 24 h, 2 researchers transcribed the recordings into text materials and combined them with the manuscripts to restore the participants’ true representations as much as possible. Subsequently, two researchers familiarised themselves with the text data and created the initial data encoding using Nvivo 14 software. Similar coded phrases were then grouped to identify potential topics, which were reviewed and named by the research group. Although individual members undertook the data analysis, the entire research group was supported throughout. Additionally, the topics of this study were derived from the collected data. After emerging, these topics were mapped to the dimensions of the empowerment theory to verify the connexion between the findings and the theory.

Improving the Credibility and Strategy of Data Analysis

To ensure the credibility of the data analysis, this study employs triangulation and member verification. This involves 2 researchers performing the initial coding independently, after which they reach a consensus on the grouping of the codes and generated topics. Any disagreements are arbitrated by a third researcher with more experience. To achieve member verification, the researchers returned the transcribed text data to some participants the next day, inviting them to provide feedback on and confirm the preliminary analysis results. This ensures the rigour of the research process and the accuracy of the results to a certain extent. This report is written in accordance with the Comprehensive Quality Reporting Criteria for Qualitative Research (COREQ),²¹ and a complete list is provided as Supplemental material.

Result

A total of 13 young and middle-aged patients with CHD participated in the study. The patients’ ages ranged from 35 to 59 years, with an average age of 48.23 ± 7.72 years. Three of the participants were women and 10 were men. To protect their privacy and information security, the participants were given codes ranging from P1 to P13. Table 2 summarises the additional characteristics of the participants who completed the interviews.

Table 2.

Participant’s Characteristics.

Characteristics(n = 13)	n (%)
Sex
Male	10 (76.92)
Female	3 (23.08)
Age, years
35-39	2 (15.38)
40-49	5 (38.46)
50-59	6 (46.15)
Marital status
Married	12 (92.31)
Divorced	1 (7.69)
Education level
Primary school and below	2 (15.38)
Junior high school	5 (38.46)
Undergraduate	6 (46.15)
Medical insurance
Employee medical insurance/commercial insurance	8 (61.54)
Urban medical insurance	5 (38.46)
Primary caregiver
Spouses	4 (30.77)
Sons and daughters	1 (7.69)
No caregiver	8 (61.54)
Comorbidity
0	2 (15.38)
1	5 (38.46)
2	5 (38.46)
≥3	1 (7.69)

The collected text data contained multiple perspectives, resulting in 41 phrase codes. These were classified into 10 potential topics, of which the research group identified 5 after an in-depth examination. These topics were then subdivided into 10 sub-topics (see Table 3). This theme coincides with all dimensions of health empowerment theory and plays an important role in the cardiac rehabilitation of young and middle-aged patients with coronary heart disease following PCI.

Table 3.

Summary of Identified Themes and Subthemes.

Main theme	Sub-theme	Codes
Personal growth	Correct cognition and good adherence	Exercise every day
	Correct cognition and good adherence	Take medicine on time
	Poor adherence due to cognitive biases	Fear of movement
		Self-reduce the dosage of medicine
		Continue to smoke and drink as usual
Self-acceptance	Two sides of self-acceptance	It didn’t have much of an impact
Self-acceptance	Two sides of self-acceptance	I feel useless
Life purpose and motivation	The polarity of life goals	In order to create better living conditions for children
Life purpose and motivation	The polarity of life goals	Life is plunged into darkness
Social support	Good social support promotes recovery	exercise partner
	Poor or lack of social support hinders recovery	A colleague offered me a cigarette No one supervises
	Poor hospital travel hinders recovery	The queue is too long
Social service utilisation	Effective use of social services	Participated in lectures on CHD
	Social services are underutilised	I didn’t dare to ask questions about medication
	The need for cardiac rehabilitation benefits is unmet	Want to know the benefits of cardiac rehabilitation

