Facilitators and Barriers to Adherence to Home-Based Cardiac Rehabilitation Exercise in Patients with Chronic Heart Failure: A Qualitative Study

Abstract

Background

Chronic heart failure (CHF) is a major global health burden. Home-based cardiac rehabilitation (HBCR) is an effective alternative to center-based programs but suffers from low patient adherence, with influencing factors within the Chinese context being underexplored.

Objective

To explore perceived facilitators and barriers to HBCR exercise adherence among Chinese patients with CHF using the Information-Motivation-Behavioral Skills (IMB) model.

Methods

A descriptive phenomenological qualitative study was conducted at a tertiary hospital in Guangzhou, China. Semi-structured interviews were performed with 22 CHF patients (NYHA I–III). Data were analyzed using Colaizzi’s seven-step method, and themes were mapped onto the IMB model.

Findings

Three IMB dimensions emerged: Information (lack of exercise knowledge; rehabilitation misconceptions); Motivation (perceived benefits, need for professional guidance, social support, poor physical perception, inertia, habit-driven motivation); Behavioral skills (active planning, self-regulation, symptom monitoring). Notably, family support - particularly from adult children - was a culturally specific facilitator, while equating daily labor with structured exercise was a unique barrier.

Conclusion

Adherence to HBCR is shaped by interlinked information, motivational, and behavioral skill deficits. Clinically, providers should (a) correct culturally rooted misconceptions using plain-language education, (b) involve family members as active supporters, (c) provide post-discharge cues to action via digital platforms, and (d) teach concrete self-regulation skills. These actionable strategies can improve long-term adherence in Chinese CHF patients.

Introduction

Chronic heart failure (CHF) represents a severe, irreversible cardiovascular disorder manifested by dyspnea, exercise intolerance, and fluid retention, which contributes to considerable global cardiovascular morbidity and mortality.¹ Globally, an estimated 64.3 million individuals suffer from heart failure, while the number of affected adults in China exceeds 12 million.^2,3 Driven by population aging and the growing prevalence of cardiovascular risk factors including hypertension, diabetes mellitus, and obesity, the epidemiological burden of CHF is projected to continuously increase worldwide.⁴

Home-based cardiac rehabilitation (HBCR) has been designated as a Class IA therapeutic recommendation for standardized CHF management.^5,6 Relative to institution-based rehabilitation protocols, HBCR yields comparable therapeutic effects in ameliorating exercise tolerance, psychological status, and health-related quality of life, alongside a reduction in hospital readmission rates.⁷ Furthermore, HBCR mitigates travel-related expenditures, time costs, and economic burdens for patients, rendering it a cost-effective and patient-centered rehabilitation modality.⁸ Nevertheless, HBCR adherence among patients with CHF remains unsatisfactory globally, which substantially limits rehabilitative efficacy.⁹ Evidence indicates that fewer than 50% of HBCR patients comply with the recommended exercise frequency of three sessions per week.¹⁰ Additionally, adherence gradually declines over time following hospital discharge, with the adherence rate decreasing by approximately 30% within six months after discharge.¹⁰ Accordingly, sustained exercise compliance constitutes a core prerequisite for optimizing CHF rehabilitation management.

Current scholarship pertaining to cardiac rehabilitation adherence predominantly adopts quantitative methodological designs, focusing on identifying demographic and clinical predictive indicators through standardized questionnaire instruments.^11,12 Such quantitative approaches possess inherent limitations in capturing patients’ intrinsic cognitive perceptions, emotional fluctuations, and context-specific behavioral barriers embedded within familial and social milieus. Moreover, the majority of existing evidence originates from Western cultural populations. In the Chinese cultural context, CHF patients’ rehabilitative behaviors are uniquely shaped by indigenous health beliefs, family decision-making mechanisms, accessibility of community healthcare services, and individualized health information acquisition behaviors. Such cultural disparities cannot be adequately reflected in Western-centric quantitative research frameworks.

