Assignment: Virtual Education in Cardiac Rehabilitation during and after the Pandemic: A Literature Review

Assignment: Virtual Education in Cardiac Rehabilitation during and after the Pandemic: A Literature Review

Assignment: Virtual Education in Cardiac Rehabilitation during and after the Pandemic: A Literature Review

Literature Review Template
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I. ABSTRACT
This is a summary of your work and is the most important section to attract a reader’s attention.
An abstract is a brief summary of your overall dissertation project, and is used to help the reader quickly ascertain the review’s purpose. Your examiner or reader should be able to make a decision on what is the focus of the dissertation based on the abstract and what information should expect to find in your review.
Please ensure you include a brief introduction to the topic, description of key methods and results, and some interpretation of findings and conclusions. Keep it succinct and factual.

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The abstract should be complete in itself; it should not contain undefined abbreviations or reference to table numbers, figure numbers and references. The abstract is about your review.
Your abstract can use approximately 5% of your word count and it should not normally be more than 300 words.
Keywords: Keywords are used to retrieve papers in an information system such as an online journal, databases or a search engine. Here you can provide three to four key words or phrases in alphabetical order, separated by commas that best describe your project and/or methodology.
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II. INTRODUCTION
The introduction section should focus on the topic of your investigation and provide information that will lead your reader and examiner to your research question and aim and objectives of your review. The Introduction should begin rather broadly and get progressively more specific, ending with a paragraph outlining your aim and objectives. Commonly, introductions are structured around three main parts/paragraphs (please do not use subheading in your introduction).
1st: The first paragraph/part deals with the importance of your topic. State why the problem you address is important. In this paragraph you should elaborate on the general problem statement and the relevance to practice, nursing or more widely to healthcare.
2nd: The second paragraph/part gives an overview of pertinent issues on the specific topic and provides important operational definitions. Do not forget to discuss what is lacking in current knowledge as well in this section.
3rd: The discussion in the two previous paragraphs should lead your reader/examiner to the third paragraph/part of your introduction which states the aims and objectives of your dissertation or the research question. Stating your aim and objectives is absolutely essential to this part of your review. If you cannot state the research question, aim and/or objectives clearly and succinctly, the reader/examiner will be lost, and it will also be impossible to you and for your readers to make the connections with other sections of your review like your Methods, Results and Discussion. Therefore, make sure that there is a statement in your paragraph along the line “The aim of this literature review was to …..”
Your introduction section usually accounts for approximately 10% of your word count. You should aim to keep this around 500words.
III. BACKGROUND
The background section of your review expands upon the key points you stated in your introduction. This section compares and contrasts published studies and identifies gaps that have not been addressed or have been unsuccessfully addressed. In this section you can discuss the topic under investigation in more detail drawing on appropriate literature. You may include, for example, professional guidelines, policy documents, government reports and other published material such as journal articles.
Sufficient background information helps your reader/examiner determine if you have a basic understanding of the research problem being investigated and promotes confidence in the overall quality of your analysis and findings. Depending on the topic being studied, the background section can take different forms and it is helpful to break this part into smaller sections/sub-sections.
When developing this section consider the following points:
• Summarise and evaluate your resources or research articles under appropriate sub-sections. Each article
should not necessarily get the same amount of attention – length indicates significance to your project.
• Provide clear transitions and strong organizing sentences at the start of sections or paragraphs. Providing
intermediate conclusions for individual sections may be helpful.
• When necessary, state why certain literature is or is not included.
This sections usually accounts for 15% to 20% of the overall word count of your review.
IV . METHODS
This section describes what was actually done: where, when, how, etc. in order to answer your research question, aims and objectives. Start the section by reminding your reader/examiner the aim of your review and then present your search strategy, inclusion and exclusion criteria and other steps you have taken to identify, analyse and synthesize relevant resources to answer your research aim and objectives. Your reader/examiner should be able to see exactly what you did and repeat it if necessary. A table with your search strategy or a PRISMA chart of how you selected your
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relevant resources may be useful to include, and you also need to describe your analysis here. Try to include important details but not trivial ones. Sub-headings can be used to help organize this section.
This sections usually accounts for 15% of the overall word count of your review.
V . FINDINGS
The findings/results section is typically fairly straightforward and factual. All results that relate to the research question should be given in detail. It is important that the results be presented with an analysis framework and are connected back to the aim and objectives of the study. If findings do not fit into the objectives, you need not (or perhaps should not) include them. The findings should be written out so that the reader does not have to study tables or graphs to get the general picture. The text should include numerical data (averages, ranges, standard deviations, rates, etc.) where appropriate and/or narrative data (e.g. quotes from papers – appropriately referenced). At this level we expect that you can present and interpret simple, quantitative results. You can use some tables and/or figures to present the data if necessary. Look through journals to see examples of what goes into tables vs. figures. There is a real skill and art to designing these compact forms of data-presentation.
This sections usually accounts for 20% of the overall word count of your review.
VI. DISCUSSION
The discussion section allows the most freedom. This is why the Discussion is the most difficult to write, and is often the weakest part of a review. Structured discussion sections can help you develop a strong discussion and address all the relevant points without omitting important information. When developing your discussion section we recommend that you:
• State the main findings of the study
• Discuss the main results/findings with reference to previous research
• Discuss policy and practice implication of the results/findings
• Analyse strengths and limitations of your review
• Offer recommendations and perspectives for practice, policy and future research work
This sections usually accounts for 25% of the overall word count of your review.
VII. CONCLUSION
The conclusion section may be combined with the discussion or presented separately. In your conclusion you may review the main points of the review, but do not replicate sections. A conclusion might elaborate on the importance of the study and suggest further work.
This sections usually accounts for 5% of the overall word count of your review.