Theme 1: Personal Growth

Correct Cognition Leads to Consistent Compliance

Having the right understanding of CR can improve patients’ cooperation and compliance with treatment. The report shows that some participants formed a correct understanding of CR after grasping the core content, and adhered well to the rehabilitation treatment. For example, they voluntarily exercise and take their medication. This demonstrates that participants have not only acquired knowledge and skills related to CHD but have also achieved significant personal growth, as evidenced by the following quote:

‘Yes, I learned last time that long-term sitting after PCI only increases the risk of disease recurrence, and proper exercise helps with recovery.’ Therefore, I play badminton every morning for more than 30 minutes at a time, and I feel sweaty afterwards.’ (P2)

‘I understand the importance of taking medication. Yes, it is essential to keep taking the medication. I take every medicine on time. Not taking the medication on time can lead to a worsening of the condition and the need for a stent, which will be more expensive.’ (With a serious expression; P7)

Poor Adherence Due to Cognitive Biases

A lack of knowledge about CR can restrict patients’ understanding of the process and their ability to participate effectively. This can result in cognitive biases regarding exercise, medication, tobacco and alcohol use, and poor compliance with treatment. For example, patients may experience a fear of exercise or privately reduce their drug doses, which affects their ability to improve during the rehabilitation process. Typical descriptions can be found in the following introduction:

‘Well, I just had a PCI. The nurse asked me to exercise, but I was afraid that it would dislodge the stent, so I didn’t do it.’ (P5)

‘The doctor asked me to take antihypertensive drugs three times a day. I tried to reduce the dose. I have reduced the number of times I take them at night and think it is better to take antihypertensives twice a day.’ (Laughs smugly; P8)

‘After the PCI, I continued to smoke and drink alcohol as usual. I drink a bottle of liquor every four to five days. However, the doctor asked me to quit smoking and drinking. It was too painful for me. I feel that my life is meaningless without drinking or smoking.’ (P4)

Theme 2: Self-Acceptance

Two Sides of Self-Acceptance

According to the data, some participants have gradually adapted to CHD and have become more optimistic about managing the condition long term. This positive psychological state indicates that they have accepted living with the disease and are more likely to follow medical professionals’ guidance, have more confidence in their rehabilitation and experience greater well-being. This is reflected in the following quote:

‘Well, even though I had PCI surgery, it didn’t affect my daily life or work much. In my spare time, fishing by the river is still my favourite activity.’ (P3)

‘During the acute onset, I felt severe chest pain and was quite nervous. Now that I am in the recovery period with a doctor’s guidance, I am full of confidence in my recovery.’ (P10)

In addition, when negative events such as PCI surgery caused participants to adapt to an unfamiliar and uncomfortable environment, they became less optimistic about their life situation and displayed negative attitudes such as complaining and pessimism. This may affect patients’ participation in and adherence to cardiac rehabilitation, which in turn affects clinical outcomes. This is reflected in the following introduction:

‘In 2013, I was diagnosed with coronary heart disease and had two stents inserted. In 2021, I had three more stents inserted. This year, doctors said my blood vessels were 99% clogged, but I have finally found a suitable stent. For me, this has been a series of setbacks, and the bad luck has all come at once.’ (P13)

‘Now, I feel like a useless person, worried about the side effects of stents every day, panicking and uninterested in doing anything.’ (P5)

Theme 3: Life Purpose and Motivation

The Polarity of Life Goals

Having a clear goal can stimulate a patient’s intrinsic motivation and encourage them to implement the CR programme more effectively. In turn, the broad benefits of rehabilitation will encourage participants to set new, achievable goals. Participants generally said that young and middle-aged people are at the stage in life where hard work is required. They all expressed clear life or health goals, which also became a driving factor in CR. The following quote illustrates this:

‘Yes, through nurses’ education, I am confident that I can achieve the following: reduce my consumption of unhealthy food, do more physical exercise, control my blood lipids, and strive for a speedy recovery.’ (P1)

‘In fact, I was in the prime of my life. To create better living conditions for my children, I will continue to work hard.’ (P3).