The Information-Motivation-Behavioral Skills (IMB) Model was employed as the theoretical framework for the present investigation (Figure 1). Conceptualized to elucidate health-related behavioral modification mechanisms, the IMB model categorizes determinants of behavioral adherence into informational cognition, internal and external motivational drivers, and behavioral skill mastery, collectively facilitating the maintenance of sustained health behaviors.^13,14 This theoretical model has been widely validated in cardiovascular rehabilitation research, offering a rigorous logical framework to interpret how patients acquire rehabilitative knowledge, sustain exercise motivation, and master self-management competencies for long-term rehabilitation adherence.¹⁵ Given its robustness in interpreting individual cognition and contextual behavioral influencing factors, the IMB model is uniquely applicable for exploring HBCR behavioral patterns among Chinese CHF patients. Utilizing semi-structured qualitative interviews, this study aims to explore the authentic experiences, perceived barriers, and facilitators associated with HBCR adherence among Chinese CHF patients. The findings of this study intend to provide in-depth contextual interpretations of HBCR adherence behaviors, supplement subtle influencing factors overlooked in quantitative investigations, and generate empirical evidence for the development of culturally tailored intervention strategies to enhance long-term rehabilitation compliance within the CHF population.

Figure 1.

Conceptual Diagram of the IMB Model.

Materials and Methods

Study Design

A descriptive phenomenological qualitative design was employed in this study. Descriptive phenomenology was selected as the most appropriate methodological approach, as it enables researchers to bracket preconceptions while capturing the essence and meaning of a shared lived experience, thereby allowing the phenomenon under investigation to emerge naturally.¹⁶ This approach is particularly suitable for obtaining direct descriptions of participants’ perceptions, feelings, and interpretations of their experiences with home-based cardiac rehabilitation exercise, with minimal researcher interpretation. The study design and reporting were conducted in accordance with the Standards for Reporting Qualitative Research (SRQR) to ensure methodological rigor and transparency.¹⁷

Study Setting

This study was conducted at The First Affiliated Hospital of Guangzhou Medical University, a tertiary academic teaching hospital located in Guangzhou, Guangdong, China. The Department of Cardiovascular Medicine at this institution is a Guangdong Provincial Key Clinical Specialty and a national training center for coronary interventional therapy, with extensive clinical and academic influence in South China. The department comprises 62 inpatient beds, including 5 coronary care unit (CCU) beds, and serves an annual outpatient volume of more than 60,000 visits.

Participants

The eligibility criteria for participants were as follows: (i) met the CHF diagnostic criteria recommended by the 2016 European Society of Cardiology Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure;¹⁸ (ii) aged 18 years or older; (iii) clinically stable following standardized treatment, with New York Heart Association (NYHA) functional class I–III; (iv) able to communicate clearly and describe their experiences; and (v) received a physician’s prescription or advice to perform home‑based cardiac rehabilitation exercise after discharge, or had a clear self‑initiated plan to engage in such exercise. This criterion ensured that participants had relevant experience or intentions regarding home‑based exercise, allowing them to share meaningful facilitators and barriers based on their pre‑admission exercise history or post‑discharge expectations. Participants who were critically ill (requiring cardiac monitoring), had mental or cognitive disorders, or had a history of heart transplantation were excluded.

Sampling and Recruitment

This study employed purposive sampling to ensure diversity in age, gender, disease duration, NYHA class, and residence (urban vs rural), with sample size determined by data saturation. All participants were recruited prior to hospital discharge. Eligible patients with CHF were identified and referred by advanced practice nurses in the cardiovascular inpatient department. Additionally, study recruitment posters were placed in inpatient wards, briefly outlining the study purpose and providing the research team’s contact information, enabling interested patients to contact us directly. For hospitalised patients, the advanced practice nurses explained the study and emphasised that participation was entirely voluntary, that declining to participate would entail no penalty, and that clinical staff would not be informed of the patient’s decision.

During the recruitment period, 28 patients met the inclusion criteria. Of these, six declined to participate (two cited lack of interest, one felt too fatigued, one had scheduling conflicts, and two did not provide a reason), yielding a refusal rate of 21.4%. The final sample thus comprised 22 participants.

