Barriers and Facilitators to the Initiation of Home-Based Exercise Rehabilitation After Radiofrequency Catheter Ablation for Atrial Fibrillation: A TDF-Based Qualitative Study

Abstract

Purpose

Home-based exercise rehabilitation is important for recovery after atrial fibrillation (AF) ablation. However, the barriers and facilitators influencing the initiation of home-based exercise rehabilitation during the early post-ablation recovery phase remain insufficiently understood. This study aimed to explore the barriers and facilitators influencing the initiation of home-based exercise rehabilitation among patients following radiofrequency catheter ablation for AF, guided by the Theoretical Domains Framework (TDF).

Patients and Methods

A descriptive qualitative study was conducted using purposive sampling. Twenty patients who had undergone radiofrequency catheter ablation for AF were recruited from a tertiary general hospital in Jiangsu Province, China. Formal data collection was conducted from August to December 2025.Face-to-face semi-structured interviews were conducted individually during routine follow-up approximately one month after ablation. The phenomenon under investigation was the initiation of home-based exercise rehabilitation during the early recovery phase, referring to patients’ transition toward intentional, planned exercise activities performed at home after discharge and recommended or guided by healthcare professionals. Data were analysed using qualitative content analysis with a hybrid inductive-deductive approach informed by the TDF.

Results

Factors influencing the initiation of home-based exercise rehabilitation were categorized into promoting and impeding factors. A total of 11 influencing factors were identified: 3 promoting factors (benefit-driven motivation, trust and recognition of professionals, and family responsibility as a motivator) and 8 impeding factors (lack of exercise knowledge, inadequate skill mastery, low exercise self-efficacy, distress from physical symptoms, poor resource accessibility, negative emotional distress, and absence of exercise plans).

Conclusion

The initiation of home-based exercise rehabilitation after radiofrequency catheter ablation for AF is influenced by multiple interacting individual, professional, and contextual factors. Support strategies should address patients’ knowledge and skills, confidence, symptom-related concerns, access to professional guidance and rehabilitation resources, and competing social responsibilities to facilitate the initiation of home-based exercise rehabilitation during early recovery.

Plain Language Summary

A TDF-informed qualitative analysis of home-based exercise rehabilitation after AF ablation

: This study systematically explores multilevel facilitators and barriers influencing exercise rehabilitation, including knowledge, skills, emotional concerns, and environmental factors.

Actionable insights for clinical practice

: Effective home programs must move beyond education to address emotional distress, simplify exercise skills, leverage family/peer support, and provide individualized written plans tailored to home environments.

Introduction

Atrial fibrillation (AF) is one of the most prevalent cardiac arrhythmias worldwide, affecting an estimated 50 million people globally.¹ The burden is particularly severe in China, where the number of patients has reached approximately 20 million. AF significantly increases the risks of stroke, heart failure, dementia, and all-cause mortality, severely impairing patients’ quality of life. Moreover, it places a substantial strain on healthcare systems and on socioeconomic development.² In China alone, AF is responsible for annual economic losses exceeding 30 billion yuan, highlighting its status as a major public health challenge.

For patients with atrial fibrillation who are unresponsive to or intolerant of drug therapy, catheter ablation is the preferred treatment option for maintaining sinus rhythm. This primarily involves using energy sources such as radiofrequency, cryoablation, or pulsed electric fields to eliminate the trigger foci and maintenance substrate of atrial fibrillation.³ Current ablation strategies commonly include pulmonary vein isolation, linear ablation, substrate modification, Marshall vein alcohol ablation, and other approaches.³ This approach effectively reduces disease burden, delays disease progression, and improves patients’ quality of life.⁴ However, postoperative patients still experience reduced exercise tolerance, which is associated with increased all-cause mortality in the early period.⁵ Studies indicate that exercise rehabilitation can improve quality of life and exercise capacity in patients following AF catheter ablation, reduce the incidence of adverse cardiovascular events, and enhance clinical outcomes.⁶

Recent systematic reviews have demonstrated that exercise-based cardiac rehabilitation is likely to improve exercise capacity, atrial fibrillation symptom burden, and health-related quality of life in patients with atrial fibrillation, while also reducing AF recurrence.⁷ Quantitative evidence further supports the clinical benefits of home-based cardiac rehabilitation. A recent meta-analysis of randomized controlled trials showed improvements in exercise capacity and cardiorespiratory fitness, including six-minute walk distance and peak oxygen uptake, among patients receiving home-based cardiac rehabilitation supported by mobile health technologies compared with usual care.⁸ These findings provide further clinical rationale for home-based exercise rehabilitation and underscore the importance of understanding the behavioural barriers that influence its initiation after AF catheter ablation.

Currently, hospital-based exercise rehabilitation programs are limited in scope and confined to major cities. Due to transportation difficulties, high costs, and limited capacity at rehabilitation centers, patient participation rates remain low.⁹ Home-based exercise rehabilitation offers a more cost-effective alternative, yet faces multiple practical challenges: some patients and caregivers lack awareness of exercise interventions, holding misconceptions such as “resting is safer”; the absence of individualized exercise prescriptions and professional guidance in home settings reduces adherence rates and limits treatment efficacy.^10,11

Previous studies have explored exercise rehabilitation participation and related barriers among patients after AF ablation; however, further qualitative exploration using behavioral theory frameworks is needed to understand the complex mechanisms underlying home-based exercise rehabilitation behaviors.^12,13 To systematically analyze barriers and facilitators of health behavior change in patients, Michie et al have proposed the Theoretical Domains Framework (TDF)¹⁴—a theoretical model for analyzing behavior change comprising 14 domains:¹⁵ Knowledge, skills, Social/professional role and identity, beliefs about capabilities, optimism, beliefs about consequences, reinforcement, intentions, Goals, Memory, attention and decision processes, environmental context and resources, Social influences, emotion and Behavioral regulation. This framework is now widely applied in studies examining key factors influencing behavioral change among patients with other chronic diseases.^16–18

Although previous studies have identified important barriers and facilitators to exercise rehabilitation after AF ablation, less is known about how these behavioural determinants interact during rehabilitation initiation and how they can be interpreted using an established behavioural theory. Guided by the TDF, this study therefore aimed to explore the barriers and facilitators influencing the initiation of home-based exercise rehabilitation among patients following radiofrequency catheter ablation for AF, with particular attention to how behavioural determinants interact during rehabilitation initiation. The findings are expected to provide a theory-informed basis for developing supportive strategies to facilitate the initiation of home-based exercise rehabilitation after AF ablation.

