Determinants of Implementing the 2024 Weight Management Guidelines in Overweight Patients with Coronary Heart Disease in China: A CFIR-Based Qualitative Study of Patient and Caregiver

Abstract

Background

The rising prevalence of overweight among patients with coronary heart disease (CHD) constitutes a critical clinical challenge. However, the multilevel determinants and patient-caregiver dynamics influencing the real-world implementation of the 2024 Weight Management Guidelines remain underexplored.

Purpose

To examine the facilitators and barriers influencing the clinical implementation of the 2024 Weight Management Guidelines from the perspectives of patients and their caregivers, and provide an evidence-based foundation for optimizing guideline-driven interventions in overweight patients with CHD.

Material and Methods

Using a descriptive qualitative design, purposive sampling was employed to conduct semi-structured, in-depth interviews between July and December 2025 with overweight patients with CHD and their family members at a tertiary hospital in Nanjing. Data were analyzed thematically within the theoretical framework of the Consolidated Framework for Implementation Research (CFIR).

Results

Implementation determinants were synthesized into five CFIR domains. Outer Setting: Media-driven health communication expanded patient awareness; however, implementation was constrained by the absence of community-based guidance, fragile social support, and a lack of peer support networks. Inner Setting: Institutional trust and effective clinician-led education served as key facilitators; however, the lack of a multidisciplinary education model remained a critical barrier. Characteristics of Individuals: Patients exhibited proactive information-seeking behaviors and a “confidence cycle” driven by positive feedback. Nevertheless, deep-seated cognitive biases (e.g, the “medication-only” fallacy), entrenched dietary preferences, sedentary lifestyles, addictive behaviors, disrupted circadian rhythms, and behavioral inertia combined with skill deficits created substantial resistance. Intervention Characteristics: While caregivers are highly willing to participate, there is a clinical lack of personalized weight management programs for patients with CHD. Implementation Process: Daily familial supervision provided vital reinforcement; however, a fragmented post-discharge care chain led to the cessation of effective professional guidance and monitoring.

Conclusion

The implementation of the 2024 Weight Management Guidelines is governed by multilevel determinants. Clinical practice should address behavioral inertia and cognitive biases while establishing a “hospital-to-home” continuum of care. Integrating family-centered participation with precision strategies is essential to enhance adherence and facilitate the successful translation of the guidelines.

Introduction

According to the latest Report on Cardiovascular Health and Diseases in China, CHD affects an estimated 11.39 million individuals nationwide, with cardiovascular disease remaining the leading cause of death in both urban and rural populations.¹ Excess body weight is a well-established independent risk factor for cardiovascular morbidity and mortality.² Evidence indicates that a higher body mass index elevates CHD risk, and that uncontrolled weight gain is associated with a more than threefold increase in cardiovascular-related mortality.³ Consequently, weight management has become an essential component of contemporary cardiovascular prevention, treatment, and rehabilitation.⁴ Among patients with established CHD, overweight and obesity are associated with worse prognosis, higher recurrence rates, and diminished response to secondary prevention therapies, underscoring the need for targeted weight management strategies in this subgroup.⁵

Despite the established clinical benefits of weight reduction, achieving and maintaining it in routine care remains challenging. Previous studies on lifestyle modification and cardiac rehabilitation in patients with CHD have identified multiple barriers, including low risk perception, limited motivation, time constraints, inadequate health literacy, insufficient post-discharge professional guidance, scarce access to individualised dietary and exercise support, and difficulties in embedding lifestyle changes into family and daily routines.^6–10 Collectively, these findings suggest that weight management in this population is not merely an individual behavioural challenge, but a complex care process shaped by patient understanding, caregiver involvement, family practices, clinical communication, and health-system resources.

These multifaceted barriers, spanning individual, familial, and organisational levels, underscore the urgent need for systemic policy interventions that extend beyond clinical settings to address the structural determinants of ineffective weight control. In response to the growing obesity burden, the National Health Commission of China launched the three-year “Weight Management Year” initiative (2024–2026), signalling a paradigm shift in chronic disease management from reactive treatment toward proactive, population-wide prevention.¹¹ The accompanying Technical Guidelines for Weight Management (2024 Edition) provide standardised recommendations for assessment, intervention, follow-up, and multidisciplinary coordination. However, a substantial “know–do gap” persists between these evidence-based recommendations and their translation into clinical practice, community care, and everyday family life. Implementation science offers systematic approaches to understanding why evidence-based interventions are adopted, sustained, or fail to integrate into real-world settings. The CFIR framework is particularly well-suited for this inquiry, as it examines implementation determinants across five domains: intervention characteristics, outer setting, inner setting, individual characteristics, and implementation process.¹² This multilevel lens is especially pertinent to CHD secondary prevention, given that sustained weight control is critically influenced by fluctuating cardiac symptoms, dietary misconceptions, and dynamic family caregiving dynamics—factors that extend well beyond individual volition.