It is important to acknowledge that conducting interviews before hospital discharge may have introduced social desirability bias. Participants who were still hospitalised and dependent on nursing care might have felt inclined to provide responses they believed would be viewed favourably by healthcare providers, especially regarding their intentions to adhere to home‑based cardiac rehabilitation after discharge. Such bias could result in overreporting of motivation, planned exercise frequency, or confidence in rehabilitation. Consequently, while the findings reflect participants’ stated intentions and expectations prior to discharge, they may not fully capture post‑discharge behavioural realities. Readers should interpret the results with this limitation in mind.

Data Collection

Interviews were conducted from March to May 2025. The initial interview guide was developed based on a comprehensive literature review and team discussions aligned with the research objectives. To ensure the scientific rigor and appropriateness of the formal interviews, a pilot test was conducted with two participants prior to the main study. The pilot focused on assessing the clarity of question wording, the logical flow of the question sequence, and the estimated interview duration. Based on insights gained from the pilot test and subsequent re-consultation with experts, the preliminary interview guide was further refined and finalized. The content of the final interview guide is presented in Figure 2.

Figure 2.

Outline of the semi-structured interview.

Semi-structured interviews were conducted by researchers, both trained in qualitative methodology and proficient in relevant interview techniques. Interviews took place in the department’s demonstration room, a quiet environment ensured to be free from interruptions. Before the interview, participants were informed of the voluntary nature of their participation and assured that refusal to participate would not affect their medical care. Anonymity and strict confidentiality were guaranteed. Following the provision of informed consent, the formal interviews commenced. The interviews revolved around the research theme and were audio-recorded in their entirety. When participants expressed uncertainty about questions, appropriate explanations were provided without the use of leading or suggestive language. Participants were not interrupted unnecessarily, while their facial expressions and body language were observed and recorded. Each interview lasted between 30 and 60 minutes.

Data Analysis

Within 24 hours after each interview, the audio recordings were independently transcribed verbatim by two researchers who were not involved in the interview process. The transcripts were further refined by incorporating notes taken during the interviews. Upon completion, the transcripts were returned to the respective participants for verification and confirmation. Data were analyzed using Colaizzi’s seven-step method.¹⁹ The process included: 1.Immersing oneself in the data through repeated and careful reading of all transcripts; 2. Identifying and extracting significant statements; 3. Formulating meanings from significant statements; 4. Coding recurrent viewpoints; 5. Clustering themes and developing detailed descriptions; 6. Continuously comparing themes and descriptions, aggregating similar viewpoints to refine and define the final themes; 7. Returning the thematic structure to the study participants for verification, integrating any new information that emerged during this member-checking process into the final, detailed description.

In cases of disagreement during the analysis, the research team engaged in collective discussion to ensure rigor and consensus, ultimately refining the final themes.

Ethics

This study was conducted in accordance with the guidelines of the Declaration of Helsinki. It was reviewed and approved by the Ethics Committee of The First Affiliated Hospital of Guangzhou Medical University (Approval No. ES-2025-K036). Written informed consent was obtained from all interviewees before the formal interview, including the publication of anonymized responses.

Rigor

The study’s methodological rigor was maintained by adhering to Lincoln and Guba’s framework of trustworthiness, which encompasses credibility, dependability, confirmability, and transferability.²⁰ To strengthen credibility, several strategies were employed, such as sustained engagement with the data, participant validation (member checking), and the practice of having multiple researchers perform independent coding. All interviews were carried out by investigators skilled in qualitative methods. A team-based approach was used where one researcher facilitated the interview while a second acted as a non-participant observer, meticulously documenting the process without intervention. Following each interview, a member check was performed to verify and corroborate the collected data.

Reflexivity was considered throughout the research process. The first author was a female nursing master’s student with three years of nursing experience, including clinical internships in cardiology wards. This background facilitated rapport building and contextual understanding of participants’ accounts of heart failure and exercise. However, to minimise potential bias stemming from her positive belief in exercise rehabilitation, she maintained reflexive memos after each interview, documenting personal assumptions and emotional responses. Regular debriefing sessions were held with a second researcher (another nursing master’s student) and a faculty supervisor, who reviewed coding decisions and challenged interpretive biases. Participants were explicitly informed that the researcher was independent of their clinical care team, reducing the likelihood of socially desirable answers. During analysis, two researchers coded independently and met regularly to resolve discrepancies through consensus.

