Cardiovascular diseases (CVDs) are disorders of the cardiovascular system and include a wide range of conditions that primarily affect the form and function of the heart and blood vessels compromising function in other body organs or systems. They are a leading cause of death worldwide with evidence reporting increasing prevalence, particularly, in developing economies (Wagner and Brath, 2011). Approximately 7.5 million CVD-related deaths (31% of all global deaths) were reported in 2012, with projected figure that will exceed 23 million by 2030  (World  Health  Organization,  2014). The burden of non-communicable diseases including CVDs is rising in sub-Saharan Africa, a region where 23% of the global prevalent rheumatic heart disease cases occurs (Global Burden of Disease Study, 2017). The increase in CVD-associated mortality in developing countries constituted over four-fifths of deaths recorded (Shariful Islam et al., 2014).

In Nigeria, non-communicable diseases were estimated to constitute 29% of all deaths, of which 11% were CVD-related (World Health Organisation, 2018). Not only has research indicated a rising prevalence of these diseases (Ike and Onyema, 2020; Osuji et al., 2014), but also escalating rates for their risk factors such as diabetes mellitus, hypertension, smoking and physical inactivity (Adeloye et al., 2017; Odili et al., 2020; Adedapo, 2017; World Health Organization, 2018; Assah et al., 2015).

The goal of CR is to modulate positively disease aetiology, in addition to ensuring the best possible physical, mental and social conditions for the cardiac patient, with a view to preserving or resuming as normal a place as possible in the community (Oldridge, 2012). The benefits of comprehensive CR for patients with CVDs include reduction in morbidity and mortality as well as significantly positively modifying CVD risk factors. It has also been shown to promote a healthy lifestyle thereby enhance quality of life (Anderson and Taylor, 2014).

Cardiac rehabilitation is, therefore, essential in ameliorating the growing burden of CVDs and in improving patient outcome (Anderson and Taylor, 2014). The literature has documented abysmally low comprehensive cardiac rehabilitation usage in resource-poor nations compared to usage in developed countries (Turk-Adawi et al., 2014). In spite of the growing burden of CVDs in these settings, cardiac rehabilitation services are available in only 8.3% of low income countries (Turk-Adawi et al., 2014). The important question is “what are the factors responsible for this trend?” Barriers to the provision or implementation of cardiac rehabilitation services previously documented include insufficient knowledge of CR (Nuhu and Gachi, 2021; Sérvio et al., 2019), lack of a comprehensive CR programme (Nuhu and Gachi, 2021), inadequate manpower and equipment (Nuhu and Gachi, 2021; Ragupathi et al., 2017), lack of resources to deliver CR (Sérvio et al., 2019), and lack of referral to CR (Ragupathi et al., 2017; Sérvio et al., 2019). This information was obtained from surveys and may miss important information as the experiences gathered may be incomplete opinions or thoughts about issues being explored (Berg and Lune, 2012). Qualitative research elicits an understanding of human conditions or situations in a variety of contexts in a manner perceived by the informants (Bengtsson, 2016). Going beyond selecting options in closed-ended questions by voicing the personal experiences of individuals from whom information is required can be more revealing than a survey as interviewees can freely express themselves based on knowledge and experience about the issue being explored. A qualitative approach was used because a detailed understanding of the interviewee’s subjective perspective of the barriers to practitioner implementation of cardiac rehabilitation to determine any important information not discerned in previous quantitative research is needed. Therefore, the objective of this study was to explore barriers to the implementation of cardiac rehabilitation services by healthcare professionals in a tertiary health facility in Kano, North-Western  Nigeria.   Such   information might contribute in helping stakeholders in the healthcare system to develop strategies that will initiate or improve its implementation.

A descriptive qualitative study design was used to obtain information from some of the healthcare professionals that constitute the cardiac rehabilitation team (cardiologists, physiotherapists and dietitians). These professionals (purposively sampled) were selected because they have the most contact and usually spend more time with the patients than other members of the team given their role in the phases of cardiac rehabilitation that promote community reintegration of the patients. Although sample sizes are determined on the basis of the information required in qualitative research so that the research question can be answered with sufficient confidence (Krippendorff, 2012; Patton, 2014), sizes ranging from 5 and 50 informants are commonly recommended (Dworkin, 2012). Thus, the unit of analysis being 10 is within this range.

A self-developed semi-structured interview guide, developed based on the potential barriers to cardiac rehabilitation services derived from the literature, was used. The guide comprised open-ended questions which were reviewed by two experts in questionnaire development and administration (to avoid ambiguity) before being piloted on three physiotherapists. Potential participants were approached during one of their weekly departmental meetings/presentations and only those that consented to be interviewed were included. Participants received an explanation of the study and then gave their written informed consent. They also consented to have the interview audio-recorded. Once consent was obtained, participants’ socio-demographic data (profession, work experience and age) were obtained via self-report and the interview commenced. The interview/discussion was initiated by asking the questions in the guide followed by further prompting questions. With the open-ended questions, participants freely explored the topic from a wide range of perspectives. Thus, a deeper understanding of the participants’ experiences and views was possible.

To establish data trustworthiness, we stayed as close as possible to the standards for reporting qualitative research (O'Brien et al., 2014). The accuracy of the transcripts was approved by both authors. After repeatedly reviewing the contents, they were broken down into primary semantic codes that were compared together, and the similar codes were categorized into subcategories. Cross-comparisons resulted in distilled subcategories, which were finally extracted as the main themes (Galvin, 2015).