Materials and Methods

The phenomenon under investigation was the initiation of home-based exercise rehabilitation during the early recovery phase (approximately one month after radiofrequency catheter ablation). In this study, home-based exercise rehabilitation referred to intentional exercise activities performed at home after discharge, recommended or guided by healthcare professionals, with the aim of promoting postoperative recovery, improving physical function, and enhancing cardiovascular health. Importantly, participants had not yet entered a standardized cardiac rehabilitation programme at the time of recruitment. Therefore, the interviews explored patients’ current physical activity experiences, perceptions and understanding of exercise rehabilitation, and the barriers and facilitators influencing their transition toward initiating home-based exercise rehabilitation.

Design

This study employed a descriptive qualitative research approach, utilizing semi-structured interviews to collect data. Descriptive research employs content analysis to characterize individuals’ expressed, surface-level, and overt experiences.¹⁹ Data were reported using the Standards for Reporting Qualitative Research (SRQR) checklist.

Participants

Purposeful sampling was employed to recruit patients who underwent AF radiofrequency catheter ablation at the Cardiovascular Department of a tertiary general hospital in Jiangsu Province, China, between August and December 2025. Patients were recruited between August and December 2025 during routine follow-up approximately one month after the procedure.

Inclusion Criteria: Age ≥ 18 years; Met diagnostic criteria for atrial fibrillation per the 2020 European Society of Cardiology (ESC) Guidelines for the Management of Patients with Atrial Fibrillation;²⁰ underwent radiofrequency ablation for AF; were in the early stage of considering or initiating home-based exercise rehabilitation after discharge; had normal cognitive, expressive, and communication abilities; provided informed consent and voluntarily participated. Participants were eligible regardless of whether they had engaged in spontaneous light physical activities (eg, walking or household activities), as these activities were not considered equivalent to a structured home-based exercise rehabilitation programme. Exclusion Criteria: Concurrent severe medical conditions contraindicating exercise; Severe mental illness, hearing impairment, or inability to cooperate with interviews. The study included 20 patients who underwent radiofrequency catheter ablation for atrial fibrillation, comprising 11 males and 9 females. Participants’ demographic characteristics are presented in Table 1.

Table 1.

General Information of Participants (n = 20)

Participant	Gender	Age (Years)	Educational Level	Place of Residence	Cohabitation Status	Marital Status	Duration of AF	AF Type	Comorbidities
P1	Male	74	Elementary school	Rural	With family	Married	1 week	Persistent AF	None
P2	Female	65	Elementary school	Rural	With family	Married	3 years	Paroxysmal AF	Hypertension, diabetes, coronary heart disease
P3	Male	71	Illiterate	Rural	With family	Married	2 weeks	Persistent AF	Hypertension
P4	Female	75	Junior high school	Urban	With family	Married	1 week	Paroxysmal AF	Hypertension
P5	Female	73	High school	Urban	With family	Married	4 years	Persistent AF	Hypertension
P6	Male	60	Junior high school	Urban	With family	Married	2 months	Persistent AF	Hypertension, coronary heart disease
P7	Male	68	Junior high school	Urban	Alone	Married	2 weeks	Persistent AF	Hypertension, coronary heart disease
P8	Female	87	Elementary school	Urban	With family	Widowed	1 year	Persistent AF	Coronary heart disease
P9	Female	68	High school	Rural	With family	Married	2 years	Paroxysmal AF	Hypertension, diabetes, coronary heart disease
P10	Male	39	Master’s degree	Urban	With family	Married	1 year	Paroxysmal AF	Hypertension, diabetes, coronary heart disease
P11	Female	62	High school	Rural	With family	Married	1 month	Persistent AF	Hypertension, diabetes
P12	Male	68	Junior high school	Urban	Alone	Married	2 years	Paroxysmal AF	Hypertension, diabetes, coronary heart disease
P13	Male	55	High school	Urban	With family	Married	1 year	Paroxysmal AF	None
P14	Female	58	Junior high school	Urban	With family	Married	6 months	Paroxysmal AF	None
P15	Male	66	Elementary school	Rural	With family	Married	2 years	Persistent AF	Hypertension, coronary heart disease
P16	Female	70	High school	Urban	With family	Married	3 months	Persistent AF	Hypertension, diabetes
P17	Male	51	Master’s degree	Urban	With family	Married	8 months	Persistent AF	None
P18	Female	78	Illiterate	Rural	Alone	Widowed	5 years	Paroxysmal AF	Coronary heart disease
P19	Male	63	Junior high school	Urban	With family	Married	1 year	Persistent AF	Hypertension, coronary heart disease
P20	Female	69	High school	Urban	With family	Married	2 years	Paroxysmal AF	Hypertension, coronary heart disease

Notes: Duration of illness refers to the time since the initial diagnosis of atrial fibrillation.

