Effectiveness Cardiac Rehabilitation Strategies in Saudi Arabia

Effectiveness of Home-based Cardiac Rehabilitation strategies for Saudi Arabia’s elderly

residents living with chronic conditions during the Covid 19 epidemic

1.0 Introduction

1.1Background Information
Cardiac Rehabilitation (CR) is an intervention based on evidence which applies health behavior
modification, exercise training and patient education to boost secondary curbing results in
patients suffering from cardiovascular disease (CVD). Programs developed for CR practice bring
down the rates of mortality and morbidity in elderly individuals who suffer from heart failure,
cardiac surgery or heart disease (Haukilahti et al., 2015 p.54).. However, such programs are yet
to be optimally applied. Currently the CR programs in Saudi Arabia are only applied in few
cardiac patients. Therefore, new delivery strategies are needed urgently to enhance patient
participation. Home-based CR is among the possible strategies. The Saudi Arabia Kingdom
(KSA) is faced with ever increasing rate of mortality caused by the cardiovascular diseases
(CVDs), especially among the elderly patients, as well as the prevailing rate of coronary heart
disease (CHD). CHD has been found to cause many deaths from CVDs in Saudi Arabia (Thomas
et al., 2019 p.34). The analysis of the data on the stated rates of epidemiology forecasts an
increase of these rates which is brought about by more exposure to risk factors that cause CVDs.
The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVR) and the
National Institute for Clinical Excellence (NICE) records that patients’ participation in phase III
cardiac rehabilitation (CR) programs is can significantly reduce mortality and morbidity rates in
elderly CHD patients due to Percutaneous Coronary Intervention (PCI) or Coronary Artery


Running gead: Effectiveness Cardiac Rehabilitation Strategies
Bypass Surgery (CABG) (Thomas et al., 2019 p.34). Unfortunately, there is no phase III offer of
CR for elderly patients in KSA. This state is made worse by the emergence of the Covid-19
epidemic across the world which has made it almost difficult for governments to give healthcare
services to other patients. There is a dire need to establish strategies that will be used to offer
effective home-based care to patients with CVDs in Saudi Arabia (Al Muallem, et al., 2015
p.34). Therefore this study shall seek to assess the effectiveness of home-based cardiac
rehabilitation strategies for the elderly patients with chronic conditions during Covid 19
1.2 Problem Statement
Towards the close of 2019, novel corona virus (Covid-19) which is highly infectious emerged as
a world pandemic with millions of cases getting reported across the world. Since Covid-19 is a
highly infectious disease affecting the respiratory system, strict measures have been imposed by
various world governments to curb its spread. In Saudi Arabia, the government has imposed
measures such as restricted movements or the famous “stay home” initiative. Consequently
provision of Home Based Cardiac Rehabilitation for elderly patients suffering from chronic heart
diseases has been greatly impacted by this pandemic. In response, strategies have been
formulated to ensure that HBCR is offered to such patients. However, the home based cardiac
rehabilitation programs have not yet been optimally applied especially during this period of
Covid 19 pandemic.
1.3 Objectives
The research aims at assessing the effectiveness of HBCR for elderly patients in Saudi Arabia.
The main objectives of this study are;


Running gead: Effectiveness Cardiac Rehabilitation Strategies
i. To assess the effectiveness of Home-based Rehabilitation strategies for Saudi Arabia’s
elderly residents with chronic conditions during the Covid 19 epidemic
ii. To highlight and discuss how the emergence covid 19 has affected the provision of Home
based cardiac Rehabilitation
iii. To evaluate the current strategies applied in HBCR
1.4 Thesis Structure
1.4.1 Research Questions
i. Are the HBCR strategies effective for elderly patients with chronic CVDs
ii. What is the scope of the existing HBCR strategies
iii. What are the impacts of Covid 19 on provision of HBCR
1.4.2 Hypothesis
1. Covid 19 affects the effectiveness of provision of home-based cardiac rehabilitation
2. HBCR strategies are effective for elderly patients with chronic Cardiovascular Diseases