Important gaps persist in the current evidence base. While existing studies have described general barriers to lifestyle modification and cardiac rehabilitation among CHD patients, most have approached weight control as an isolated individual behaviour or as a peripheral component of broader lifestyle management.¹³ Far less attention has been devoted to weight management as a guideline implementation issue—one shaped by interactions among patients, caregivers, health professionals, family environments, community resources, and organisational workflows. Although implementation frameworks have been applied in other chronic disease contexts, limited empirical research has used CFIR to systematically examine the implementation of the 2024 Chinese weight management guidelines specifically among overweight patients with CHD.

The role of family caregivers constitutes another critical gap. This omission is particularly consequential, given that the guidelines emphasise long-term, family-based behavioural intervention, and caregivers frequently influence patients’ dietary choices, physical activity, medication adherence, follow-up attendance, and overall daily self-management. The perceptions, barriers, and facilitators experienced by patient–caregiver dyads may be mutually reinforcing or, conversely, conflicting.¹⁴ To date, it remains unclear how overweight patients with CHD and their caregivers conceptualise the relationship between weight management and CHD, how they interpret and respond to guideline-recommended practices, what individual, familial, organisational, and contextual factors enable or hinder implementation, and how these factors interact within the Chinese sociocultural context.

This study addresses these gaps by applying the CFIR framework in a qualitative investigation of overweight patients with CHD and their primary family caregivers in China. Specifically, we aimed to identify multilevel barriers and facilitators influencing the implementation of guideline-recommended weight management practices and to synthesise patient and caregiver perspectives to develop a contextually grounded understanding of implementation within this high-risk population. By moving beyond generic descriptions of lifestyle-change obstacles, this study offers empirical, theory-informed evidence on how national weight management recommendations can be translated into sustainable practice across hospital, community, and household settings. These findings may ultimately inform the design of tailored, feasible implementation strategies to support long-term weight management for overweight patients with CHD in China.

Methods

Study Design

This descriptive qualitative study was guided by the CFIR framework. We employed face-to-face, semi-structured interviews and thematic analysis to explore perceptions of weight management among overweight patients with established CHD and their primary caregivers. The research team comprised a chief nursing professor, two nursing postgraduate students, and two senior cardiac nurses, who collectively ensured methodological rigor and clinical relevance throughout the study. Reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.¹⁵

Study Setting

The study was conducted in the Cardiovascular Medicine Department of Jiangsu Province Hospital (the First Affiliated Hospital with Nanjing Medical University), a large tertiary A-class hospital and the provincial flagship referral centre in Jiangsu Province, China. The department is a National Key Clinical Specialty that receives patients from urban and rural areas across Jiangsu and neighbouring provinces, ensuring a socioeconomically diverse patient population.

Recruitment and Sampling

We purposively recruited overweight patients with established CHD and their primary caregivers from this setting between July and December 2025. Attending cardiologists identified eligible patients, who were then approached by a trained research assistant in a private room. The research assistant explained the study purpose, procedures, voluntariness, confidentiality, and the right to withdraw, after which written consent was obtained. Caregivers were recruited through enrolled patients, with separate consent obtained from each. All 18 eligible patients and 12 caregivers approached consented to participate (100% response rate), and no enrolled participant withdrew after providing consent.

Participant Eligibility

Patients were included if they were aged 18 years or older, had a confirmed CHD diagnosis with overweight (BMI 24.0–27.9 kg/m², defined according to Chinese criteria), and could communicate verbally in Mandarin. Patients were excluded if they had severe cognitive impairment, psychiatric disorders, or life-threatening comorbidities. Caregivers were included if they were an immediate family member (spouse, parent, or child) identified by the patient as the primary caregiver, aged 18 years or older, able to communicate effectively, and familiar with the patient’s lifestyle and disease management.

Sample Size Determination

Sample size was determined by the principle of information saturation, defined as two consecutive interviews yielding no new codes relevant to the CFIR domains. Saturation was monitored iteratively through team reviews after every three to five interviews. The final sample comprised 18 patients and 12 caregivers. Demographic characteristics of participants are presented in Tables 1 and 2.

Table 1.

