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 >18 years 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.