REFERENCES
In this section you should record all references to published material that you cited and refer to in your review. This is particularly likely to include material from your background reading on the topic but also material around specific books you used for your design and methodology sections or other resources and published guidelines. The important element is that this list needs to be comprehensive
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The Faculty uses the APA 6th referencing style and the library offers comprehensive resources in getting started with referencing, using specific software to help you manage your references, to examples of how your references should look like in the text and reference list.
APPENDIX
We recommend that you limit the use of appendices to only the ones that are needed and developed by you to support your project. Please note that it is not appropriate to use appendices as a means of circumventing the word limit. Any content of appendices should be discussed with your supervisor.

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Abstract

The prevalence of cardiovascular diseases has increased dramatically globally, resulting in adverse health outcomes, including increased disability rates, high morbidity and mortality rates, many years of life lost, and disability-adjusted life years. This trend is associated with increased CVD modifiable risk factors, including diabetes, obesity, and hypertension. The prevalence of cardiovascular cases and deaths are higher in low and middle-income countries than in developing nations due to the high incidence of risk factors. The desire to reduce CVD morbidity and mortality rates has necessitated appropriate management of CVD and risk factors via cardiac rehabilitation. However, access to medical facilities among CVD patients has been compromised during the pandemic due to social distancing rules. As a result, the home-based cardiac intervention has become the commonly cost-effective approach adopted in managing CVD during the pandemic. This paper assesses how virtual education has been used in cardiac rehabilitation during the pandemic. Data was collected by reviewing previous studies on this topic. Evidence collected from previous studies supports the use of virtual education interventions, including exercise training, dietary education, medication management, and smoking counseling in increasing physical activities, dietary habits, medication management adherence, and smoking cessation. It was concluded that incorporating virtual education in CR benefits CVD patients. The study findings support the implementation of virtual education in CR in clinical practices to improve the health outcomes of CVD patients.