Results

Characteristics of Participants

A total of twenty-two patients with chronic heart failure were ultimately enrolled in this study and were assigned identifiers from P1 to P22 based on the interview sequence. The mean age of the participants was 60.91 years (range, 35–81 years). Among them, 12 were male and 10 were female; one was unmarried and one was widowed. The disease duration ranged from 3 months to 16 years. All 22 interviewees were interviewed once, with each session lasting between 26.12 and 68.74 minutes, culminating in a total interview duration of 891.46 minutes. The transcribed text amounted to 147,000 Chinese characters. The interviewees’ basic information is presented in Table 1.

Table 1.

General Information of the Interviewees (n = 22)

Code	Gender	Age (Years)	Education Level	Occupation	Marital Status	Disease Duration (Years)	NYHA Class	Residence	Comorbidities
P1	Male	38	High School	Driver	Unmarried	0.3	III	Rural	Yes
P2	Male	35	Junior High	Self-employed	Married	1	I	Urban	Yes
P3	Female	69	Primary School	Farmer	Widowed	5	II	Urban	Yes
P4	Female	79	Primary School	Retired	Married	2	II	Urban	Yes
P5	Female	73	Bachelor’s	Retired	Married	16	I	Urban	Yes
P6	Female	55	Junior High	Worker	Married	1	II	Urban	Yes
P7	Male	72	Technical School	Retired	Married	1	I	Township	Yes
P8	Female	53	Primary School	Self-employed	Married	0.5	I	Urban	Yes
P9	Male	69	Technical School	Retired	Married	1	I	Urban	Yes
P10	Female	54	Bachelor’s	Accountant	Married	1	I	Urban	Yes
P11	Male	70	High School	Retired	Married	5	II	Urban	Yes
P12	Female	74	Junior High	Retired	Married	0.5	I	Urban	No
P13	Male	61	Junior High	Retired	Married	2	I	Urban	Yes
P14	Female	61	Primary School	Retired	Married	1	III	Urban	Yes
P15	Male	73	High School	Retired	Married	2	I	Urban	Yes
P16	Male	50	Associate Degree	Civil Servant	Married	1	I	Urban	Yes
P17	Male	54	Technical School	Worker	Married	1	I	Urban	Yes
P18	Female	62	Junior High	Retired	Married	1	I	Urban	No
P19	Female	59	High School	Teacher	Married	3	I	Urban	No
P20	Male	55	Primary School	Farmer	Married	5	III	Rural	Yes
P21	Male	65	Associate Degree	Farmer	Married	3	II	Rural	Yes
P22	Male	81	Bachelor’s	Retired	Married	2	II	Urban	Yes

Abbreviation: NYHA, New York Heart Association functional classification.

Main Findings

Based on the Information-Motivation-Behavioral Skills (IMB) model, three core dimensions were derived: Information factors, Motivation factors, and Behavioral skills factors. These three dimensions did not exist independently, but interacted dynamically and influenced each other to jointly shape patients’ exercise adherence. A thematic model summarizing the relationships among themes is presented in Figure 3.

Figure 3.

Factors Influencing Adherence to Home-Based Cardiac Rehabilitation.

Theme 1: Information Factors

Information deficits directly undermine motivation; without knowing what is safe, patients develop fear. Accurate information alone, however, cannot guarantee adherence if behavioral skills are absent.

Lack of Exercise Knowledge

Inadequate knowledge of exercise type, intensity, safety, and implementation directly reduced patients’ willingness to initiate and sustain exercise. Many participants expressed fear of adverse events due to uncertainty about safe exercise parameters.