Data analysis

The qualitative data were analysed using general inductive approach to content analysis, organising the themes derived into barriers to implementation of cardiac rehabilitation services. The audio recorded information was transcribed to texts which were read and re-read the transcripts to identify similarities (Stuckey, 2014) and themes were formed from the process of inductive analysis of the raw data. The analysis was undertaken by adhering to standard protocol for thematic analysis of qualitative data (Creswell, 2014). From the transcribed texts, we identified similar words or expressions which were classified into codes. The codes were grouped together to form categories with overlapping categories being collapsed to form themes. Any divergent views noted during the analysis were discussed in order to reach consensus.

Demographic characteristics of the informants

Three cardiologists, six physiotherapists and one dietician working at the Aminu Kano Teaching Hospital were interviewed. The age of the informants ranged from 32 to 39 years old with the mean being 35.6 years. Most of them were male individuals and had working experience ranging from 5 to 11 years (Table 1). Themes were classified as barriers to using or implementing cardiac rehabilitation in the facility. The two main themes that emerged are (1) professional issues/constraints and (2) management/policy issues. These themes and their related categories are listed in Table 2 and the transcribed interviews are shown in Appendix.

“There is discordance actually, if it were a team it would be better so that we can work together…… because only a dietician can prescribe the amount of calories a patient can take for weight reduction and for maintenance of weight………… that is why that team is necessary…………. (Dietician)

Lack of enabling environment

“I believe one of the barriers is not having………… adequate equipment and the work environment is not good”………….…. (Physiotherapist 1)

“The work environment is the cardiac rehab unit for members to come together and work. It does not exist! Unfortunately, our clients are missing the benefits of cardiac rehabilitation”………. (Physiotherapist 2)

The study was carried out to investigate the barriers to implementation of cardiac rehabilitation services in one of the major tertiary health facilities in North-Western Nigeria. To our knowledge, this is the first published work that has qualitatively investigated barriers to the use of cardiac rehabilitation among health professionals in a resource-constraint setting.

Strong evidence abounds detailing the efficacy of cardiac rehabilitation for individuals diagnosed with CVDs, patients with CVD-related events or procedures and those with a moderate to high risk of developing CVD (Buckley et al., 2017; Piepoli et al., 2014; Smith et al., 2011). In spite of this and the growing epidemic of CVDs, cardiac rehabilitation is scarcely available in developing countries. Poor funding was identified, inadequate skills were perceived, there was lack of awareness about the role of allied health professionals, lack of collaboration among professionals and most importantly, lack of facilities or a unit for cardiac rehabilitation or its unavailability as barriers to cardiac rehabilitation in the setting in question. Some of these factors are in line with the results of previous surveys (Sérvio et al., 2019; Ragupathi et al., 2017). Sérvio et al. (2019) revealed that failure to refer patients to a cardiac rehabilitation programme was related to lack of adequate awareness of the benefits of the programme on the part of physicians. Moradi et al. (2011) reported inadequate knowledge of cardiac rehabilitation among physicians as one of the factors influencing its utilisation which is incongruent to the present findings.

Most of the previous qualitative studies were conducted in advanced countries where cardiac rehabilitation was available and so investigation focused on the reasons for its underutilization such as patient lack of enrolment in the programme for fear of partaking in physical exercise, and logistical challenges (transportation, distance) as well as high cost of cardiac rehabilitation (De Vos et al., 2012; Jin et al., 2014; Sérvio et al., 2019).

Until we have functional comprehensive cardiac rehabilitation programmes, it will be impossible for us to categorically state that such factors as exercise phobia, knowledge, and income militate against the implementation of cardiac rehabilitation. Thus, the problem is ubiquitous and cardiac rehabilitation is substantially under-utilised worldwide (Laukkanen, 2015; Supervia et al., 2019; Turk-Adawi et al., 2019). While the issue, in developed countries, is underutilization, non-existence is what is generally encountered in resource-constrained settings.

The findings of the present study have indicated that an important barrier to the implementation of a team-oriented cardiac rehabilitation was lack of awareness about the crucial contribution of professionals, particularly those involved in non-pharmacological management. For example, the physiotherapist is a highly trained exercise and rehabilitation specialist who prescribes or structures, administers and supervises physical exercise (de Andrade et al., 2014) of varying modes. The physiotherapist is licensed to administer therapeutic exercise in the management of medical conditions including CVDs as well as to patients post-surgery. The physiotherapists that served as informants in the current study generally believed that healthcare professionals such as physicians and cardiologists were not aware of the role of physiotherapy in the management of patients with CVDs.

An important limitation of this study was that physiotherapists constituted the largest number of informants. As such, the findings were based mainly on the perspective of the physiotherapists. Future studies should balance the number of processionals; the other practitioners not included here should also be interviewed.

It was concluded that a comprehensive team-oriented cardiac rehabilitation programme was not available at Aminu Kano Teaching Hospital in Kano, North-Western Nigeria. The attention of the hospital management should be drawn to this important omission. Until we work as a team and effectively manage our patients with cardiac diseases, they will continue to miss the benefits of cardiac rehabilitation.

The authors have not declared any conflict of interests.