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Virtual Education in Cardiac Rehabilitation during and after the Pandemic: A Literature Review

            The prevalence of cardiac disorders has increased dramatically worldwide. This trend is associated with an increase in environmental, social, and behavioral risk factors (Brant et al., 2022). According to Roth et al. (2020), cardiovascular diseases (CVD) particularly stroke, rheumatic heart disease, and ischemic heart disease (IHD) have increased substantially worldwide, becoming a major cause of rising disability and mortality rates globally. Over 80% of CVD-related deaths were reported in low and middle-income countries (Anand et al., 2020). The high rates of ischemic heart disease burden and deaths in these countries are associated with metabolic risk factors (Wang et al., 2021). Roth et al. (2020), reported an almost double increase in CVD from 271 to 523 million in 1990 and 2019, respectively. Additionally, CVD deaths raised steadily from 12.1 to 18.6 during this period (Baddour et al., 2022). Similar trends were reported in years of life lost and disability-adjusted life years (DALYs). Approximately, a 100% increase was reported in disability, rising from 17.7 to 34.4 million over that period (Roth et al., 2020). Ischemic heart disease-related DALYs increased steadily from 9.14 million in 1990 to 194 million in 2019. Additionally, IHD deaths and prevalent cases reached 9.14 and 197 million in 2019 (Roth et al., 2020). Stroke-related DALYs and deaths have also been increasing steadily from 1990 to 2019. About 143 million stroke-related DALYs, 6.55 million deaths, and 101 prevalent cases were reported in 2019 (Roth et al., 2020).

            Consequently, a multidimensional intervention has been adopted to address this global public health concern. Various states, nations, and regions have adopted different interventions to reduce the high prevalence of cardiovascular diseases, CVD-related years of life lost, CVD-related disability-adjusted life years (DALYs), and death cases. Cardiac rehabilitation (CR) is one of the most common interventions used treatment of CVD. According to Taylor et al. (2022), cardiac rehabilitation is a complicated intervention, which aims to improve functionality, health-related quality of life, and overall well-being of individuals diagnosed with heart disease. This intervention involves a wide range of activities, including exercise training, education regarding lifestyle changes, and emotional support (Winnige et al., 2021). CR is an effective and efficient secondary strategy for preventing CVDs through lifestyle modification, including dietary changes and increasing physical activities, which are customized to an individual patient. The primary goal of cardiac rehabilitation programs is to prevent physiological and psychological distress attributed to cardiovascular disease, prevent further complications, reduce the risk of related deaths, and enhance cardiovascular functioning to improve the quality of life (Taylor et al., 2022). For this reason, cardiac rehabilitation is recommended in various patient populations, including those with cardiovascular diseases such as heart failure, ischemic heart disease, or myocardial infarctions. Additionally, CR is appropriate for individuals following various cardiovascular interventions, including coronary artery bypass grafting or coronary angioplasty (Winnige et al., 2021). CR is recommended for these patients to prevent further progression of CVD and help them cope with stress related to CVD treatment.

            However, cardiac rehabilitation has changed during the COVID-19 pandemic due to social distancing rules. According to Monaghesh and Hajizadeh (2020), COVID-19 prevention guidelines advocates for telehealth and home-based care to reduce congestion in healthcare facilities, lowering the risk of contracting the coronavirus among the healthcare providers and the patients seeking treatment for other illnesses. Similarly, cardiac rehabilitation has adopted virtual education to limit contact between healthcare professionals and CVD patients. Nonetheless, the use of virtual education in cardiac rehabilitation during the COVID-19 pandemic remains unclear in various parts of the world. The aim of this literature review was to evaluate studies on the use of virtual education in cardiac rehabilitation during the COVID-19 pandemic.