2.0 Literature Review

2.1 Introduction
In spite of the rising cases of cardiovascular diseases (CVDs) among the elderly patients,
apparently there is a string bias in the rehabilitation and CVDs treatment that comprise of several
preventive strategies. Information contained in Ades and colleagues and many other institutions
shows that CVD elderly patients are less possibly to be referred to cardiac rehabilitation


Running gead: Effectiveness Cardiac Rehabilitation Strategies
programs which are formal. Even if they are referred, they usually experience very poor
compliance to the programs because of lack of strong inputs on recommendations by the
referring doctors. In most health institutions in Saudi Arabia, such as King Faisal Specialist
Hospital and Research Center, routine referrals of elderly patients for cardiac rehabilitation are
done; however, just a half of these referrals are attended frequently as compared to patients who
are of younger age (Ponikowski et al., 2014). Nonetheless, a number of caregivers have reported
remarkable results of “formal phase II cardiac rehabilitation and exercise-training program on
obesity indexes, plasma lipids, quality of life (QOL), behavioral characteristics, and exercise
capacity, comprising sub groups of elderly patients who are above 75 years of age and women
who are older” (Sheehy, 2020 p.19462).
2.2 Theoretical Review
Healthcare services on cardiac rehabilitation are the major and crucial constituent in the
continued care for elderly patients suffering from cardiovascular diseases (CVDs).
Recommendation of the class IA, medical referrals to cardiac rehabilitation registers 1 out of 9
measures of performance for prevention (secondary) as established by the American Heart
Association and American College of Cardiology following; coronary artery bypass graft
surgery, percutaneous coronary intervention or myocardial infarction (MI) or symptomatic
peripheral arterial disease (intermittent claudication) or in the setting of stable angina. Cardiac
rehabilitation referrals are also done following cardiac transplantation, setting in of chronic heart
failure (HF) with lowered ejection fraction or valve surgery. CR referrals following MI is the
“defect-free care” section strategy performance involved in the Centers for Medicare and
Medicaid services in the agreement core set of cardiovascular performance strategies Haukilahti
et al., 2015 p.54).. The effectiveness and safety of the conventional clinically monitored, Center-


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based Cardiac Rehabilitation (CBCR) model are strongly founded, and CBCR is thus effective in
lowering readmissions to hospitals, mortality and morbidity in elderly patients suffering from
CVDs as well as secondary events (Quait et al., 2017 p. 100).
Conversely, the implementation and effect of CBCR in Saudi Arabia has been considerably
slowed by significant underutilization by eligible elderly patients. Information from various
databases and registries show that even though CBCR referral, talking in overall terms, is
improving, participation by eligible elderly patients is still low in most of the sub-elderly groups.
Participation is particularly reduced among the beneficiaries of Medicare, women and elderly
persons from underserved populations such as the ones from those within the lower
socioeconomic stratum, the ones who are underinsured or uninsured. Clearly state-of-the-art
delivery strategies are required urgently for a bigger percentage of elderly patients in Saudi
Arabia who currently do not take part in cardiac rehabilitation. Among the most promising
approaches is the alternative site or popularly known home-based cardiac rehabilitation (HBCR),
that can be implemented in different settings such as nonclinical settings including parks, health
clubs and community centers or home setting which is the most appropriate during Covid 19
pandemic (Haukilahti et al., 2015 p.54).. Conceptually, HBCR can possibly aid in addressing
most of the challenges which CBCR programs have been facing such as logistical, geographical
as well as other access-related challenges. Even though home-based exercise training is usually
advocated for by CBCR staff for their CVD patients during occasions when they are physically
absent from the centers, outstanding HBCR programs are yet to be fully explored and strategized
to effectively provide care for elderly CVD patients. Nonetheless, NICE guidelines on CVD
prevention suggests “home-based cardiac rehabilitation with or without telemonitoring is
promising the increment of the participation and supporting behavioral change. Additionally,