I used to run every morning, but last week I became extremely short of breath, felt my heart would jump out, and broke out in cold sweat. I heard heart attacks are caused by intense exercise. Will I be in danger if I run after discharge? Just thinking about it scares me. (P20)

I feel short of breath halfway through walking, and my legs are severely swollen. The doctor told me to stop exercising. My heart function is poor; exercise consumes too much energy, and I worry my body cannot bear it. (P9)

Insufficient Rehabilitation Cognition

Patients showed clear misconceptions about exercise rehabilitation, including inappropriate exercise selection, resistance to low-intensity exercise, and an oversimplified understanding of therapeutic exercise. Some participants equated daily activities such as biking for transportation or doing household chores with structured rehabilitation exercise, underestimating the need for a targeted, progressive exercise prescription. Others believed that medication alone was sufficient and that exercise provided little additional benefit, reflecting a narrow view of disease management.

I did pull-ups and sit-ups downstairs every day to build muscle, which I thought was good. But I fainted and was hospitalized. The doctor said resistance exercise is too intense for me. I am not interested in other exercises like Tai Chi—it requires too much thinking and effort, and I do not want extra pressure. (P7)

I know exercise is important, but when you’re sick, medicine comes first. Just walking every day isn’t going to make me better. (P21)

I don’t like walking. My exercise is riding the shared bikes downstairs. I ride them every day when I go out—it’s convenient, and that counts as exercise, right? (P11)

Theme 2: Motivation Factors

Motivation is ignited by information and sustained by skills. Conflicts between positive motivators (perceived benefits) and negative motivators (poor physical perception) are often resolved through behavioral skills. Over time, repeated success can turn conscious motivation into automatic habit.

Perceived Benefits of Exercise

Perceived physical and psychological improvements—including better sleep, appetite, bowel function, stress relief, and improved physiological indicators—served as strong internal motivators for long-term adherence.

I found that after exercise, I eat well, sleep well, and have smooth bowel movements the next day. Exercise brings many benefits, so I must keep it up. (P6)

I walk and do exercises every day. My body feels much more comfortable. During my recent follow-up ultrasound, the doctor said I am recovering well. Exercise really helps my disease. (P14)

I kept swimming for six months, lost about 10 kg, and my blood lipids returned to normal. Exercise really makes a difference. (P2)

Jogging is interesting; it clears my mind, activates my thinking, and relieves stress and worries. (P16)

Professional Guidance

Many patients wanted to improve their health through exercise but lacked knowledge and skills, expressing a strong desire for professional guidance from healthcare providers.

I saw online that three bedtime movements can relieve foot swelling. I followed the video lying down, but it felt meaningless, and I persisted only intermittently. (P13)

My health is poor. I want to get better, so I walk with others, but I feel tired after walking too much and sometimes do not want to go. (P8)

Social Support

Family supervision, peer companionship, and social encouragement significantly promoted exercise adherence.

A friend as overweight as me lost more than 10 kg by swimming. He took me to swim, and we supervised each other to persist. (P2)

My long-time friends often invite me for morning tea. After eating, we walk in the park and sometimes practice Tai Chi. (P3)

Sometimes I feel too tired and want to skip exercise. But my husband always takes me out. I know it is for my health, so I have to listen (smile). (P10)

My daughter will take me to Northern Shaanxi this year, where there is a lot of mountain climbing. I must prepare in advance, so I walk every day. (P14)

Perceived Poor Physical Perception

Chest tightness, shortness of breath, cough, and other discomforts after exercise reduced motivation to continue.

After walking for 10 to 20 minutes, I feel chest tightness and have to stop immediately. (P5)

My husband wants me to jog in the morning, but I cannot. My heart function is poor, and I feel breathless when running. (P10)

When my cough is severe, I do not go out and rest at home. (P4)

Inertia

Laziness and low initiative were common barriers to consistent exercise behavior.

I am lazy. I tried exercising but could not persist. It feels boring. I prefer watching TV or using my phone at home. (P11)

I am a bit lazy. I will not exercise alone unless friends invite me. (P3)

I am relatively lazy and can only persist intermittently. (P19)

Habit-Driven Motivation

Patients with high adherence emphasized that exercise had become an automatic habit; breaking the routine caused physical and psychological discomfort.