Background

            Cardiovascular diseases contribute to the high mortality rate globally. Additionally, these conditions increase hospitalization rate, increased disabilities, and impaired functionality, imposing a huge burden on patients, their families, and the healthcare system. Studies indicate that the high prevalence of CVD is associated with lifestyle (Winnige et al., 2021). According to (Brant et al., 2022) modifiable risk factors such as hypertension, obesity, and diabetes contribute to the high burden of cardiovascular diseases. In another study, Groenewegen et al. (2020) pointed out coronary artery disease, diabetes, hypertension, obesity, and smoking as significant factors increasing the risk of heart failure. Furthermore, Einarson et al. (2018), associated the high prevalence of cardiovascular diseases in the aging population with lifestyle diseases, including hypertension, diabetes, and obesity. Touloumi et al. (2020) also attributed the high prevalence of cardiovascular diseases among adults living with various lifestyle diseases, including hypertension, obesity, diabetes, and hypercholesterolemia. Lastly, Powell-Wiley et al. (2021) in their study findings reported, dyslipidemia, hypertension, and type 2 diabetes, and obesity as key risk factors for cardiovascular diseases. The current trend of cardiovascular diseases can be reversed by reducing significant risk factors, including hypertension, diabetes, and obesity. Health systems, local, and national leaders have adopted cardiac rehabilitation as an intervention for achieving primary and secondary prevention to reverse the current trend.

Cardiac Rehabilitation as a CDV Prevention Strategy

            Cardiac rehabilitation has gained popularity as a CVD prevention approach. Taylor et al. (2022) consider cardiac rehabilitation as a complicated intervention that focuses on improving cardiovascular functioning, quality of life, and overall well-being of individuals diagnosed with heart disease. Winnige et al. (2021) describe CR as an intervention that involves a wide range of activities, including exercise training, education regarding lifestyle changes, and emotional support, which are customized to meet the healthcare needs of an individual patient. According to Bellmann et al. (2020), cardiac rehabilitation (CR) is a multidimensional intervention, which is designed to provide optimum physical and psychological support to individuals diagnosed with cardiovascular disease, reversing the course of an illness or preventing the disease from progressing. Bellmann et al. (2020) subdivided CR into three major approaches, including exercise training, psychological intervention, and lifestyle modification, which are completed in 3 to 4 weeks. Lolley and Forman (2021) further described as a comprehensive multi-disciplinary program, which aims at reducing morbidity and mortality rates among cardiovascular patients.

Several factors are considered to determine if an individual qualifies for CR. Chindhy et al. (2020), reported various cardiac rehabilitation indicators, including a recent myocardial infarction, chronic stable angina, acute coronary artery syndrome, congestive heart failure, and individuals who have undergone a percutaneous coronary intervention, coronary artery bypass surgery, cardiac transplantation, or valvular surgery. However, the exercise training aspect of cardiac rehabilitation is contradicted for patients with unstable angina, complex ventricular arrhythmias, acute decompensated congestive heart failure, intracavitary thrombus, recent thrombophlebitis, severe pulmonary hypertension, symptomatic or severe aortic stenosis, uncontrolled inflammatory, severe obstructive cardiomyopathies, or any musculoskeletal disease that limits participation in exercise or vigorous physical activities (Mampuya, 2018).

Although CR has been used as a CVD prevention intervention for the long term, the practice has changed during the COVID-19 pandemic following. Virtual education has been incorporated into cardiac rehabilitation during the pandemic to limit interaction between the professional team and CVD patients, preventing transmission of the coronavirus.