Running gead: Effectiveness Cardiac Rehabilitation Strategies
Cochrane and colleagues reviews on cardiac rehabilitation have conclusively proposed that “low-
to moderate-strength evidence that CBCR and HBCR” register same impacts on quality of life as
well as cost among elderly patients who in the recent past were diagnosed of revascularization or
MI (Haukilahti et al., 2015 p.54)..
HBCR single application or coupled with CBCR offers a potential alternative which can enhance
CR provision to elderly patients in Saudi Arabia. HBCR has been integrated into the Medicare
systems of many countries such as Australia, United Kingdom, Canada among others. HCBR
bears many advantages including the potentiality to overcome most logistical challenges such as
scheduling barriers and transportation, which have been main challenges in programs of CBCR.
Moreover, it has the possibility of expanding the depth and breadth of counseling, educational as
well as monitoring of opportunities for elderly patients since HBCR services cab likely be used
throughout (Thomas et al., 2019 p.34). In contrary CBCR programs are normally time-bound –
about 3 to4 hours in a week. Since most elderly patients with CVDs take more than 5000 hours
walking every year, without the help of health workers, it is crucial to equip them with
behavioral change strategies which can be done in their home as well as community
environments. Nevertheless, HBCR implementation encounters considerable challenges in Saudi
Arabia; most noteworthy is a deficient reimbursement by the Centers of Medicaid and Medicare
services as well as tertiary players. Interestingly, a recent research on the CR-eligible elderly
patients indicates that most of them prefer home-based than Centre-based approach
(Montgomery et al., 2013 p.65).


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2.3 Empirical Review
Lavie and Milanie (2004), state that the major common symptom among the elderly patients with
CVD events is depression with a point prevalence of 18%. Such elderly patients experience
lower HDL levels, lower QOL scores somatization, hostility and reduced exercise capacity.
When cardiac rehabilitation was carried out in these patients, they registered a 57% lowering of
the prevalence of depression scores (p<0.0001) and more than 32% boosts in their quality of life
scores and also recorded enhancements in exercise “capacity, HDL as well as other CVD risk
factors (p 33). Even though elderly is commonly defined as more than 65 years, most health
experts concur that most of the patients between 65 and 75 years are somehow young, less
information is available for extremely elderly patients. CVD patients who are very elderly going
home-based cardiac rehabilitation have been found to register improvements to significant levels
of plasma lipids, such as summed cholesterol (-5%; p=0’01), low-density lipoprotein (LDL)
cholesterol (-6% p = 0.04) HDL (+6%; p = 0.05), triglycerides (-16%; p<0.001), as well as a
LDL/HDL ratio (-8%, p = 0.02) and also gradual improvements in approximated exercise
capacity (+39%; p = 0.00001). Such improvements showed to be more in elderly patients (Sipilä
et al., 2019 p. 300)
Elderly patients with chronic CVD conditions, especially elderly women, are possibly the rapidly
growing portion of the population in society and in health practices of cardiovascular, this
segment of the society is likely going to be the least referred to and be provided with cardiac
rehabilitation programs. For many parameters, boosts after cardiac rehabilitation are statistically
same in the elderly patients as compared to other patients. Nonetheless, elderly patients have
recorded great improvements in obesity indexes due to home-based cardiac rehabilitation such as
body mass index (-2% vs 0%; p < 0.03), percentage of body fat (=10%; -5%; p < 0.01). The


Running gead: Effectiveness Cardiac Rehabilitation Strategies
boosts in the weight of the body are specifically remarkable because obesity is apparently the
strongest risk factor in elderly women. Various literature based performed experiments support
the positive results of strength training and aerobic exercise training in generally enhancing
quality of life and physical fitness. Notably, elderly patients taken through particular strength
training enhanced their upper extremity strength, social QOL as well as physical QOL. In deed
support strength training and physical exercises points to the effectiveness of home v=based
cardiac rehabilitation (Haukilahti et al., 2015 p.654). The major segments of HBCR found to be
effective with elderly patients with CVD include; dietary counseling, exercise training, patient
education and assessment, behavioral activation such healthy eating habits, physical activity and
smoking cessation, risk factor control including hypertension, diabetes mellitus, obesity and lipid
abnormalities as well as psychological interventions. Such intervention components can easily be
implemented at home even in the absence of monitoring by health care providers (Haukilahti et
al., 2015 p.654).
2.4 Conceptual Framework
Intervention Target behaviors intermediate outcomes Secondary Prevention Goals