However, some participants spoke of their lack of purpose and motivation in life, and said that they were not interested in much. This may directly affect their interactions with others and with the outside world, which in turn interferes with CR programmes. The following quote describes this situation:

‘Although PCI surgery relieved my chest pain symptoms, I often felt flustered after the operation. I couldn’t find anything interesting to do, I felt that life was meaningless, and I couldn’t see any hope.’ (P5)

‘Ever since I had the PCI surgery, I’ve been feeling unwell all over, with a strong sense of frustration, and my life seems to have fallen into a gray gloom.’ (P12)

Theme 4: Social Support

Good Social Support Promotes Recovery

Good social support can serve as a ‘booster’ for CR. Participants mentioned that support from partners and family members can boost confidence, encouraging active participation and persistence in rehabilitation. The following answers illustrate this:

‘I have a regular sports partner and we meet downstairs every day to play badminton. His company and encouragement have given me great support, and now I no longer experience asthma symptoms when climbing stairs.’ (P2)

‘My sister is a nurse and has a lot of medical knowledge. Since finding out that I had been diagnosed with CHD, she has often called me to remind me to take my medication on time, exercise more and reduce my alcohol consumption. These concerns from my family have helped me a lot and made me more confident in my recovery.’ (P3)

Poor or Lack of Social Support Hinders Recovery

Social customs in China, such as delivering cigarettes and drinking wine together, have led to a resurgence of bad behaviour. This poor social support contributes to relapse, which has a negative impact on CR. The following introduction explains this in detail:

‘I knew that smoking was bad for my health, so I quit while I was in hospital. After I was discharged, someone at work handed me a cigarette and I couldn’t resist the temptation, so I started smoking again.’ (P13)

‘I am a contractor and socialise with my peers, all of whom rely on ‘wine table culture’ to maintain our relationships. I know this is not good for my health, but I can’t help it.’ (P11).

In addition, a lack of social support can lead to a failure to complete CR. This means that people are more likely to slack off when coping with CR if they lack social support. The following answers explain this phenomenon:

‘I am a long-distance driver who often drives between Yunnan, Guizhou and Sichuan. I don’t even have the conditions to eat on time, let alone ensure normal working hours and rest periods. It is very difficult to persist with CR without supervision.’ (P6)

‘I think CR is something that only people with plenty of time can do. My work is already very demanding, and I want to rest when I occasionally have some free time. Moreover, no one will supervise me.’ (P4)

Poor Hospital Travel Hinders Recovery

Participants also shared their experiences of travelling to the hospital, including the difficulty of parking and congestion caused by the increase in outpatient numbers. This had an adverse effect and hindered confidence in continuing with CR. The following answers illustrate this obstacle:

‘Every time I drive to the hospital for rehabilitation, there is a queue stretching from the hospital entrance to the Changqing Road intersection. I was stuck there for two hours; it was so inconvenient.’ (P1)

‘The hospital campus is too small and has too few parking spaces. My car can’t even drive to the admissions area. Even if you enter the campus, there are no parking spaces. It’s not worth being stuck in traffic at the hospital entrance for hours just to do rehabilitation.’ (P10)

Theme 5: Social Service Utilisation

Effective Use of Social Services

The report shows that effective use of social services drives CR. It can save participants from worrying about the cost of treatment and help them to retain their knowledge of coronary heart disease. The following answers provide an explanation:

‘Yes, I am an insurance beneficiary. I have both employee medical insurance and commercial insurance, both of which have a high reimbursement ratio, so I don’t worry about the cost of treatment.’ (P9)

‘We were invited to participate in a CHD lecture organised by the hospital. During the lecture, the nurse taught us how to manage the condition, including dietary recommendations. They also used food models, which we found particularly impressive.’ (P7)

Social Services are Underutilised

The data showed that participants did not make full use of social services. This is often reflected in limited access to essential services, such as educational materials on popular science provided by medical institutions, and professional guidance on CR provided by healthcare professionals. The following answers illustrate this situation:

‘There are many information boards in the Department of Cardiovascular Medicine. Because I was in a hurry for examinations and surgeries, I didn’t read them carefully until I was discharged from hospital.’ (P12)

‘The doctor prescribed me a lot of medicine, and I was worried that taking multiple drugs would harm my body, but I didn’t dare ask the doctor questions.’ (P11).