Demographic Characteristics of Patient Participants (n = 18)

ID	Sex	Age (Years)	BMI (kg/m2)	Education Level	Occupation	Marital Status	Living Arrangement
B1	Female	52	26.3	Primary School	Homemaker	Married	With Spouse
B2	Male	65	27.9	Vocational College	Retired	Married	With Children
B3	Female	53	25.1	High School	Retired	Married	With Spouse
B4	Male	58	27.5	Junior High School	Retired	Married	With Spouse
B5	Male	47	27.8	Bachelor’s Degree	Office Staff	Married	With Spouse
B6	Male	55	24.9	Junior High School	Farmer	Married	With Spouse
B7	Female	54	26.5	High School	Office Staff	Married	With Spouse
B8	Female	55	26.5	Junior High School	Retired	Married	With Spouse
B9	Male	58	25.7	Bachelor’s Degree	Engineer	Married	With Spouse
B10	Female	55	27.0	High School	Retired	Married	With Spouse
B11	Male	53	27.1	Vocational College	Office Staff	Married	With Spouse
B12	Female	43	26.1	Bachelor’s Degree	Office Staff	Married	With Spouse
B13	Male	62	26.8	Junior High School	Homemaker	Married	With Children
B14	Female	51	25.3	Bachelor’s Degree	Office Staff	Married	With Spouse
B15	Female	48	26.9	Vocational College	Manager	Married	With Spouse
B16	Female	64	27.5	High School	Retired	Married	With Spouse
B17	Male	50	25.9	Bachelor’s Degree	Teacher	Married	With Spouse
B18	Female	60	26.7	Junior High School	Self-employed	Married	With Children

Abbreviation: BMI, Body Mass Index.

Table 2.

Demographic Characteristics of Caregiver Participants (n = 12)

ID	Sex	Age (years)	Education Level	Occupation	Marital Status
C1	Male	50	Junior High School	Homemaker	Married
C2	Female	63	High School	Retired	Married
C3	Male	53	High School	Retired	Married
C4	Female	57	No formal education	Homemaker	Married
C5	Female	44	Bachelor’s Degree	Office Staff	Married
C6	Female	52	Primary School	Farmer	Married
C7	Male	50	Vocational Secondary School	Office Staff	Married
C8	Male	55	Junior High School	Retired	Married
C9	Female	57	Junior High School	Retired	Married
C10	Male	54	High School	Retired	Married
C11	Female	55	Junior High School	Office Staff	Married
C12	Male	38	Bachelor’s Degree	Office Staff	Married

Interview Guide

Drawing on the CFIR framework and the 2024 clinical practice guidelines, the research team developed separate semi-structured interview guides for patients and caregivers. The draft guides were reviewed by an expert panel and pilot-tested with two patients and two caregivers (not included in the final sample), with refinements made based on feedback. The final interview guides are presented in Tables 3 and 4.

Table 3.

Interview Guide for Patients

NO.	Interview Questions	Aligned CFIR Domain
1.	Have you encountered weight management information through the media, community programs, or health insurance policies?	Outer Setting
2.	Beyond the hospital, what additional support do you desire (e.g, community activities, family doctors, or policy subsidies)?	Outer Setting
3.	What specific weight management support has been provided by your current clinical department or hospital?	Inner Setting
4.	Have healthcare professionals communicated with you regarding the importance of weight management in CHD management?	Inner Setting
5.	What is your perception of the relationship between weight management and the progression of coronary heart disease?	Individual Characteristics
6.	How confident are you in your ability to control and maintain your body weight?	Individual Characteristics
7.	What specific weight management strategies or methods have you previously attempted?	Individual Characteristics
8.	What is your primary psychological barrier during weight management (e.g, difficulty with persistence, lack of motivation, or entrenched habits)?	Individual Characteristics
9.	In what ways could healthcare providers best assist you in sustaining weight management (e.g, regular monitoring, personalized guidance, or family involvement)?	Implementation Process

Abbreviations: CFIR, Consolidated Framework for Implementation Research; CHD, coronary heart disease.

Table 4.

Interview Guide for Caregivers

NO.	Interview Questions	Aligned CFIR Domain
1.	Through which channels do you acquire weight management knowledge? Is this information helpful in guiding the patient’s weight management?	Outer Setting
2.	Have healthcare providers in the clinical department communicated with you regarding the patient’s weight management?	Inner Setting
3.	How would you describe your level of understanding regarding the role of weight management in CHD prognosis?	Individual Characteristics
4.	Do you find the current hospital-provided protocols (e.g, dietary advice, exercise guidance) feasible for implementation at home? What difficulties have you encountered?	Intervention Characteristics
5.	Within the home environment, what factors influence the patient’s adherence to weight management (e.g, conflicting family dietary habits, limited time/energy, lack of professional guidance, or financial pressure)?	Inner Setting / Individual
6.	What types of collaborative support (e.g, family-centered health education, joint follow-ups, or training in caregiver engagement skills) do you expect from the hospital?	Implementation Process

Abbreviations: CFIR, Consolidated Framework for Implementation Research; CHD, coronary heart disease.

