There is a paucity of data examining the PA experiences of people with CHD and depressive symptoms. The aim of the current study was to provide an in-depth account of barriers to and facilitators of PA in this population. The rich descriptive data derived from participants highlights the hindrances and motivators to maintaining PA after a cardiac event. There were numerous factors that negatively impacted on PA levels, including having negative perceptions towards health and life changes as a result of the cardiac event, having low mood and low motivation to exercise, feeling physically restricted or fearful of exercise, lacking knowledge regarding exercise and perceiving external barriers, such as financial constraints and weather conditions. These barriers were highly salient for a number of participants, particularly those who were inactive, and often appeared to have a negative influence on PA levels.
The results of the present study highlight the breadth of intrapersonal barriers. The intrapersonal barriers reported, such as lack of motivation, low mood, physical restrictions and negative perceptions of life changes, provided a major hindrance to participants’ ability to be physically active. Although there was a small number of participants in this study who reported financial concerns and weather conditions as being potential barriers, overall, environmental and organisational factors, such as lack of safety, access to facilities and lack of time were not mentioned as being problematic for the present sample. This finding concurs with those of Fleury et al.
 who in their study of post-CR participants also reported that intrapersonal barriers to PA comprised the majority of overall barriers.
The dominance of intrapersonal factors as barriers to PA participation reported by participants with CHD and depressive symptoms may be a unique finding for people with a chronic illness, as numerous studies of the general population have identified a major influencing effect of environmental barriers on PA participation
[27, 28]. Surprisingly, not one participant in the current study reported that they did not have time to exercise. Perhaps this could be due to the fact that most of the participants were no longer working full-time, and had more time to invest into exercise than working people. Or maybe the intrapersonal barriers such as lack of motivation and negative perceptions of health changes were more salient to people with depression and CHD. It is also possible that, if these intrapersonal factors were addressed and overcome, a new set of barriers at environmental and institutional levels may be uncovered. Further investigation of this possibility is required.
Participants reported low mood to be a barrier to PA in its own right and in addition, low mood appears to be linked to a number of the other barriers. Lack of motivation, negative perceptions of health and life changes, fear and uncertainty are all intertwined with depression and low mood
. It is possible that, because the participants in the present study were also experiencing depressive symptoms, the ability to overcome barriers, such as lack of motivation and negative perceptions, may have been even more difficult than would be the case for people without depressive symptoms. It is likely that there is a confounding and complex relationship between depression, CHD and maintenance of PA. This hypothesis requires further investigation using quantitative methods.
In support of our hypothesis was the finding that barriers to PA were more frequently reported by inactive individuals than by active individuals. In particular, holding negative perceptions about life changes and health and having a lack of motivation to exercise were not considered a barrier to being physically active for any participants who were active, yet they were problematic to the majority of inactive participants. It is possible that simply being active provides motivation to be continually involved in PA and encourages positive perceptions about the changes to one’s life and health. Active individuals may be faced with the same barriers as inactive individuals, but have been able to overcome these barriers more effectively. Interestingly, low mood appeared to impact on PA levels of both active and inactive people. Health professionals can use this information to understand the possible barriers to PA, especially for people who are inactive, and to attempt to help patients overcome these barriers.
Participants in the current study also identified a number of factors that assisted in motivating them to engage in PA. Active participants reported more facilitators to PA than did inactive participants. In particular, being aware of psychological changes associated with exercise was an important facilitator in maintaining PA. This acted to inspire and encourage participants to adhere to their PA program. Other studies with cardiac and psychiatric populations have also identified mental health benefits to be a major motivator to PA
[29, 30]. It is possible that because the participants in the current study were experiencing depressive symptoms, they may have been even more aware of any positive psychological changes resulting from exercise. These possibilities could be the focus of further quantitative studies.
For many participants, especially those who were active, one of the key facilitators mentioned was the importance of having a reason for exercising. The present results indicate the importance of identifying the main reasons for exercising and then focussing on those reasons whilst exercising to ensure PA maintenance. Surprisingly, few qualitative studies in either cardiac or non-cardiac populations have reported this as a facilitator, suggesting that it might be particular to people with CHD and depression. One study reported CR participants who consistently engaged in exercise programs used their desire to survive and improve their health as the driving force in their motivation to exercise
. Encouraging people to identify the main reasons for exercising could be a very useful strategy in PA interventions, particularly for those with depression, for whom having a definite focus and engaging in goal setting can be important in maintaining PA
. Again, this possibility requires focussed research.
The present study provides an in-depth analysis of previously unexplored experiences of PA for people with depressive symptoms and CHD. Despite the strength of the findings in the current study, there were a number of limitations. First, the sample was not necessarily representative of the wider cardiac population. All participants had taken part in an earlier quantitative study undertaken by the same researchers and had expressed an interest in being involved in further research. In addition, the participants were all from an Australian or European background. Caution should therefore be exercised when generalising these results to CHD patients from other cultural backgrounds. Second, the CDS was administered up to four weeks prior to the interview, thus it is unclear whether depressive symptoms were present at the time of the interview. Importantly, previous studies have demonstrated that patients’ depression levels remain largely stable in the 12 months after a cardiac event
. Therefore, it is highly likely that participants were still experiencing at least some degree of depressive symptoms at the time of the interview.
The findings from the current study provide a preliminary depiction of some of the relevant barriers to and facilitators of PA for a group of participants experiencing both depressive symptoms and CHD. To further validate and verify these findings, a large scale quantitative study is required. A study of this type could include a sample of both depressed and non-depressed cardiac patients to ascertain the extent or prevalence of these barriers and compare the relative importance of the barriers to and facilitators of PA. Investigations could also include whether or not the barriers and facilitators were present before the cardiac event. In the current study, there were insufficient numbers to investigate whether there were differences in barriers and facilitators for males and females. A larger study is required to investigate gender differences in barriers and facilitators. The gender imbalance in this study is a result of the commonly seen larger number of males compared to females who experience a cardiac event (ratio 80:20).
The information gained through the current research may be useful in developing and implementing an intervention to encourage PA maintenance for people with CHD and depression. These findings could also provide valuable information for health care professionals working with both active and inactive people with CHD, particularly those in hospital- and community-based CR programs. Working with patients to identify and overcome relevant barriers and promote facilitators of PA could assist health professionals to be sensitive to the needs of people with CHD and depressive symptoms, and possibly improve health outcomes. The prevalence of depression in people with CHD, and the negative effect of the combination of CHD and depression on physical and psychological health together highlight the importance of the present research.