Virtual Education in Cardiac Rehabilitation during and after the Pandemic

The COVID-19 Outbreak

            Corona virus was first reported in Wuhan China December 2019 (Zhu et al., 2020). The coronavirus disease is characterized by various symptoms, including fever, cough, difficulty in breathing, and invasive lesions on the right and left lungs (Zhu et al., 2020). The virus can cause viral pneumonia if it spreads to the lower respiratory tract. Respiratory distress syndrome and dyspnea are also reported in severe cases (Zhu et al., 2020). The virus was spreading rapidly in the whole of China and the entire world. Consequently, The World Health Organization (WHO) declared the COVID-19 outbreak a global pandemic a public health emergency of international concern on March 11, 2020 (Cucinotta & Vanelli, 2020). By February 19, 2020, the Chinese government reported a substantial increase in COVID-19 infections, reaching 44,412 and 74,280 in Wuhan and entire China, respectively. Additionally, approximately 1497 and 2009 deaths were reported in Wuhan and entire China, respectively. Furthermore, 919 and 3 infections and death had been confirmed globally. Therefore, intensive interventions, targeting the Wuhan city and Hubei Province were introduced to prevent the virus from spreading rapidly to all parts of China and the world.

The Impact of COVID-19 Pandemic in the United Kingdom

            United Kingdom has also been adversely affected by the COVID-19 pandemic. However, the UK population was not affected by the COVID-19 equally. The prevalence of the COVID-19 in the United Kingdom was significantly high in some demographic populations, including the elderly adults, the minority ethnic groups, male sex, individuals with pre-existing health conditions, and people living in a particular geographical area. Hull et al. (2020) indicated that the prevalence of COVID-19 infections and deaths is relatively high among Black, Asians, and other minorities. Bambra et al. (2020) also reported that the prevalence of COVID-19 was higher among the minorities residing in areas with higher socio-economic deprivation. This trend was associated with factors associated with ethnicity, including population density, occupation, public transport use, housing conditions, and household composition. Additionally, the risk of contracting the virus was relatively high among healthcare workers as they interacted with people at high risk during care delivery. Hence, the U.K government implemented a series to limit social contact, which would reduce the likelihood of coming into contact with individuals infected with COVID-19. These preventive measures also aimed to limit contact between people with chronic illnesses such as CVD and healthcare workers due to the high risk of contracting the virus among this population. People with chronic illnesses are more likely to contract the COVID-19 disease than the general population (Fekadu et al., 2021). Moreover, Sanyaolu et al. (2020) considered chronic illnesses, including heart diseases and diabetes comorbidity for the COVID-19. For this reason, virtual healthcare was incorporated into the prevention, management, and treatment of CVD to reduce the risk of exposure to the virus in this population. In particular, virtual education was incorporated into cardiac rehabilitation.

The Role of Virtual Education in Cardiac Rehabilitation

            Before the outbreak of the COVID-19 pandemic, approximately 100 000 heart attack patients were admitted to hospitals in the U. K (Dalal et al., 2021). Additionally, about 200 000 U.K citizens were diagnosed with heart failure annually (Dalal et al., 2021). Furthermore, cardiovascular diseases are diagnosed in about 7.4 million individuals in the UK (Dalal et al., 2021). This number is anticipated to rise further due to improved coronary heart disease survival and an increasingly ageing population. In complying with national and international COVID-19 guidelines the U. K concerning lockdown and social distancing, accessibility, provision, and usage of cardiovascular healthcare reduced dramatically among patients living in Europe and North America (Dalal et al., 2021). Consequently, the U.K has adopted home-based cardiac rehabilitation (HBCR) as the most cost-effective and efficient intervention for achieving positive outcomes among individuals diagnosed with cardiovascular disease. According to Pinto et al. (2022), home-based multidisciplinary digital CR programs gained popularity during the COVID-19 pandemic as an alternative intervention for health outcomes in patients with cardiovascular disease (CVD) following the suspension of center-based CR. The home-based focuses on improving health outcomes of CVD patients through various activities, including promoting exercises, advocating for smoking cessation, BP control, providing psychosocial support, and diet and weight management. A diagram indicating activities promoted by telerehabilitation is included in the appendices.