Data Collection

One-on-one, face-to-face interviews were conducted in Mandarin Chinese by Shanshan Liu (first author; 10 years of experience in cardiovascular nursing and qualitative research) and Yuting Wang (co-author; 10 years of clinical cardiology experience). Neither interviewer had a prior therapeutic or professional relationship with participants, and all participants were informed of the interviewers’ independence from their clinical care. Both interviewers completed a 20-hour training programme in qualitative interviewing—covering techniques, probing strategies, ethics, and role-play with feedback—followed by a pilot phase in which each conducted two practice interviews with non-participants and received team feedback prior to formal data collection.

Interviews were audio-recorded with participants’ permission, supplemented by field notes, and conducted in a quiet hospital conference room, with each session lasting 45 to 60 minutes. All recordings were transcribed verbatim in Chinese within 48 hours. For publication, representative quotes were translated into English by a bilingual researcher and independently back-checked by a second bilingual researcher; discrepancies were resolved through discussion.

Data Analysis

Data were managed using NVivo 12.0 software. To assess inter-coder reliability, two researchers independently coded a randomly selected subset of nine transcripts (30% of the total 30 interviews), using NVivo’s coding comparison query to calculate Cohen’s kappa (κ).¹⁶ The analysis yielded κ = 0.72, indicating substantial agreement. Disagreements were resolved through a structured process: (1) each coder documented their rationale; (2) they discussed discrepancies against the raw data and CFIR definitions; (3) unresolved disagreements were adjudicated by a third researcher (Prof. Zejuan Gu, corresponding author, a senior qualitative methodologist). Themes were iteratively refined through team meetings and peer debriefing sessions with clinicians and implementation scientists.

Formal member checking was not performed, as participants were difficult to contact after hospital discharge. Trustworthiness was ensured through investigator triangulation (dual coding), peer debriefing, and the use of rich verbatim quotations to support findings.

Ethical Considerations

This study complied with the principles of the Declaration of Helsinki and was approved by the Ethics Committee of the First Affiliated Hospital with Nanjing Medical University (Approval No. 2025-SR-851). Written informed consent was obtained from all participants, who were assured of their right to withdraw at any time without affecting their clinical care. All data were anonymized and stored on a password-protected, encrypted server accessible only to the research team.

Results

CFIR-based facilitators and barriers

Using the CFIR framework, we identified five domains of factors that influenced implementation of the 2024 Weight Management Guidelines. Within each domain, we found both facilitators and barriers, Table 5 provides a summary of these findings.

Table 5.

CFIR-Based Facilitators and Barriers to Weight Management in Overweight CHD Patients

CFIR Domain	CFIR Construct	Direction	Implementation Implication
Outer Setting	External Policy & Incentives	+	Use existing multi-channel platforms to reinforce weight management messaging post-discharge.
Outer Setting	Community-level gaps	−	Build formal referral and communication pathways between tertiary hospitals and community clinics.
Outer Setting	Patient Needs & Resources	−	Provide peer support groups or supervised group activities to counteract negative social influences.
Inner Setting	Institutional trust	+	Leverage institutional credibility to strengthen patient and family trust in weight management advice.
Inner Setting	Professional information support	+	Ensure that inpatient education is reinforced with actionable next steps and easy access to follow-up services.
Inner Setting	Absence of multidisciplinary collaborative education	−	Integrate weight management advice with other chronic disease education, rather than delivering it as separate, piecemeal instructions.
Individual Characteristics	Knowledge & Beliefs about the Intervention	+/−	Provide self-directed learning resources for motivated patients; expand dietary education on processed foods, condiments, and cooking methods; address exercise-related fears with clinician-approved guidance.
Individual Characteristics	Self-Efficacy	+	Build in early, visible milestones (e.g, weekly weight check-ins) to reinforce self-efficacy.
Individual Characteristics	Other Personal Attributes (habits and behavioral inertia)	−	Offer gradual, stepwise dietary modification involving the family cook; provide time-efficient, home-based exercise options (e.g, short walking routines) that fit into daily chores.
Intervention Characteristics	Evidence Strength & Quality	+	Use acute events as teachable moments to engage caregivers; reinforce the prognostic benefits of weight control to strengthen caregiver commitment.
Intervention Characteristics	Design Quality & Packaging	−	Tailor weight management plans to individual comorbidities, age, and functional status. Avoid generic handouts.
Implementation Process	Engaging	+	Systematically include family caregivers in discharge planning and counseling sessions.
Implementation Process	Reflecting & Evaluating	−	Establish structured follow-up contacts (phone, WeChat, or home visits) to maintain accountability; designate a clear contact person (e.g, a clinical nurse coordinator) for post-discharge weight-related questions.