In this study, home-based exercise rehabilitation referred to the process of preparing for and initiating planned exercise activities at home after discharge following radiofrequency catheter ablation for atrial fibrillation, aiming to promote postoperative recovery and improve physical function. Because participants had not entered a standardized rehabilitation programme, this study focused on barriers and facilitators related to rehabilitation initiation rather than adherence to an established rehabilitation programme.

Following radiofrequency catheter ablation, patients received routine postoperative care and discharge education, including medication management, symptom monitoring, and general lifestyle recommendations. In the study setting, standardized cardiac rehabilitation programmes and individualized home-based exercise prescriptions were not routinely available after discharge. Patients received routine follow-up, including telephone follow-up by nurses; however, structured exercise supervision or digital rehabilitation support specifically designed for home-based exercise rehabilitation was not routinely provided.

Ethics

This study was approved by the Ethics Committee of the First Affiliated Hospital of Soochow University (Approval No. 2025640).

Data Collection

Face-to-face semi-structured interviews were conducted to explore patients’ perceptions, experiences, and factors influencing the initiation of home-based exercise rehabilitation after radiofrequency catheter ablation for atrial fibrillation. All interviews were conducted by the first author, a registered nurse with a bachelor’s degree and clinical experience in cardiovascular nursing. JJW was not involved in participants’ clinical care and had no prior relationship with any participant before the study. To maintain reflexivity, a reflexive journal was kept after each interview and regular team discussions were held to critically examine how the researcher’s background and assumptions might influence data collection and interpretation. Rather than attempting to eliminate researcher influence, this process aimed to recognize and critically examine it.

The interview guide was developed based on the Theoretical Domains Framework (TDF), relevant literature, and the research objectives. The guide explored participants’ understanding of home-based exercise rehabilitation, perceived facilitators and barriers, emotional experiences, social influences, and factors affecting their willingness to initiate exercise rehabilitation. The same interview guide was used throughout the study to ensure consistency in data collection. The interview guide is provided in Supplementary File 1.

A pilot interview was conducted in July 2025 with three participants to assess the clarity and appropriateness of the interview questions. Data from the pilot interviews were not included in the final analysis. Formal data collection was conducted from August 2025 to December 2025 after ethical approval was obtained. At discharge, eligible patients were informed about the study and invited to participate in an interview during their routine follow-up visit approximately one month after radiofrequency catheter ablation. All interviews were conducted face-to-face and individually in a quiet and private room at the hospital during follow-up visits, with only the participant and interviewer present.

Before each interview, the researcher established rapport with participants, explained the study purpose and procedures, and obtained written informed consent before audio recording. During the interviews, probing, clarification, and paraphrasing techniques were used to encourage participants to describe their perceptions, experiences, and concerns regarding home-based exercise rehabilitation. Field notes documenting participants’ nonverbal expressions and researchers’ reflections were recorded after each interview. Each interview lasted approximately 30–60 minutes. Interviews were discontinued if participants experienced discomfort or distress.

Data collection and preliminary analysis were conducted iteratively. Saturation was assessed jointly by the first author and a senior qualitative researcher throughout the interview process. Preliminary saturation was considered when no new substantive codes emerged across three consecutive interviews. Formal saturation was confirmed after the 20th interview, as the final three interviews (Nos. 18–20) generated no additional codes or themes relevant to the research questions. This assessment was reviewed and confirmed by the research team during regular analysis meetings.

Data Analysis

All audio recordings were transcribed verbatim in Chinese by the first author immediately after each interview. The transcripts were anonymized and imported into NVivo 12.0 for data management and analysis. Two researchers independently analyzed the data using qualitative content analysis. First, the researchers repeatedly read the transcripts to become familiar with the data and identified meaningful units related to the research questions. The meaning units were condensed, coded, and grouped into subcategories. Related subcategories were further compared and integrated to develop themes.

A hybrid inductive-deductive approach was adopted for data analysis. This two-stage process, consisting of inductive coding followed by deductive mapping onto the TDF domains, ensured that the findings remained grounded in the data while still allowing for theoretical interpretation.

Initial open coding was conducted inductively from the interview transcripts to allow participants’ experiences and perspectives to emerge before applying the theoretical framework. Subsequently, the identified codes and themes were mapped onto the relevant TDF domains through deductive analysis. The 14 TDF domains served as an interpretive framework rather than a rigid predefined coding structure. Codes that could not be immediately categorized within the TDF domains were retained and discussed by the research team until consensus was reached regarding their conceptual fit and subsequent mapping. The coding framework illustrating the relationships among interview questions, initial codes, categories, themes, and corresponding TDF domains is provided in Supplementary File 2.

To enhance credibility, member checking was conducted with five participants who had completed the interviews and returned for follow-up. The five participants were purposively selected to represent the diversity of the sample in terms of age, gender, educational level, and place of residence. Participants reviewed a summary of the preliminary findings, including themes, subthemes, and representative quotations, and confirmed whether the interpretations reflected their experiences. All participants agreed that the findings accurately represented their experiences, and no substantial modifications were required.

All interviews were conducted in Mandarin Chinese, and no interpreter was involved during the interview process. Initial coding and data analysis were performed using the original Chinese transcripts to preserve contextual and cultural meanings. After the analytical framework was finalized, representative quotations were selected and translated into English by the first author, a native Chinese speaker. A bilingual co-author with expertise in cardiovascular nursing independently reviewed the translated quotations for semantic and cultural equivalence. Any discrepancies between the Chinese and English versions were discussed and resolved through consensus. Formal back-translation was not performed; however, the review and consensus process helped ensure that the original meanings of participants’ statements were accurately preserved.