Exercise training

Dietary education

Medication Management

Tobacco Counseling

Psychological Assessment

Exercise Capacity,
Cardiovascular symptoms
Body mass index, Waist
Blood pressure, Glycemic
control, lipid levels
Tobacco use

Anxiety, Depression

Physical fitness
functional capacity
Quality of lise

Cardiovascular events
Adverse events cost and
resource use

Physical Training

Healthy Living

Smoking Cessation

Stress management


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2.5 Summary
The discovery that cardiac rehabilitation services, especially can safe lives and yet they are
underutilized points to the urgent need of coming up with new approaches to supplement the
provision of CR services. Generally, effectiveness of HBCR is attributed to various components.
Interventions constituting dietary counseling, exercise training, psychological support, weight
management lipid management and blood pressure management as well as healthy lifestyle, have
been established to greatly enhance the QOL of elderly patients with CVDs. However,
determination of most beneficial and the best components of the HBCR interventions is made
difficult by the length and intensity of the program, patient characteristics as well as the delivery
mechanisms. HBCR offers a promising alternative option in provision of CR services for stable
low-to moderate risk elderly patients with CVD especially in this period of Covid 19 pandemic.

3.0 Methodology

Research methods refer to the techniques and tools utilized in carrying out a research and a range
of tools which are applied for various enquiry types. Different research methodologies are
available including qualitative, quantitative as well as mixed methods
3.1 Design
This research will utilize a qualitative research design through collection of primary data. The
selected participants will be requested to voluntary give their experiences which relate to their
feelings of the provision of home based cardiac rehabilitation particularly after the onset of
Covid 19 pandemic. Such experiences shall be collected, documented and eventually subjected
to analysis. The research participants will comprise of CVD elderly patients, health care


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providers as well as administrators. In addition, researcher’s experiences acquired through
participatory observation will also be considered for analysis.
3.2 Setting
The research shall be conducted in respective homes and community centers where CVD elderly
patients are residing in Riyadh and its environs. The city of Riyadh hosts several elderly patients
with CVD and the number keep increasing as indicated in the world health organization (WHO)
database. Such numbers, although spread likewise across the world, are becoming more
prevalent in Saudi Arabia and especially in Riyadh. This renders the city a percent study area for
this research.
3.3 Sampling
Purposive sampling technique will be adopted by this research. The researcher shall judge who
to participate among the elderly CVD patients in their various homes or in a community center.
Various homes and community centers will be identified and then the researcher shall visit the
identified places and select the participants.
3.4 Research Instruments
A questionnaire which is well structured shall be used as an instrument for gathering primary
data. The questionnaire will comprise of two sections. The first section is for entering the
demographic data of the respondents such as Sex, Age and years with CVD. The section is
crucial because it will give the age of the participants and indicate how long the patient has been
suffering from CVD. The other part will consists of different research questions framed to


Running gead: Effectiveness Cardiac Rehabilitation Strategies
provoke responses on the experiences related to the effectiveness of home based cardiac
rehabilitation strategies since the onset of Covid 19 pandemic.
3.5 Data Collection Procedure
Various means can be employed in collecting primary data such as online distribution of
questionnaires, hand delivery as well as using google documents. This research project shall opt
for the use of hand delivery means since the participants are mostly elderly people hence need of
personal touch. Filled up research questionnaires from respondents will be picked with the help
of research assistants. The responses will be cleaned, documented and subjected to analysis.
3.6 Data Analysis
The collected data shall be subjected to descriptive data analysis mode of evaluation. The data,
after collection, shall be coded and entered into software for analysis. In particular SPSS data
analysis will be opted for and then the data will be translated into such measures of variability as
skewness, kurtosis, and central tendency.
3.7 Ethical Considerations
Research ethical considerations will be considered during the conduct of the research. Such
considerations shall include upholding the confidentiality of every personal detail of the
participants. In addition, the participants will be informed concerning their consent before
participating. The aim and the objective of the study will be made known to the participants and
their freedom to choose to participate and withdraw before and during participation. Lastly,
every crucial approvals and licenses shall be sought and any fee required shall be given out
before the onset of this research.


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