Notes: Direction: “+” indicates a facilitator; “−” indicates a barrier; “+/−” indicates that both facilitating and impeding sub-themes were identified under the same construct. Source: Representative quotes supporting each construct are presented in the Results section, organised by CFIR domain and sub-theme.

Abbreviations: CHD, coronary heart disease; CFIR, Consolidated Framework for Implementation Research.

The following sections describe each domain in detail, with representative quotations from patients and caregivers.

Domain 1: Outer Setting — Community and Peer Environment

The outer setting refers to factors outside the hospital that influence weight management implementation, including community resources, peer networks, and social support.

Sub-Theme 1: Diverse Health Communication Channels

Participants noted that the hospital now uses multiple channels to share health information. This increased access to weight management advice during hospital visits.

There are definitely more ways the hospital communicates now—bulletin boards, lectures, and mobile push notifications. Accessing information has become much more convenient. (B2)

Sub-Theme 2: Fragile Social Support and Community-Level Gaps

Despite good access to information inside the hospital, participants struggled to maintain weight management after discharge. They described weak peer support and limited community resources.

Several patients reported negative social pressure from friends and neighbours. One patient explained how teasing from her peer group undermined her motivation.

I enjoy square dancing, but when my friends heard I wanted to lose weight, they teased me, saying I shouldn’t ‘toss and turn’ at my age and that being ‘plump’ prevents illness. Their reactions, combined with having no one to exercise with, made me lose heart. (B2)

Others pointed to a lack of community-level services. One patient described how weight management was simply not on the agenda at the local clinic.

When we go to the community clinic, it’s just for minor ailments. They don’t even ask about my weight, and the doctors don’t seem to care about it, let alone discuss weight management. (B6)

Domain 2: Inner Setting — Hospital Organization and Professional Climate

The inner setting captures organisational characteristics within the tertiary hospital, including leadership, culture, and clinical workflows.

Sub-Theme 3: Institutional Trust and Professional Information Support

Patients and caregivers expressed strong trust in the hospital and its professionals. This trust made them more receptive to weight management advice.

This is a major tertiary hospital; the doctors and nurses are very professional. If they recommend weight management, it must be for our own good. We will certainly cooperate. (C5)

Some patients also reported that hospital-based education raised their awareness of the link between weight and CHD, prompting them to seek further professional input.

During this hospitalization, the nurse explained the specific risks of being overweight. I hadn’t realised the link between CHD and weight before. I plan to consult the nutrition department for professional advice. (B5)

Sub-Theme 4: Absence of Multidisciplinary Collaborative Education

However, participants also reported that health education was often delivered in a fragmented way. Patients with multiple comorbidities received separate, uncoordinated advice from different specialists. This created confusion.

One patient described the burden of piecing together conflicting instructions.

As you get older, you have so many problems. Every time I’m at the hospital, doctors tell me to watch this or that. But the instructions for my hypertension, diabetes, and CHD are so much to take in at once. It’s a headache to figure it all out. (B13)

Domain 3: Individual Characteristics — Patient and Family Knowledge, Beliefs, and Habits

This domain covers individual-level factors, including knowledge, attitudes, self-efficacy, and behavioural patterns of patients and their families.

Sub-Theme 5: Proactive Health Literacy and Positive Feedback Loops

Some patients showed strong intrinsic motivation. They actively sought CHD-related knowledge and took initiative in managing their weight. When early efforts produced visible results, their confidence grew.

Since my diagnosis, I’ve been searching for CHD-related knowledge. If the doctor says I need to lose weight to control my lipids, I’ll learn how to do it better. (B3)

One patient described how successful weight loss reinforced her motivation.

I’ve adhered to the plan for three months, lost 5 pounds, and my lipid levels are back to normal. Seeing results makes me happy, and the doctors praised my progress. (B17)

Sub-Theme 6: Cognitive Biases, Entrenched Habits, and Behavioural Inertia

Nevertheless, important barriers persisted at the individual level. Long-standing dietary habits were a common challenge. One patient explained how family cooking preferences made dietary change difficult.