Adopting cardiac rehabilitation then results in a wide range of positive outcomes, including reduced morbidity and mortality rates, a decline in hospital admissions rates, an increase in physical activity rates and exercise capacity, and improvement in cardiac functioning, health-related quality of life, and psychological wellbeing (Long et al., 2019). During the pandemic, these benefits are achieved through the virtual CR program, which is a significant component of HBCR innovations (Dalal et al., 2021). This innovation involves communication between a healthcare professional and a CVD patient via various communication forms, including telephone and video conferencing, letters, e-mails, text messaging, online platforms, and smartphone applications. Therefore, virtual education has enhanced telerehabilitation through the following interventions.

Exercise training: This is a significant component of home-based cardiac rehabilitation virtual training. It aims at increasing the patient’s physical activity level. Exercise training involves creating awareness concerning physical activities effective for reducing the risk of CVD or preventing the disease from progressing. Physical activity counseling is individualized to meet the healthcare needs of a CVD patient. Some patients are recommended peak exercise capacity, including bicycle ergometer, treadmill, and validated walk test. On the other hand, exercise training can be designed to meet the needs of individual patients who cannot engage in cycling- or walking-based activities (Dalal et al., 2021). The education program also aims at creating awareness concerning the frequency, intensity, or duration of exercise. Sari and Wijaya (2021) reported that the CR program contains various exercise components, including aerobic training, strength/resistance exercise, posture, flexibility, coordination, and balance, which results in the desired exercise results. However, home-based CR during lockdown and quarantine is associated with reduced physical activities among cardiovascular disease patients than center-based exercise (Pinto et al., 2022). Therefore, a professional team should educate CVD patients on the significance of engaging in physical activities regularly to achieve the desired exercise results.

Dietary education: Virtual education in cardiac rehabilitation also aims at promoting healthy eating. It focuses on providing dietary/nutritional counseling to CVD patients. The client is informed about the most appropriate diet based on one’s healthcare needs. The patient is informed about healthy food choices that prevent the condition from progressing. Furthermore, the patient is educated about food appropriate for weight loss and management (Dalal et al., 2021). According to Yu et al. (2018), reducing excess calories and improving dietary composition play a significant role in preventing primary and secondary cardiovascular incidents. Sari and Wijaya (2021) also reported that controlling nutritional intake is recommended to regulate CVD risk factors, including obesity, diabetes, hypertension, and dyslipidemia.  

Medication management training: This intervention aims at enhancing medication adherence. Cardiovascular disease patients should also be educated on how to adhere to the prescribed dosage. According to Schwartz et al. (2019), pharmacological management in CVD patients controls cardiovascular risk factors and comorbidity, including hypertension, dyslipidemia, obesity, and diabetes. CVD patients have prescribed blood pressure and blood cholesterol-lowering medicines. Forman et al. (2021) also reported that adhering to the prescribed medication prevents multimorbidity in CVD patients. Thus, medication management in CVD patients prevents primary and secondary coronary artery disease. Merck (2018) further reported that pharmacokinetics should be considered when prescribing medication to elderly patients with CVD to ensure drug safety. Therefore, patients should be advised to report drug-related side effects immediately to a medical practitioner to prevent adverse outcomes.

Tobacco counseling: Virtual education in CR also focuses on achieving smoking cessation. This virtual component creates awareness regarding smoking cessation. According to Dalal et al. (2021), a professional team should access CVD patients’ smoking status, including the use of other tobacco products. The patient should then be an encouragement to quit smoking all tobacco products to prevent the disease from progressing. In severe cases, CVD patients should be referred to a professional psychotherapist for smoking cessation (Dalal et al., 2021). According to Gallucci et al. (2020), tobacco cessation reduces the risk of heart attack events among CVD patients. Additionally, a report published by Gallucci et al. (2020) indicated that secondhand smoke exposure and active smoking contribute to over 30% of coronary heart disease (CHD) deaths. In another study, Jeong et al. (2021) reported that smoking cessation lowers the risk of cardiovascular disease (CVD). Hence, the interprofessional team should emphasize smoking cessation during virtual education of CVD patients. A diagram indicating virtual education interventions will be included in the appendices.  