In addition, under the influence of traditional Chinese beliefs, the male role is often associated with strength and masculinity, making men more inclined towards resistance training such as rowing and weightlifting. In contrast, aerobics is viewed as a flexibility exercise, typically led by and attended by women. Male participants often perceive it as an activity ‘for women only’, leading to feelings of discomfort and embarrassment towards this specific form of exercise.

‘During my hospital stay, the nurses taught me how to do aerobics. But that’s something for women—I felt quite awkward doing it as a man. I think it varies from person to person, so I wanted to ask if there were other exercises more suitable for me. However, seeing how busy they were with their work, I didn’t feel comfortable bothering them again.’ (P10)

The Need for Cardiac Rehabilitation Benefits is Unmet

The report suggests that medical professionals provide insufficient information on the benefits of rehabilitation, despite participants having a strong demand for CR benefits. Participants prefer to receive authoritative answers from medical professionals in order to quickly fill knowledge gaps and return to work. This helps patients stay motivated to recover. The following responses reflect this situation:

‘Well, I learned about CR from the doctor, but they only mentioned/suggested it and didn’t explain its efficacy or benefits. I wish they had been more specific.’ (P4)

‘I didn’t know anything about medicine or CR. Later, the doctor recommended it to me during rounds, but did not explain its benefits. I thought that if it worked, I would do it a few more times so that I could recover as soon as possible and return to work. I still have a backlog of cases to deal with.’ (Eager facial expression; P13)

Discussion

Based on the health empowerment theory, this study explores the factors affecting stage II CR for young and middle-aged CHD patients after PCI. The results support the theory’s expectations, expand its corresponding dimensions, and illustrate the close connexion between the empirical and theoretical. The findings suggest that medical professionals should provide more personalised empowerment strategies during secondary CR to improve patient engagement and compliance. These strategies include knowledge and skill transfer, psychological counselling, and improving social service utilisation. These findings emphasise the important role of patients in the recovery process, contributing to the optimisation of intervention regimens and better health outcomes. Therefore, personalised empowerment strategies can help to optimise and improve intervention programmes, thereby improving rehabilitation outcomes.

Gain the Knowledge and Skills to Achieve Personal Growth

Participants’ mention of behaviours such as a fear of exercise and unauthorised reduction of medication doses provides rich empirical details about the personal growth dimension of health empowerment theory, reflecting biases in their perception of CR. Such misperceptions increase the risk of cardiovascular disease recurrence, which in turn affects rehabilitation adherence. This is consistent with previous findings.²² This finding also suggests that cognitive biases are a major barrier to CR participation and adherence rates, highlighting the need for healthcare professionals to improve health education. In order to address these biases and enhance adherence, medical professionals are encouraged to adhere to the 2021 ESC Clinical Practice Guidelines: Cardiovascular Disease Prevention, as well as the scientific statements of the American Heart Association and the American Cardiovascular and Pulmonary Rehabilitation Association,^23
-25 to educate and guide patients. Help patients acquire knowledge (eg, which foods help control blood lipids)²⁶ and skills (eg, how to choose exercises that ensure both intensity and safety) relating to medication, exercise, nutrition and tobacco use, and at the same time encourage them to establish and maintain an awareness of active rehabilitation. Encourage them to actively participate in rehabilitation treatment so they can continuously improve their personal abilities and ultimately achieve personal growth.