Our family prefers strong flavours; it’s a lifelong habit. If there’s less oil or salt, the food simply doesn’t taste good. (B11)

Some caregivers held misconceptions about exercise safety. One caregiver worried that physical activity might worsen her spouse’s condition.

Can people with CHD even exercise? Won’t that make my spouse’s condition worse? (C9)

Others struggled with time constraints and daily routines. A patient described how household responsibilities left little room for exercise.

After finishing housework, I just want to watch shows. I don’t have time during the day; the whole family relies on me. (B16)

Several participants also showed gaps in practical dietary knowledge. One caregiver followed the doctor’s “low salt” advice but overlooked hidden sources of sodium in processed foods.

The doctor said ‘low salt,’ so I use less salt when cooking. But I didn’t realise there was so much hidden oil and salt in snacks and crackers. (C4)

Domain 4: Intervention Characteristics — Perceived Complexity and Adaptability of Guidelines

This domain addresses how participants perceived the weight management guidelines themselves, including their complexity, adaptability, and evidence base.

Sub-Theme 7: Strong Caregiver Readiness and Intervention Urgency

Caregivers expressed strong motivation to support weight management. This motivation was often driven by fear of recurrent cardiac events. One caregiver described being “terrified” by her spouse’s recent episode.

I was terrified by my spouse’s recent episode. Once we return home, I will strictly follow the doctor’s instructions, supervise his adherence, and help get his weight under control. We simply cannot let him remain this overweight anymore. (C11)

Another caregiver emphasised the value of health as a priority.

Our health is everything. Now that we know weight management reduces the risk of recurrence, I will fully support him. (C5)

Sub-Theme 8: Lack of Personalised and Adaptive Protocols

However, participants also reported that the standard plans they received from the hospital were generic and did not account for individual differences. This reduced their perceived feasibility.

The dietary and exercise plans from the hospital all seem identical. They don’t consider my spouse’s specific situation or his other underlying conditions. (C10)

Domain 5: Implementation Process — Execution and Sustainment of Weight Management Activities

This domain focuses on how weight management activities were executed and sustained beyond the clinical encounter.

Sub-Theme 9: Familial Supervision and Relational Reinforcement

Daily supervision by family members emerged as a powerful facilitator. Patients who had a caregiver monitoring their behaviour felt more accountable and less likely to slack off.

My spouse watches me every day, reminding me to walk and managing my meals according to the doctor’s orders. Having someone there makes me feel secure and less likely to slack off. (B8)

Sub-Theme 10: Fragmented Care Chain and Lack of Longitudinal Monitoring

Despite strong in-hospital education and family support, the care chain often broke down after discharge. Participants described losing momentum when structured follow-up was absent.

One patient explained how work and fatigue overtook his initial enthusiasm.

I exercised for a while, but work got too busy. When I got home, I just wanted to lie down. Since no one was there to manage me, it just fizzled out. (B9)

Another patient highlighted the lack of accessible post-discharge support.

The doctors explained everything clearly at discharge, but at home, there’s no oversight. I’ve slowly started to relax. If my weight goes up and I want to ask why, I don’t even know who to call. (B15)

Discussion

Using the CFIR as an analytic framework, this study identified multilevel determinants affecting the implementation of the 2024 Weight Management Guidelines among overweight patients with CHD. The findings directly address the study objective by showing that implementation is shaped not by a single barrier, but by interacting factors across the outer setting, inner setting, individual characteristics, intervention characteristics, and implementation process. Four mechanisms were particularly salient: inadequate community and peer support after discharge, strong but insufficiently mobilised trust in hospital-based professionals, persistent cognitive and behavioural resistance at the individual level, and the need for personalised follow-up supported by family caregivers.

A novel finding emerged from comparing patient and caregiver accounts side by side. Patients and caregivers often pointed to different types of barriers. Patients commonly cited personal habits, lack of willpower, or daily fatigue as reasons for non-adherence.¹⁷ Caregivers, in contrast, more frequently highlighted system-level gaps—unclear discharge plans, no designated contact person, and absent community follow-up.^18,19 These divergent views suggest that the two groups do not always share the same understanding of what “implementation failure” means. The mismatch itself may be a useful target for intervention: aligning patient and caregiver expectations about weight management could improve mutual support and reduce friction after discharge. This dual-perspective contrast has rarely been captured in previous CFIR-based studies, which typically report either patient or provider views.