Quality Control

(1) The researcher had undergone systematic qualitative research training and continuously refined interview techniques. During pre-interviews, guidance and oversight were provided by a professor with extensive qualitative research experience. (2) Strict adherence to voluntary participation and confidentiality principles was maintained. Research subjects could terminate the interview at any time during the process. The researcher personally safeguarded interview and medical information, ensuring no external disclosure. (3) The pace of conversation was adjusted as needed during interviews, with clarification sought for ambiguous statements. (4) Given that the study was guided by the TDF framework, researchers acknowledged that theoretical perspectives might influence data interpretation. Reflexivity was maintained throughout the analysis process by continuously reflecting on researchers’ perspectives and potential influence on coding and theme development. Regular team discussions were conducted to critically review interpretations and achieve consensus.

Results

At the time of interview (approximately one month after radiofrequency catheter ablation), none of the participants had initiated a structured home-based exercise rehabilitation programme. Although some participants reported engaging in spontaneous light physical activities, such as walking or household activities, these activities were not performed according to structured rehabilitation plans. Therefore, the findings presented below reflect patients’ perceived barriers and facilitators to initiating home-based exercise rehabilitation during the early post-ablation recovery phase.

This study identified 3 themes and 5 subthemes for promoting factors and 8 themes and 15 subthemes for impeding factors, as shown in Table 2.

Table 2.

Themes, Subtheme and Sample Statements of Participants

Theoretical Domains Framework	Theme	Subtheme	Sample Statements of Participants
Knowledge	1. Lack of exercise knowledgea	1.1 Insufficient understanding of exercise objectives	“I’m not sure what sports suit me, since besides grocery shopping, I just water the plants and sweep the floor. I’ve never actively researched what exercises I should do or what I’m capable of doing.” (P1)
			“I just do whatever sports make me feel good. I don’t really know what’s suitable for me.” (P14)
			“My wife and I are getting older and need to recuperate, so we don’t do any exercise.” (P9)
		1.2 Insufficient understanding of optimal exercise timing	“No one told me when exactly I should start exercising after getting home.” (P16)
Skills	2. Inadequate skill masterya	2.1 Difficulty in acquiring new skills	“It’s mainly because I’m a bit lazy at heart—if it’s a difficult exercise, I’m not really willing to do it.” (P4)
			“I tried following the video, but the movements are too complicated for me to remember.” (P15)
		2.2 Digital divide among the elderly	“I’m getting older, and I don’t know how to use electronic devices. I also don’t feel the need to wear a fitness tracker.” (P9)
			“I don’t even know how to search for exercise videos on my phone.” (P18)
		2.3 Insufficient self-monitoring skills	“I don’t judge exercise intensity; I think if you don’t feel uncomfortable after working out, the intensity is probably just right.” (P5)
			“I just go by how I feel. If I feel okay, I keep going.” (P19)
Social/professional roles and identity	3. Social role conflicts and responsibilities	3.1 Family responsibility as a motivatorb	“Not just for myself, but also for my wife and kids—when I’m hospitalized, someone has to stay with me full-time. It’s exhausting for them too. If exercise really helps me get sick less often, I’d definitely be willing to do it.” (P6)
			“I need to get my health back on track. If I die, my son won’t have anyone to look after him, and my wife would be under too much pressure.” (P3)
		3.2 competing family responsibilities and limited timea	“I have to take care of my grandkids during the day. By the time I’m free, I’m too tired to exercise.” (P20)
Beliefs about capabilities	4. Low exercise self-efficacya		“I’m not very confident about it, because I feel my current exercise routine works well for me. I don’t experience any discomfort when I work out, and if I were to make adjustments, I’m not sure I’d be able to do it well or stick with it.” (P12)
			“I’m worried I won’t be able to keep going if it gets too hard.” (P14)
Goals	5. Benefit-driven motivationb	5.1 Improve clinical indicators	“I have diabetes, so even if it’s just to control my blood glucose, I have to keep exercising.” (P13)
			“My blood pressure has been unstable Exercise should help with that.” (P16)
		5.2 Alleviation of physical symptoms	“I just feel like my body was in better shape when I practiced Tai Chi—at least I didn’t catch colds or get sick as easily back then.” (P8)
			“I hope to feel better physically, especially with this leg. I hope that after exercising, my leg will feel more and more comfortable and less swollen.” (P9)
			“I used to have trouble sleeping. Since I started walking every day, I sleep much better.” (P19)
Memory, attention and decision processes	6. Distress from physical symptomsa	6.1 fatigue	“Even walking a little makes me feel exhausted. I just want to lie down.” (P18)
		6.2 pain	“I’ve been feeling a dull ache in my chest, like it’s being pulled, so I’ve been lying in bed most of the time these past few days without much movement.” (P12)
Environmental context and resources	7. Poor resource accessibilitya	7.1 Insufficient professional guidance	“The doctor never mentioned anything about exercise after I got home, so I figured it probably wasn’t that important.” (P9)
			“The doctor didn’t say much about exercise when I was discharged. I wasn’t sure if I should do anything.” (P15)
		7.2 Physical environment constraints	“The environment is so bad right now, I really don’t want to exercise outdoors.” (P2)
			“It’s too cold to go outside in winter, and I don’t have space at home to move around.” (P20)
		7.3 Lack of family support	“My son doesn’t support this. He keeps telling me to stop messing around—we’re not short on money, so just close the shop. Riding a bike every day isn’t safe either. You should just stay home.” (P12)
			“My wife thinks I’m too old to exercise. She says I should just rest.” (P15)
		7.4 Absence of peer support	“The main thing is that lately no one has been working out with me. If I had a friend to exercise with, I’d definitely be able to stick with it better.” (P9)
			“I see other people exercising in the park with friends, but I don’t have anyone to join me.” (P17)
Social influences	8. Trust and recognition of professionalsb	8.1 Trust in expertise	“Of course I’ll follow the doctor’s orders. What the doctor says is definitely professional—I haven’t studied medicine.” (P10)
			“I trust what the rehabilitation specialist says. They know better than I do.” (P14)
		8.2 Recognition of authority	“I’ll do as you say. I always listen to doctors and nurses—if they tell me to move, I move; if they tell me to stay still, I stay still.” (P3)
			“Whatever the doctor recommends, I’ll follow. They have the authority.” (P11)
Emotion	9. Emotional concerns and psychological barriersa	9.1 Fear of exercise-triggered symptom recurrence	“I’m afraid the illness might come back. (so) I definitely won’t dare to exercise for now.” (P8)
			“What if my heart starts racing again? I’m too scared to try.” (P16)
		9.2 Worry about unaccompanied exercise-related emergencies	“I always worry something might happen when no one is around.” (P18)
		9.3 Persistent low mood and loss of motivation	“I’m feeling down, like I’m depressed. My mind is all over the place, especially at night. When the lights go out, I can’t even bring myself to open my eyes when I hear noises outside.” (P4)
Behavioral regulation	10. Absence of exercise plansa		“I don’t have an exercise plan; you guys just get it for me.” (P9)
			“I don’t really have a plan. I just walk when I feel like it.” (P20)