I am used to walking after meals. If I do not go out, I feel uncomfortable. (P5)

I exercise in the park every day, even when it rains. I feel unwell these days in the hospital without exercising. (P14)

I have always had a habit of exercising, probably because I was a dance teacher when I was young. I feel uncomfortable if I stop. (P18)

Theme 3: Behavioral Skills Factors

Behavioral skills bridge intention and action. Even motivated patients with correct information may fail to adhere if they lack skills to adjust intensity or monitor symptoms. Skills develop through practice and feedback, which in turn reinforce motivation.

Active Planning

Patients who recognized the importance of exercise actively planned routines and sought community resources to manage their condition.

I used to run a lot but got too tired. I want to learn swimming and plan to go once or twice a week. (P10)

A retired doctor practices Tai Chi downstairs. Since my illness, I join them every morning. I have no choice because my health is poor. (P12)

Self-Regulation

Many patients intended to adjust exercise modes according to physical tolerance and prioritize disease management after discharge.

Thinking about how serious I was that day, almost losing my life, I must persist in exercise to gain confidence for myself and my family. (P6)

After discharge, I will not do pull-ups or push-ups anymore. I will switch to walking. High-intensity exercise may do more harm than good. (P7)

I must squeeze time for exercise even if busy. After this experience, I dare not neglect it. (P2)

Symptom Monitoring

Patients learned to recognize warning signs (fatigue, shortness of breath, palpitations) and adjust intensity accordingly.

When I feel too tired, I stop at slight warmth. Comfort is the most important. (P4)

My daughter-in-law bought me a sports bracelet to monitor heart rate. During square dancing, I check it and rest if my heart beats too fast or I feel chest tightness. (P6)

I set a goal of walking until slight sweating. If I feel flustered, I slow down or sit to rest before continuing. (P7)

Discussion

Using a qualitative descriptive phenomenological design, this study examined perceptions, experiences, and determinants of exercise adherence to home-based cardiac rehabilitation among Chinese patients with chronic heart failure. Patients’ accounts demonstrate that adherence is a dynamic, iterative process shaped by information access, motivational forces, and behavioral skills for self-management. Grounded in the IMB model, three interlocking core dimensions and associated sub-themes were identified, illustrating how knowledge gaps, misconceptions, internal and external motivation, and self-regulatory competencies collectively shape adherence. Whereas prior qualitative research has largely focused on Western cohorts or clinic-based rehabilitation, this study advances knowledge by investigating culturally specific facilitators and barriers among Chinese CHF patients in home-based settings, a population understudied in deep qualitative inquiry. Unique culture-bound factors emerged, particularly robust family support from adult children and the misconception that daily household labor substitutes for structured rehabilitation exercise. This result should be interpreted carefully, given all participants shared the lived experience of chronic heart failure and home rehabilitation. Rather than indicating homogeneity, the findings reflect shared experiential pathways in knowledge uptake, motivation, and skill development across the illness trajectory, suggesting adherence is shaped not only by clinical and sociodemographic traits but also by patients’ cumulative real-world experiences of sustaining exercise at home.⁹

Contemporary guidelines strongly endorse exercise-based cardiac rehabilitation for CHF.^6,21 The 2021 ESC guidelines²¹ and the 2024 AHA core components update²² both give exercise training a Class IA recommendation, and the AHA statement now formally recognizes virtual and home-based models as legitimate alternatives to center-based programs.²² Yet our findings reveal a critical gap: these guidelines tend to assume that once access barriers are removed, patients will adhere to the prescribed exercise. Among our participants, even those who clearly understood the benefits of exercise and lived close to community facilities often struggled to maintain regular activity. The missing piece was neither access nor knowledge, but the lack of structured training in how to self-manage exercise. One participant knew that exercise was beneficial but could not distinguish ordinary chest discomfort from warning signs that should prompt him to stop. Another had strong family support and genuine motivation, yet gave up walking entirely after experiencing dyspnea because she had no idea how to adjust intensity. These cases suggest that simply providing exercise prescriptions without embedded skills training is unlikely to achieve optimal adherence, even when programs follow guideline recommendations.

