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Cardiac rehabilitation services for people in rural and remote areas: an integrative literature review.

INTRODUCTION
Morbidity and mortality from heart disease continues to be high in Australia with cardiac rehabilitation (CR) recognised as best practice for people with heart disease. CR is known to reduce mortality, reoccurrence of heart disease, hospital readmissions and costs, and to improve quality of life. Australian Aboriginal and Torres Strait Islanders (Australian First Peoples or Indigenous peoples) have a greater need for CR due to their higher burden of disease. However, CR referral, access and attendance remain low for all people who live in rural and remote areas. The aim of this integrative review was to identify barriers, enablers and pathways to CR for adults living independently in rural and remote areas of high-income countries, including Australia.


METHODS
Studies were identified through five online data bases, plus reference lists of the selected studies. The studies focused on barriers and enablers of CR for adults in rural and remote areas of Australia and other high-income countries, in English peer-reviewed journals (2007-2016). A mix of qualitative, quantitative and mixed method studies were reviewed through a modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), followed by a critical review and thematic analysis.


RESULTS
Sixteen studies were selected: seven qualitative, four quantitative and five mixed method. Five themes that influence CR attendance were identified: referral, health services pathways and planning; cultural and geographic factors necessitating alternative and flexible programs; professional roles and influence; knowing, valuing, and psychosocial factors; and financial costs - personal and health services. Factors identified that impact on referral and access to CR were hospital inpatient education programs on heart disease and risk factors; discharge processes including CR eligibility criteria and referral to ensure continuum and transition of care; need for improved accessibility of services, both geographically and through alternative programs, including home based with IT and/or telephone support. Also, the need to ensure that health professionals understand, value and support CR; the impact of mental health, coping with change and competing priorities; costs including travel, medications and health professional consultations; as well as low levels of involvement of Australian First Peoples in their own care and poor cultural understanding by non-Australian First Peoples staff all negatively impact on CR access and attendance.


CONCLUSION
This study found weak systems with low referral rates and poor access to CR in rural and remote areas. Underlying factors include lack of health professional and public support, often based on poor perception of benefits of CR, compounded by scarce and inflexible services. Low levels of involvement of Australian First Peoples, as well as a lack of cultural understanding by non-Australian First Peoples staff, is evident. Overall, the findings demonstrate the need for improved models of referral and access, greater flexibility of programs and professional roles, with management support. Further, increased education and involvement of Australian First Peoples, including Indigenous health workers taking a lead in their own people's care, supported by improved education and greater cultural awareness of non-Australian First Peoples staff, is required.