A key finding was that patients and caregivers could obtain weight management information during hospital encounters, but often lacked sustained support once they returned to the community. Participants described limited proactive community-based services, weak peer-support networks, and occasional misunderstanding from peers, all of which reduced motivation and contributed to discontinuation of behavioural management. This finding suggests that the outer setting remains an underdeveloped component of guideline implementation. It is consistent with previous evidence that peer support can improve self-efficacy, adherence, and long-term engagement in chronic disease management.²⁰ Our study extends this evidence by showing that, for overweight patients with CHD, the absence of community and peer support can disrupt the transition from professional advice to everyday practice. Community support should therefore be understood not as an optional adjunct, but as a key implementation bridge between hospital-based guidance and sustained self-management after discharge.²¹ Future studies should test whether community-based weight monitoring, structured health education, peer mutual-aid groups, and hospital-community referral pathways can improve adherence to guideline-recommended weight management behaviours.

Participants also expressed strong trust in tertiary medical institutions and hospital-based professionals. This trust facilitated acceptance of weight management advice and strengthened awareness of the relationship between excess weight and CHD prognosis. However, the findings also showed that health education was often delivered through a single-discipline or fragmented model.^22,23 For patients with CHD and multimorbidity, inconsistent or insufficiently coordinated messages from different professionals could create confusion and reduce the feasibility of implementation. This finding is consistent with previous studies showing that patients with chronic cardiovascular conditions often rely on specialist advice but require coordinated multidisciplinary support to translate medical recommendations into daily self-management.²⁴ Our findings further suggest that institutional trust becomes an implementation asset only when it is converted into coherent, actionable, and patient-centred guidance. Trust alone may increase awareness, but it is unlikely to sustain behavioural change if education remains siloed. Implementation strategies should therefore move beyond single-provider education and towards multidisciplinary team-based care involving physicians, nurses, dietitians, rehabilitation specialists, and community health workers. Future intervention studies should evaluate whether MDT-led education can provide consistent messages, individualised goals, and coordinated hospital-community transition plans.

At the individual level, participants showed some awareness of the importance of health management, and some patients developed a positive “confidence cycle” when early behavioural changes produced visible benefits. Nevertheless, important barriers persisted, including entrenched dietary preferences, sedentary lifestyles, addictive behaviours, disrupted circadian rhythms, and difficulty maintaining stable routines.^6–10 A particularly important barrier was the tendency to prioritise medication over lifestyle modification, which led some patients to underestimate the role of weight control in CHD management. These findings are consistent with behavioural change theories and cardiovascular rehabilitation research showing that lifestyle change is gradual, non-linear, and influenced by motivation, perceived benefit, self-efficacy, and environmental cues.²⁵ The present study adds context-specific evidence that cognitive and behavioural resistance among overweight patients with CHD is not simply a knowledge deficit. Rather, it is embedded in long-standing habits, family routines, illness perceptions, and expectations of medication-centred care. Our data further show that most participants could recite the health risks of excess weight and the basic principles of diet and exercise. The bottleneck was not lack of awareness. Patients knew what they should do; they simply could not sustain it after leaving the hospital because the system offered no structured handover, no accessible follow-up contact, and no accountability mechanism. This distinction matters for intervention design. It shifts the emphasis from delivering more education to building post-discharge support systems that help patients act on what they already know. For implementation practice, this means that one-off education is unlikely to be sufficient. Patients require staged behavioural interventions that assess readiness for change, set achievable short-term goals, reinforce early progress, and provide support during relapse. Future studies should test stage-based counselling, motivational interviewing, self-monitoring tools, and feedback mechanisms that help patients progress from awareness to sustained action.

Caregiver involvement emerged as an important facilitator of implementation. Caregiver readiness and daily supervision supported patients’ dietary control, physical activity, medication adherence, follow-up attendance, and self-management, consistent with previous research.²⁶ However, participants also reported that existing guidance was often too general and insufficiently adapted to individual comorbidities, exercise tolerance, dietary preferences, family resources, and daily routines. Such “one-size-fits-all” advice reduced perceived feasibility and limited sustained implementation. We also identified culturally specific beliefs and social dynamics that are not adequately captured in the existing CFIR-based implementation literature. Several participants reported being teased by friends or neighbours for attempting weight loss, with some being told that “being plump prevents illness” or that exercise at an older age is risky. Others struggled with family cooking habits that were deeply ingrained—strong flavours, heavy oil, and reliance on processed condiments—and found that general dietary advice did not translate well to their daily meals. These contextual factors are not merely anecdotal. They shape the feasibility of guideline implementation in real-world Chinese households. Implementation strategies need to address these social and cultural barriers directly, rather than assuming that clinical recommendations will be accepted and followed without modification. The study also identified a fragmented post-discharge care chain. Professional supervision was concentrated mainly in hospital settings, whereas patients and caregivers often lacked structured follow-up support at home. This finding echoes the commonly reported problem of “hospital-based planning without home-based follow-up”.²⁷ Our study further suggests that this discontinuity may weaken implementation of the 2024 guidelines because weight management requires repeated assessment, adjustment, feedback, and reinforcement over time. Implementation strategies should therefore emphasise a hospital-to-home continuum of care. Personalised weight management plans should be developed before discharge and adjusted during follow-up according to patients’ risk profiles, comorbidities, family capacity, and behavioural progress. Digital health tools, remote monitoring, and structured caregiver participation may help maintain continuity. Future intervention studies should test integrated models in which caregivers act as co-implementers, supported by professional feedback and community-based follow-up.