Notes: a: Impeding factors; b: Promoting Factors.

Promoting Factors

Theme 1. Benefit-Driven Motivation

Subtheme 1.1 Improvement of Clinical Indicators

Patients believe that exercise can help restore their clinical indicators, such as blood glucose and blood lipids, to normal levels, thereby improving their quality of life. This belief serves as a significant internal motivation for them to persist with their exercise regimen.

I have slightly hyperlipidemia. Exercise should help lower them a bit, and it’s definitely good for cardiovascular health. (P10)

Subtheme 1.2 Alleviation of Physical Symptoms

Some patients directly focus their exercise goals and motivation on improving sleep, alleviating gastrointestinal discomfort, and reducing leg swelling.

I either can’t fall asleep or can’t wake up properly. Some say practicing the Eight Brocades can help you sleep without sleeping pills and even improve your appetite. (P5)

Theme 2. Trust and Recognition of Professionals

Subtheme 2.1 Trust in Expertise

Participants described strong trust in healthcare professionals’ exercise rehabilitation knowledge and recommendations, which influenced their decisions to initiate exercise.

The doctor told me exercise is good for my heart and lungs, so I’m definitely going to exercise. (P6)

Subtheme 2.2 Recognition of Authority

Patients’ recognition of the status and identity of healthcare professionals makes them more willing to comply with medical advice.

Whatever exercise you tell me to do, I’ll do it. (P1)

Theme 3. Social Role Conflicts and Responsibilities

Subtheme 3.1 Family Responsibility as a Motivator

Patients experienced psychological distress due to shifts in family roles, believing that maintaining good health was crucial for reducing the burden on their families. A strong sense of responsibility drove them to actively pursue health.

I need to get my health back on track. If I die, my son won’t have anyone to look after him, and my wife would be under too much pressure. (P3)

Impeding Factors

Theme 1. Lack of Exercise Knowledge

Subtheme 1.1 Insufficient Understanding of Exercise Objectives

Patients returning home after surgery often face information gaps and insufficient understanding of the purpose of exercise, which hinders the effectiveness of intervention measures. Additionally, some elderly patients, influenced by traditional notions of aging, mistakenly believe that rest is appropriate for the elderly.

I don’t know which sports suit me best. I just do whatever sports make me happy and feel good. (P2)

Subtheme 1.2 Insufficient Understanding of Optimal Exercise Timing

Some patients are unclear about when to begin exercise rehabilitation after discharge.

Should I be moving around or not one month after my surgery? (P3)

Theme 2. Inadequate Skill Mastery

Subtheme 2.1 Difficulty in Acquiring New Skills

Although medical staff provided detailed guidance and training to patients before discharge, most elderly patients found exercises like Tai Chi and Baduanjin too complex, presenting practical difficulties in learning and memorizing the movements.

Baduanjin and Tai Chi are a bit challenging to learn, but I think I could stick with simpler exercises. (P13)

Subtheme 2.2 Digital Divide Among the Elderly

Due to factors such as age and receptivity, patients face challenges in utilizing digital technologies.

I don’t know how to use a smartwatch, and I’ve never used one. At my age, I probably won’t learn how to use one either. They’re just for young people. (P5)

Subtheme 2.3 Insufficient Self-Monitoring Skills

Some patients lacked the knowledge and skills to monitor objective indicators and adjust exercise intensity as prescribed in exercise prescriptions, relying instead on their subjective perception of physical sensations during exercise for self-monitoring.

I can judge for myself based on how I feel. If I feel uncomfortable, I’ll stop and rest. (P1

Theme 3. Social Role Conflicts and Responsibilities

Subtheme 3.1 Competing Family Responsibilities and Limited Time

Some respondents indicated that the responsibilities and pressures associated with their social roles hindered their exercise routines.

When I’m busy, I just can’t find time to exercise. As the only manager in our department, I can’t take time off. (P10)

Theme 4. Low Exercise Self-Efficacy

Some patients expressed confusion about the complexity and uncertainty of exercise rehabilitation, lacking confidence in the process.

I’m worried I won’t be able to keep going. (P4)

Theme 5. Distress From Physical Symptoms

Subtheme 5.1 Fatigue

Most patients reported feeling fatigued and physically drained during home-based exercise rehabilitation after discharge, leading them to discontinue the program prematurely.

I’ve lost all my strength and can’t move anymore. Now, aside from doing the Eight Brocades every day, I just lie around the rest of the time. (P2)

Subtheme 5.2 Pain

Some patients experienced persistent pain that limited their physical activity.