The IMB model helps explain why this skills gap persists. A recent study in older adults with heart failure showed that self-efficacy served as a key mediator connecting social support to adherence.²³ Other research has similarly confirmed that self-efficacy fully mediates the relationship between motivation and physical activity in heart failure populations.²⁴ Our qualitative data complement these findings by specifying the concrete behaviors through which self-efficacy operates in the exercise domain. Participants who could articulate clear strategies—monitoring fatigue (“stop at slight warmth”), using wearables to track heart rate, or switching exercise modes when symptoms flared—kept exercising even when their motivation fluctuated. In contrast, participants who believed exercise would help them but had no tactical knowledge of intensity regulation consistently reported adherence failures. This pattern fits the IMB model’s premise that behavioral skills are often a key proximal determinant of sustained health behavior, while acknowledging that information and motivation also matter and may sometimes compensate for skill deficits.

Several culturally specific patterns set our findings apart from Western literature on cardiac rehabilitation adherence.²⁵ First, social support in our sample came predominantly from adult children rather than spouses—a pattern rarely highlighted in Western qualitative studies, where spousal support tends to dominate. One participant’s daily walking motivation was explicitly linked to preparing for a trip planned by her daughter. This filial involvement is a culturally congruent resource that HBCR programs could deliberately tap, for example through family-inclusive discharge planning or technology-mediated check-ins with adult children who live far away. Second, we encountered a distinctive cognitive barrier: equating household chores or transport biking with structured exercise. Several participants considered such daily activities sufficient rehabilitation, reflecting a utilitarian view of physical activity that may be stronger in Chinese cultural contexts where productivity is highly valued.²⁶ Correcting this misconception requires more than generic patient education; it demands explicit comparative framing—for example, illustrating the dose equivalence between a 30-minute structured walk and typical household tasks.

When we examined variations in adherence patterns by disease severity, age, and place of residence, several clinically meaningful distinctions emerged that go beyond simple demographic predictors. Disease severity (NYHA class) did not affect whether patients recognized exercise benefits, but it shaped the content of their fear. Class III participants worried about precise symptom thresholds—“After walking10-20 minutes, I feel chest tightness and have to stop immediately”—whereas milder patients expressed more general concerns about “overexertion.” This finding is consistent with Chinese population data showing that lower NYHA class and higher self-efficacy are independent protective factors for achieving exercise targets.²⁷ It also suggests that NYHA class should inform not the decision to recommend exercise but how to calibrate intensity guidance: class III patients need explicit instruction on using a Borg scale or heart rate reserve to find their personal safety limit just above symptom onset. Age influenced the preferred mode of self-regulation rather than the presence of skills. Younger participants spontaneously adopted wearables and smartphone apps, while older participants relied on embodied heuristics (“stop at slight warmth”) or family reminders. Notably, older participants were not less skilled—they had developed alternative strategies that worked well without technology. This cautions against assuming that digital interventions are either always appropriate or always inappropriate based on age alone.²⁸ Urban-rural differences were most pronounced in information access and social infrastructure. Rural participants had fewer sources of rehabilitation information, held more pronounced misconceptions (eg., equating farm work with prescribed exercise), and had less family support because adult children had often migrated for jobs. They also lacked community resources that urban participants took for granted, such as retired doctors leading morning Tai Chi groups. National survey data confirm that cardiac rehabilitation participation remains extremely low in rural China (13.8%) compared with urban areas (35.0%),²⁹ and contextual barriers such as policy fragmentation and weak primary care integration further disadvantage rural patients.²⁶ These three subgroup distinctions are not merely descriptive; they have direct implications for designing tailored HBCR programs, as discussed in the following section.