Provide Psychological Counselling and Accept ‘Surviving With Illness’

Participants mentioned that due to a series of discomforts following PCI surgery, they are not optimistic about their current state of living with chronic illnesses. This formulation transcends the boundaries of the self-acceptance dimension of positive attitudes towards life, deepening the diverse manifestations of the theory in the experience of living with chronic disease. This is consistent with Pan’s findings.²⁷ It suggests that medical professionals should pay attention to the emotional experience of this group, understand the reasons for these feelings and use acceptance and commitment therapy as a strategy to support acceptance of the disease and psychological adjustment in this population.²⁸ Through a conservative and controlled approach, patients can be taught to express their discomfort, accept the new environment after PCI surgery and gradually improve their adaptability. Ultimately, patients can be guided to accept reality and move towards a more positive life. Additionally, studies have demonstrated a positive correlation between family support and self-acceptance,²⁹ indicating that patients with robust family support exhibit a higher level of acceptance of the disease. Therefore, family members should create an inclusive environment for patients, provide the necessary understanding and support, and help them learn to live with the disease and adapt to life with a positive attitude.

Define Life Purpose to Stimulate Latent Motivation

The participants’ descriptions of their lack of life purpose and motivations further enrich the connotation of the life purpose dimension in the empowerment theory. This reflects their acceptance of external arrangements in rehabilitation practice and their lack of personal goals, which weakens their sense of agency in the rehabilitation process and can easily lead to frustration and hinder the effectiveness of CR programmes. This is similar to Kim’s research.³⁰ This finding highlights the primary role of patients in the recovery process, suggesting that they are the experts who truly understand their own experiences and needs. Their input is therefore crucial in setting goals and improving plans.³¹ To address the issue of lacking life purpose, it is recommended that medical professionals collaborate with patients to develop short-term goals that are easily achievable and based on evidence-based treatment strategies and patient preferences, while ensuring patient autonomy is respected. For instance, they could gradually increase their jogging exercise from 15 to 30 min per week. Achieving this goal can confirm the patient’s efforts, enhance their subjective initiative and continue to stimulate motivation. This motivation has the potential to contribute significantly to participation in and adherence to CR, thereby enhancing rehabilitation outcomes.

Enhance Social Support and Optimise the Medical Experience

The findings of this study on the impact of poor and lacking social support on empowerment theory expand the connotation of the social support dimension. The poor social support can lead to a return to negative behaviour. According to reports,³² cigarette delivery and wine-drinking culture are still common ways of socialising in China. Many patients know that smoking and drinking alcohol hinder recovery, but due to emotional factors, they tend to accept passively rather than actively refuse. This suggests that medical professionals should guide patients to abandon harmful social practices and encourage them to reject behaviours that harm their health. Furthermore, policymakers should take action to limit their use by imposing mandatory controls on tobacco and alcohol, such as raising excise taxes on tobacco and alcohol.³³ In addition, a lack of social support may mean that patients do not have adequate coping mechanisms to overcome difficulties, which hinders the recovery process. This is consistent with the results of Beleigoli’s study.³⁴ Social support is an important part of empowerment theory and a key goal of CR intervention. Therefore, we recommend that medical professionals provide professional guidance and that family or friends provide encouragement and emotional support, to enhance patients’ ability to cope with rehabilitation challenges and improve outcomes. Furthermore, traffic congestion provides a more contextual understanding of the social support dimension,³⁵ and the difficulty and time-consuming nature of parking more accurately reflects the complexity and diversity of the CR process. This suggests that hospital managers should consider making changes from the patient’s perspective to solve the traffic congestion dilemma. This includes encouraging employees to travel sustainably, adding temporary drop-off points, and so on, in order to optimise the medical travel experience and promote the effective development of CR.