I’ve been feeling a dull ache in my chest, like it’s being pulled, so I’ve been lying in bed most of the time these past few days without much movement. (P12)

Theme 6. Poor Resource Accessibility

Subtheme 6.1 Insufficient Professional Guidance

Most patients reported that during the home-based exercise rehabilitation phase following discharge, they did not receive professional guidance and advice from healthcare providers.

I don’t know what sports I’m suited for because no one has ever told me. (P3)

Subtheme 6.2 Physical Environment Constraints

Adverse physical environmental conditions, particularly cramped indoor spaces and harsh outdoor natural environments, directly hindered patients’ ability to engage in physical activity and fostered a negative attitude toward exercise rehabilitation.

Our place isn’t very spacious, so it’s a bit cramped to do the Baduanjin. (P1)

Subtheme 6.3 Lack of Family Support

Family support was crucial for recovery, but some patients reported that the support provided by their families often remained limited to verbal encouragement.

My husband supports me in exercising, but he won’t lift a finger to help me with the housework. He never helps me with anything. (P4)

Subtheme 6.4 Absence of Peer Support

The lack of supervision and encouragement from friends during the home rehabilitation phase left patients feeling isolated and lacking motivation, making it difficult to stick to their exercise plans.

I’ve been living here for half a year now, but I don’t have many friends. I don’t really socialize with people in the neighborhood either, and I can’t find anyone to exercise with. (P7)

Theme 7 Emotional Concerns and Psychological Barriers

Subtheme 7.1 Fear of Exercise-Triggered Symptom Recurrence

Fear of exercise and concerns about exercise-triggered symptom recurrence were major barriers to initiating home-based exercise rehabilitation after ablation. Even among those considered suitable for home-based rehabilitation following professional assessment, many participants remained concerned that exercise might trigger atrial fibrillation recurrence or exacerbate existing symptoms. These concerns about potential risks reduced their willingness to initiate exercise.

I’ve always been worried about AF recurrence, and I usually feel flustered when I’m inactive. I had a sudden discomfort and fell on my head before, which made me afraid to exercise now. (P3)

Subtheme 7.2 Worry About Unaccompanied Exercise-Related Emergencies

Some participants expressed concern about exercising alone at home, primarily because they worried that a medical event might occur during exercise when no one was available to provide assistance.

I’m home alone. What if I get short of breath or feel tightness in my chest while exercising? (P6)

Subtheme 7.3 Persistent Low Mood and Loss of Motivation

Some participants described persistent low mood, reduced interest, and fear associated with sleep, which appeared to reduce their motivation to initiate home-based exercise rehabilitation.

I’m feeling down, like I’m depressed. My mind is all over the place, especially at night. When the lights go out, I can’t even bring myself to open my eyes when I hear noises outside. (P4)

Theme 8 Absence of Exercise Plans

Exercise plans could positively influence patients’ acceptance and adherence to physical activity. However, most patients in this study reported lacking a clear exercise plan, engaging in physical activity rather casually, and having no structured approach to managing rehabilitation exercises for their condition.

I don’t have an exercise plan; I just follow whatever the doctor tells me to do later. (P1)

Cross-Theme Variation and Interactions

Across participants’ accounts, barriers and facilitators did not appear to operate independently, and their influence varied according to individual and contextual circumstances. Professional recommendations could strengthen motivation to initiate exercise when participants trusted healthcare professionals and recognized the benefits of rehabilitation; however, concerns about symptom recurrence or exercise-related harm could weaken this motivation despite professional encouragement. Social responsibilities also showed a context-dependent role. For some participants, family responsibility motivated rehabilitation because recovery was perceived as necessary for resuming valued family roles, whereas for others, competing family or occupational demands restricted the time and opportunities available for exercise. Participants’ responses to healthcare professionals also varied, ranging from trust in professional expertise to reliance on medical authority. These contrasting accounts indicate that the same individual or contextual factor could function differently depending on how it was perceived and experienced by the participant.

Discussion

Guided by the TDF principles, this study provides a systematic analysis of the barriers and facilitators influencing the initiation of home-based exercise rehabilitation after AF radiofrequency ablation. The findings reveal that the initiation of home-based exercise rehabilitation after AF radiofrequency ablation is influenced by multiple layers. Research indicates that reasons for refusal to participate in cardiac telerehabilitation among elderly chronic disease populations include advanced age, personal preferences, low educational attainment, and reduced physical activity levels.²¹ Other studies highlight external barriers to elderly participation in exercise rehabilitation, such as lack of companionship, insufficient discretionary time, and inadequate equipment.^22,23 Healthy aging is a focal point in rehabilitation, with active health serving as its foundation. Active health represents a holistic medical perspective that promotes individuals’ subjective initiative, emphasizes quality of life, and encourages sustained engagement in health maintenance through enhancing health literacy and cultivating positive health behaviors.²⁴ The ability of middle-aged and elderly patients after AF radiofrequency ablation to adapt to exercise rehabilitation therapy and promote physical and mental recovery may be an important determinant of their quality of life and disease prognosis.

This study found that patients’ motivation for home-based exercise rehabilitation after surgery stems not from a superficial understanding of exercise efficacy, but from direct perceived benefits. These benefits manifest as improvements in clinical indicators and relief from physical symptoms. Patients’ motivation for home exercise rehabilitation arises not only from positive outcome expectations, but also from personally experiencing the effects of consistent exercise and overall physical recovery. Positive exercise experiences may reinforce patients’ favorable evaluations of physical activity, enhancing their intrinsic motivation. When conducting health education, healthcare providers should consciously guide patients to focus on and document the short-term, positive physical changes brought about by exercise. This approach consolidates and sustains their intrinsic drive, enabling self-empowerment.²⁵ Furthermore, our research indicates that trust and recognition of healthcare professionals also play a role in promoting the initiation of home-based exercise rehabilitation.

