Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the Theoretical Domains Framework

Question: What are the barriers and enablers of referral, uptake, attendance and completion of pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD)?

Design: Systematic review of qualitative or quantitative studies reporting data relating to referral, uptake, attendance and/or completion in pulmonary rehabilitation.

Participants: People aged >18years with a diagnosis of COPD and/or their healthcare professionals.

Data Extraction and analysis: Data were extracted regarding the nature of barriers and enablers of pulmonary rehabilitation referral and participation. Extracted data items were mapped to the Theoretical Domains Framework (TDF).

Results: A total of 6969 references were screened, with 48 studies included and 369 relevant items mapped to the TDF. The most frequently represented domain was 'Environment' (33/48 included studies, 37% of mapped items), which included items such as waiting time, burden of illness, travel, transport and health system resources. Other frequently represented domains were 'Knowledge' (18/48 studies, including items such as clinician knowledge of referral processes, patient understanding of rehabilitation content) and 'Beliefs about consequences' (15/48 studies, including items such as beliefs regarding role and safety of exercise, expectations of rehabilitation outcomes). Barriers to referral, uptake, attendance or completion represented 71% (n=183) of items mapped to the TDF. All domains of the TDF were represented; however, items were least frequently coded to the domains of 'Optimism' and 'Memory'. The methodological quality of included studies was fair (mean quality score 9/12, SD 2).

Conclusion: Many factors - particularly those related to environment, knowledge, attitudes and behaviours - interact to influence referral, uptake, attendance and completion of pulmonary rehabilitation. Overcoming the challenges associated with the personal and/or healthcare system environment will be imperative to improving access and uptake of pulmonary rehabilitation.