On the basis of these findings, we propose a conceptual implementation model in which successful implementation of the 2024 Weight Management Guidelines depends on the interaction of four core mechanisms: hospital trust, caregiver involvement, personalised follow-up, and community-peer support. In this model, hospital trust promotes patients’ initial acceptance of guideline-recommended practices, particularly when advice is delivered through coordinated multidisciplinary teams. Caregiver involvement translates professional recommendations into daily routines by supporting diet, physical activity, medication adherence, and follow-up. Personalised follow-up maintains behavioural momentum by adapting goals to patients’ clinical conditions, preferences, and family circumstances. Community and peer support provide an external environment that reinforces adherence after discharge. These mechanisms are mutually reinforcing: hospital guidance activates motivation, caregivers sustain daily implementation, personalised feedback helps prevent relapse, and community support reduces isolation and promotes long-term maintenance. Together, they form a hospital–family–community continuum that may offer a viable pathway for sustained implementation of the guidelines (Figure 1).

Figure 1.

Conceptual implementation model for weight management guideline implementation among overweight patients with CHD.

The proposed model also identifies priorities for future intervention testing. Rather than evaluating education alone, future studies should examine multicomponent implementation strategies that combine MDT-based hospital education, caregiver training, individualised weight management plans, digital or telephone follow-up, and community-peer support. Such interventions should assess not only clinical outcomes, including weight change and cardiovascular risk indicators, but also implementation outcomes, including acceptability, feasibility, adoption, fidelity, adherence, and sustainability.

Conclusion

Overall, these findings directly address the study’s objectives by demonstrating that successful implementation of the 2024 Weight Management Guidelines among overweight patients with CHD requires far more than enhancing patient knowledge; it depends on coordinated, multi-level action spanning hospitals, families, communities, and follow-up systems. By applying the CFIR, this study offers a theoretically grounded explanatory account of how multilevel determinants interact, and provides an empirical foundation for the design of targeted implementation strategies in future research.

The findings of this study are derived from a large tertiary hospital in Nanjing, Jiangsu Province. As a qualitative study, our aim was analytical generalizability—identification of transferable mechanisms—rather than statistical generalizability. However, the single-center design and the specific cultural and organisational context may limit the direct transferability of findings to other healthcare settings. Readers should consider these contextual factors when interpreting our results.

Future multicenter qualitative and mixed-methods studies are needed to validate the transferability of these implementation determinants across diverse healthcare settings in China. Additionally, intervention studies employing mixed-methods designs should evaluate the effectiveness of the proposed strategies—including multidisciplinary team-based education, caregiver training, personalised weight management plans, structured follow-up, and community-peer support—in improving guideline adherence and clinical outcomes. Such studies would provide a more robust evidence base for translating the 2024 Weight Management Guidelines into sustainable practice and bridging the persistent know–do gap in cardiovascular secondary prevention.

Strengths and Limitations

A key strength is the application of the CFIR framework, which provided a structured lens for analysing implementation determinants. Semi-structured interviews enabled in-depth exploration of both patient and caregiver perspectives. Limitations include the single-site design, which limits statistical generalizability. However, as a theory-driven qualitative study, it prioritises analytical generalizability—identification of transferable mechanisms—over population-level inference. To support transferability assessment, we have provided detailed contextual information about the study site. The core mechanisms identified are conceptually grounded and likely to resonate across diverse Chinese settings, though their manifestations may vary. Future multicenter and mixed-methods research should validate these determinants across varied contexts. Additionally, the reliance on self-reports without objective clinical or longitudinal data should be addressed in future studies.

Funding Statement

This work was supported in part by Jiangsu Hospital Association Management Innovation Research Project (grant number JSYGY-3-2025-706).

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 no conflicts of interest in this work.