Patients’ acceptance of exercise recommendations is influenced both by medical authority and their trust in healthcare providers. The former reflects recognition of professional credentials, while the latter stems from trust built through direct interactions. Therefore, healthcare providers should prioritize maintaining a professional image, practicing empathetic communication, and fostering ongoing engagement to strengthen these trust relationships.

While direct perceived benefits and trust in healthcare professionals serve as crucial motivators, this study also identified a complex array of barriers that impede patients’ engagement in home-based exercise rehabilitation. Recent methodological literature has suggested that qualitative research focusing on barriers and facilitators should move beyond simply cataloguing individual factors and instead explore how behavioural determinants interact within complex contexts.²⁶ Consistent with this perspective, the present study found that the barriers identified during the initiation of home-based exercise rehabilitation rarely functioned independently but instead reinforced one another. In particular, inadequate professional guidance often contributed to uncertainty regarding the safety and appropriateness of exercise after discharge. This uncertainty subsequently reduced participants’ confidence in initiating exercise, increased emotional concerns about symptom recurrence, and encouraged reliance on subjective physical sensations rather than structured self-monitoring. As a result, several participants gradually postponed or avoided initiating planned home-based exercise rehabilitation. Together, these findings provide a more integrated understanding of how multiple behavioural determinants influence the initiation of home-based exercise rehabilitation.

In this study, patients who underwent AF radiofrequency ablation demonstrated disparities in knowledge regarding exercise rehabilitation. While a minority clearly understood the purpose of exercise, the majority lacked sufficient awareness of the objectives, methods, and timing of exercise rehabilitation. This resulted in uncertainty regarding how and when to initiate exercise rehabilitation.^11,25 Analysis suggests this may be related to the predominantly middle-aged and elderly patient population, whose access to information is limited, relying primarily on verbal advice from healthcare providers and television news. On the other hand, Yu et al²⁷ categorized exercise rehabilitation engagement among chronic heart failure patients into four stages—inactive, awakening, dependent, and self-directed—based on the Patient Health Engagement model. These stages reflect progressive trends in patients’ cognition, emotions, and behaviors. In this study, most patients remained essentially in an inactive stage before the initiation of structured exercise rehabilitation, with their cognition, emotions, and behaviors yet to be activated. Existing research predominantly investigates or intervenes in factors influencing exercise participation and maintenance, overlooking its time-varying characteristics throughout the rehabilitation process. Although the cross-sectional interview design did not allow direct observation of within-person changes over time, participants’ accounts suggested that the relative importance of barriers and facilitators may vary across the postoperative recovery process. Therefore, healthcare providers may consider proactively transitioning from executors to facilitators, prioritizing the phased obstacles patients encounter during home-based exercise rehabilitation. Utilizing multiple channels such as educational brochures and instructional videos can assist patients in progressing from the “inactive stage” to the “awakening stage”.

Additionally, patients in this study encountered difficulties in mastering the skills required for home-based exercise rehabilitation. Some patients reported that traditional exercises such as Baduanjin and Tai Chi involved complex movements that were challenging to learn and remember, potentially related to age-related cognitive changes. Complex motor skills demand higher levels of physical coordination. To successfully learn new skills, exercise task design should ensure difficulty levels align with individual capabilities to facilitate early engagement.²⁸ Some patients also underestimated the importance of self-monitoring during exercise, relying more on subjective feelings than objective indicators to judge exercise intensity, thereby increasing exercise risks. Furthermore, the digital divide exacerbated the difficulty of skill acquisition, a finding consistent with previous studies.²⁵ This suggests that intervention strategies should consider technological accessibility, potentially lowering barriers through voice-interactive devices, one-button operation interfaces, and age-friendly tool designs.

Patients’ perceptions of the value and risks associated with home-based exercise rehabilitation, as well as their postoperative psychological state, also influence exercise levels. When patients perceive the value of postoperative home-based exercise rehabilitation to outweigh its perceived risks, they develop positive exercise intentions. Perceived value of exercise helps enhance behavioral motivation and exercise self-efficacy, positively promoting physical activity. Conversely, perceived exercise risks may evoke worry and low mood, potentially limiting engagement in physical activity. Concurrently, concerns about adverse cardiac events and uncertainty regarding exercise safety further amplify patients’ fear, diminishing their intrinsic motivation. Additionally, some patients lacked clear exercise plans, leaving them without guidance when facing cognitive biases about risks or emotional fluctuations. This makes them prone to interrupting exercise due to immediate worries or discomfort, hindering the initiation of planned exercise rehabilitation behaviors.

Therefore, enhancing patients’ self-efficacy may be a relevant target for future interventions aimed at promoting initiation of home-based exercise rehabilitation. Candidate strategies could include establishing phased activity goals and utilising case sharing to help patients build confidence. In addition, identifying psychological barriers and emotional fluctuations, and providing appropriate emotional support, may help address some of the perceived barriers reported by participants. However, as the study did not objectively measure exercise engagement, these suggestions should be interpreted as hypothesis-generating options for future research rather than practice recommendations supported by the present findings.