Digital health—wearables, apps, and telemonitoring systems—has shown promise in improving exercise capacity and reducing readmissions in heart failure populations, with meta-analytic evidence suggesting outcomes comparable to center-based programs.²⁶ A comparative systematic review of telehealth delivery models in heart failure care similarly concluded that phone call support and reminder interventions are most often recommended as practical and feasible approaches.³⁰ However, among younger, digitally literate urban patients, a fully app‑based intervention that integrates the three IMB domains may be particularly effective. Wearables provide real‑time feedback on heart rate and step count—addressing information deficits; automated coaching messages teach symptom monitoring and intensity titration—building behavioral skills; and progress dashboards sustain motivation. This aligns with evidence showing that the combination of a wearable device and a smartphone app yields the greatest improvements in VO₂peak.⁷ For older patients who rely on embodied strategies, digital tools should be offered as optional enhancements rather than replacements. Low-tech alternatives—printed Borg scales, paper exercise logs, scheduled phone follow-ups—remain essential. Hybrid models that let patients choose between app-based and paper-based tracking, while using automated SMS reminders as a bridge, could respect patient preferences without excluding those who are less comfortable with technology. For rural patients facing both access and literacy barriers, the priority should be basic information correction and low-tech skills training delivered through community health workers or simple voice messages, rather than sophisticated wearables. The 2024 AHA statement explicitly raises equity concerns about virtual rehabilitation delivery;³¹ our data suggest that rural-urban disparities in HBCR adherence will widen unless digital interventions are deliberately layered. Future pragmatic trials should test stratified IMB-based digital interventions where patients are assigned to different technology intensities (high, low, or hybrid) based on age, digital literacy screening, and rural residence.¹² Qualitative research could also explore how family members—especially adult children of rural patients who have moved away—might be engaged as remote coaches through simple messaging platforms, turning geographical distance into a resource rather than a barrier.

Based on the IMB framework and the above subgroup analyses, three actionable recommendations emerge: (1) For NYHA class III patients, explicit calibration training using the Borg scale or heart rate reserve should be integrated into discharge planning; (2) For older patients relying on embodied heuristics, low-tech alternatives such as printed Borg scales and scheduled phone follow-ups should be offered as co-primary options rather than digital-only solutions; (3) For rural patients with limited information access, community health worker-led skills training and voice-message reminders should precede any wearable deployment. Implementation of these stratified IMB-based strategies may close the adherence gap that current guideline recommendations overlook.

Limitations

This study has several limitations. First, the single‑center design, conducted at one tertiary hospital in Guangzhou, limits the generalizability of our findings to other regions or healthcare systems in China, particularly rural areas with different resource availability and cultural norms. Second, the reliance on self‑reported data may introduce recall bias and social desirability bias. Although we assured participants of anonymity, emphasized that there were no “right” or “wrong” answers, and used open‑ended questions, the fact that interviews were conducted before hospital discharge—when patients might still feel dependent on healthcare providers and wish to present themselves as compliant—could have led to overreporting of positive attitudes toward exercise and underreporting of true barriers (eg., lack of motivation or fear). Third, the cross‑sectional design does not allow us to establish causality or track changes in adherence behaviors over time. Finally, while we employed purposive sampling to achieve diversity, the sample may not capture all perspectives (eg., patients who refused to participate or those with very low health literacy). Future multi‑center or longitudinal studies, including follow‑up interviews after patients have spent several weeks at home, are needed to address these limitations and enhance the transferability of findings.

Conclusion

Guided by the Information-Motivation-Behavioral Skills (IMB) model, this study reveals that home-based cardiac rehabilitation exercise adherence in Chinese patients with chronic heart failure is a complex behavior determined by the interplay of information, motivation, and behavioral skills. Based on these findings, we propose the following actionable recommendations: (a) correct information deficits by using plain-language education to address culturally rooted misconceptions (eg., equating household labor with structured exercise, prioritizing medication over exercise); (b) strengthen motivation by involving family members—particularly adult children—as active supporters, and by using digital platforms (eg., WeChat, SMS reminders) to provide post-discharge cues to action; (c) build behavioral skills by teaching self-regulation strategies such as perceived exertion scaling (“stop at slight warmth”), symptom monitoring (eg., slowing down or resting when experiencing chest tightness), and using wearable devices; and (d) stratify interventions according to NYHA class, age, and urban/rural residence (eg., low-tech approaches for rural and older patients, app-based tracking for younger urban patients). These findings provide a theoretically grounded, patient-centered foundation for developing culturally appropriate cardiac rehabilitation programs with clear, implementable strategies.

Funding Statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data Sharing Statement

The datasets used and analysed during the current study are available from the corresponding author Xiaobing Wu on reasonable request.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare that they have no competing interests in this work.