Improve Utilisation and Meet Demand for Benefits

This report’s findings on the underutilisation of hospitals or healthcare professionals correspond to access to necessary services in the social service utilisation dimension. This finding provides a basis for confirming the theory. Previous studies have shown that underutilisation of social services weakens cardiac rehabilitation.³⁶In order to improve the utilisation rate of social services, hospital managers should provide patients with accessible popular science materials for easy browsing. Medical professionals should undergo doctor-patient communication training to recognise and respond to patient needs, even if they are not clearly expressed.³⁷ This efficient communication style is expected to enhance patient engagement and improve adherence to rehabilitation programmes. Additionally, the benefits sought in CR align with the material resources required by individuals in terms of social service utilisation. This is consistent with Xia’s findings.³⁸ The desire for benefits may be the main motivator that stimulates patient adherence to CR. To meet this demand, medical professionals should provide information on the benefits and safety of CR when initially discussing rehabilitation options with patients, including improving cardiorespiratory fitness and returning to work,^39,40 to ensure patients have access to reliable information. Hospital managers should establish channels to encourage patients to seek advice, such as online consultation services, so that patients can access professional guidance at any time.

Conclusion

Thirteen young and middle-aged CHD patients who had undergone PCI were interviewed in depth based on the health empowerment theory. The aim was to explore the factors affecting participation and compliance in CR and to inform the improvement of the phase II CR intervention plan. The research confirms the complex correlation between health empowerment theory and CR experience. All dimensions of the theory are consistent with the findings. The results of the study emphasise the importance of individualised empowerment and suggest that meeting the needs of CR benefits is key to improving and optimising CR intervention programmes and increasing participation rates and compliance.

Strengths and Limitations of the Study

Guided by the theory of health empowerment, this study explores the views of young and middle-aged CHD patients on stage II CR after PCI. The results provide a new perspective on the subsequent phase II CR intervention plan, which is crucial for improving CR participation and adherence rates. However, the study has some limitations. First, the sample is gender imbalanced. It should be noted that gender is a key factor affecting participation in secondary CR. Previous studies have shown that women often have lower referral, enrolment, and programme completion rates for cardiac rehabilitation than men.⁴¹ Therefore, the results of this study should be interpreted with consideration of the uneven sex distribution. To date, women remain underrepresented in CR research.⁴² To enhance the practical guidance value of the findings, future studies need to include more women. Secondly, the generalisability of the findings may be limited because the samples were recruited from the same hospital. It is recommended that the sample size and scope of selection be expanded in future studies to comprehensively investigate participants’ views and experiences of CR.

Supplemental Material

sj-docx-1-inq-10.1177_00469580261427100 – Supplemental material for Individualised Empowerment in Secondary Cardiac Rehabilitation in Patients With Coronary Heart Disease: A Qualitative Study

Supplemental material, sj-docx-1-inq-10.1177_00469580261427100 for Individualised Empowerment in Secondary Cardiac Rehabilitation in Patients With Coronary Heart Disease: A Qualitative Study by Xiaojuan Ding, Jing Bai, Weixing Jiang, Yunxia Li and Sanming Zhang in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

We would like to appreciate all the participants in this study for their strong supports.

ORCID iD

Xiaojuan Ding

Ethical Considerations

The study received ethical approval from the Ethies Committee of the First Affiliated Hospital of Hebei North University, code K2024195.

Consent to Participate

Written and oral informed consent was obtained from all participants.

Author Contributions

Xiaojuan Ding: conceptualisation, methodology, investigation, formal analysis, project administration, supervison, writing-original draft, writing-review and editing; Jing Bai: software; data curation, writing-original draft; Weixing Jiang: investigation, data curation, resources; Yunxia Li: investigation, formal analysis, visualisation; Sanming Zhang: resources, project administration, writing-review and editing. All authors have reviewed the manuscript. These authors contributed equally to this work.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Key Research and Development Programme Project of Zhangjiakou City (Key R&D Programme Project of Zhangjiakou; No. 2421049D). No funding was received for this study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.

Supplemental Material

Supplemental material for this article is available online.

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