The current level of family support received by patients failed to meet their needs, and caregivers similarly lacked knowledge about AF home-based exercise rehabilitation. Family support could be enhanced by strengthening caregivers’ knowledge and skills and guiding healthy behaviors. The absence of peer support was a widespread issue, with most patients expressing a desire to exchange experiences with others. Developing a mobile peer support application for AF patients could be explored as a candidate approach to leverage the peer role model effect for knowledge sharing and emotional interaction among patients,²⁹ though its feasibility and acceptability would require systematic evaluation before implementation. External environmental constraints also hindered home-based exercise rehabilitation. Most patients could not access sustained professional guidance after discharge, and limited living conditions directly restricted exercise implementation. This finding suggests that future programmes may benefit from developing exercise plans that take into account patients’ residential environments. However, the specific strategies for implementing such environmental adaptations would need to be developed and tested in collaboration with patients and healthcare providers.³⁰

This study also found that social roles exert a dual effect on home-based exercise rehabilitation among AF patients. Family responsibilities translated into intrinsic motivation for patients to initiate rehabilitation, while occupational responsibilities became barriers to initiating exercise rehabilitation due to time conflicts. Therefore, healthcare providers should conduct individualized assessments of patients’ social role characteristics: reinforcing intrinsic motivation for those driven by family responsibilities, and assisting those experiencing occupational role conflicts in exploring fragmented exercise regimens, such as short sessions of 5–10 minutes spread throughout the day, which may help them incorporate physical activity into daily routines despite time constraints.

Patients undergoing radiofrequency catheter ablation for atrial fibrillation represent a clinically heterogeneous population. The barriers and facilitators influencing the initiation of home-based exercise rehabilitation may differ according to AF type, cardiac function, symptom burden, and comorbidities. Although our sample included patients with both paroxysmal and persistent AF and varied comorbid conditions, the study was not designed to systematically compare experiences across these clinical subgroups. Future research incorporating more detailed clinical phenotyping is warranted to explore whether patients with different clinical profiles face distinct barriers or facilitators to initiating home-based exercise rehabilitation.

Limitations

This study has several limitations. First, the single-center design and recruitment of participants from one hospital in Jiangsu Province may limit the transferability of the findings to other geographic and healthcare contexts. Second, purposive sampling from a single tertiary hospital may limit the transferability of the findings, and participants who agreed to participate may have differed from those who declined, potentially introducing selection bias. Future multicenter qualitative studies involving more diverse populations are warranted to enhance the transferability of the findings. Third, patients with severe cognitive impairment, significant physical disabilities, or severe medical conditions were excluded to ensure the feasibility of data collection and participant safety. Consequently, the perspectives of more vulnerable post-ablation patients with greater rehabilitation needs may not have been fully represented. Fourth, participants were interviewed approximately one month after radiofrequency catheter ablation; therefore, the findings primarily reflect barriers and facilitators during the early initiation phase of home-based exercise rehabilitation and may not fully capture how behavioural determinants change throughout the rehabilitation process. Future longitudinal qualitative studies are warranted to explore how these factors evolve over time and vary across different patient characteristics and rehabilitation stages. Fifth, the absence of a standardised operational definition and objective assessment of exercise behaviour (eg, exercise frequency, intensity, duration, or adherence) may limit comparability across studies. In addition, postoperative symptom burden and clinical improvement were not systematically assessed; therefore, we were unable to distinguish intentional avoidance of exercise from reduced physical activity attributable to postoperative symptoms, medical limitations, or clinical advice. Finally, as a qualitative study informed by the Theoretical Domains Framework, the findings may have been influenced by researchers’ interpretations. Although a hybrid deductive–inductive analytical approach, team discussions, and member checking were used to enhance methodological rigour, both interpretive bias and framework-driven confirmation bias cannot be completely excluded.

Policy Implications

These findings can inform institutional policies and cardiac rehabilitation guidelines to improve post-ablation exercise education and support systems. Additionally, they may provide practical references for healthcare professionals to develop individualised communication strategies and design rehabilitation plans tailored to patients’ home environments, social contexts, and psychological readiness, thereby enhancing patient engagement in home-based exercise rehabilitation.

Conclusion

This qualitative study, grounded in the TDF, explored patients’ perceived facilitators and barriers to home-based exercise rehabilitation during the early recovery phase following atrial fibrillation radiofrequency ablation. Participants reported that their exercise behaviors were shaped by a complex interplay of individual and contextual factors. Key facilitators included benefit-driven motivation, trust and recognition of healthcare professionals, and family responsibility as a motivator. Key barriers included lack of exercise knowledge and skills, low exercise self-efficacy, fear of symptom recurrence, physical discomfort, poor resource accessibility, and absence of exercise plans. Notably, some participants expressed passive compliance with provider instructions rather than active engagement, suggesting that the quality of patient-provider interaction may be relevant to patients’ initiation of home-based exercise rehabilitation during the early post-ablation period.

These findings highlight that home-based exercise rehabilitation in this population is not solely a matter of individual motivation but is embedded within social, informational, and environmental contexts. The results offer an empirical foundation for developing multi-component intervention strategies that address not only patients’ psychological concerns but also their informational needs and social support systems. Future research is needed to examine how these perceived barriers and facilitators evolve over longer recovery trajectories and to test whether interventions targeting the identified factors can improve exercise adherence and clinical outcomes in this population.

Data Sharing Statement

The data in this study are not publicly available as they relate to the privacy of the participants.

Ethics Approval and Consent to Participate

This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the First Affiliated Hospital of Soochow University (Approval No. 2025640). Written informed consent was obtained from all participants prior to the interviews, including consent for the publication of anonymized responses and direct quotations.

Consent for Publication

All participants provided written informed consent for the publication of anonymized responses and direct quotations.

Author Contributions

Jiajia Wu: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draft.

Lei He: Data curation, Formal analysis, Investigation, Writing – review & editing.

Jing Wang: Data curation, Formal analysis, Investigation, Writing – review & editing.

Xiangyu Wang: Data curation, Formal analysis, Investigation.

Bingqing Lu: Data curation, Investigation.

Zhi Zhao: Methodology, Resources, Formal analysis.

Sijia Sun: Methodology, Resources.

Cuilian Chen: Supervision, Writing – review & editing.

Bo Chen: Supervision, Writing – review & editing.

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. Jiajia Wu, Lei He, and Jing Wang have contributed equally to this work and share first authorship.

Disclosure

The authors declare no competing interests.