Methods

            This review aimed to evaluate studies on the use of virtual education in cardiac rehabilitation during the COVID-19 pandemic. This section of the literature review presents a methodology for answering the research question that states; “Does virtual education enhance cardiac rehabilitation during the pandemic?”

Search Strategy and Inclusion and Exclusion Criteria

An electronic search was performed in various reliable nursing databases, including CINAHL, Emcare, Embase, the Cochrane Library, APA PsycInfo, and PubMed. Only qualitative and quantitative studies were considered following PRISMA checklist. The quality of the studies was assessed using the Critical Appraisal Skills Program. Keywords, including virtual education, cardiac rehabilitation, cardiovascular disease patients, exercise training, dietary education, medication management adherence, and smoking cessation were used to guide the search process. The inclusion criterion was used to select studies suitable for this review. The first inclusion criteria was being relevant to the topic of study. Thus, studies on virtual education in cardiac rehabilitation were selected for the study. The second inclusion criteria was being a quantitative or a qualitative study. Qualitative and quantitative studies on virtual education in cardiac rehabilitation were selected for this study. Another inclusion criteria involved being written in English and published in the past 3 years. Hence, qualitative and quantitative studies on virtual education in cardiac rehabilitation that were written in English and published from 2019 January to 2022 June were selected for the review. The last inclusion criteria was accessibility of a complete study. Therefore, complete qualitative and quantitative studies on virtual education in cardiac rehabilitation that were written in English and published from 2019 January to 2022 June were selected for this review.

On the contrary, studies that did not meet the inclusion criterion were excluded from this study. First, qualitative and quantitative studies on other topics rather than virtual education in cardiac rehabilitation were excluded from this study. Secondly, other study types such as systematic reviews on virtual education in cardiac rehabilitation were excluded from the study. Furthermore, qualitative and quantitative studies on virtual education in cardiac rehabilitation that contained an abstract only were excluded in this review. Qualitative and quantitative studies on virtual education in cardiac rehabilitation that were written in other languages rather than English were also excluded from this review. Lastly, qualitative and quantitative studies on the topic of interest, which were published more than 3 years ago were excluded from the study. Twelve (12) studies that met the inclusion criteria were selected for the study (n = 12).

Analysis and Synthesize of Relevant Resources

            Out of 127 articles that were obtained after the initial search, 12 qualitative and quantitative studies of high quality were included in the review upon meeting the inclusion criteria. The study findings indicated effectiveness of home-based CR in enhancing management of cardiovascular diseases during and after the pandemic. The most significant facilitator of cardiovascular management in home-based cardiac rehabilitation was accessibility, technology, and social support. A quantitative study on CVD indicated a statistically dramatic decrease in hospital admissions among CVD patents during and after the pandemic (Shoaib et al., 2021). On the contrary, a significant increase in home-based cardiac rehabilitation was reported during and after the pandemic, resulting in better health outcomes than the usual care among CVD patients (Dalal et al., 2020). Long et al. (2019) also reported effectiveness of home-based CR than usual care in cardiovascular management. A statistically significant difference in heart attack events and CVD mortality was reported in studies that compared home-based cardiac rehabilitation and usual care. Furthermore, Imranm et al. (2019) conducted a randomized controlled trial, which indicated improved exercise capacity, nutrition habits, medication management, and smoking in CVD patients receiving virtual education in CR than potential alternatives, including usual care. Participating in a center- or home-based CR significantly improved health-related quality of life than no rehabilitation during and after (Long et al., 2019; Imranm et al., 2019).  Eleven (11) out of13 trials comparing center- and home-based cardiac rehabilitation using validated questionnaires reported significant improvement in health-related quality of life. However, no statistically significant difference was reported between center- and home-based cardiac rehabilitation (Thomas et al., 2019). Additionally, the US scientific statement reported a significant decline in cardiovascular modifiable risk factors following home-based cardiac rehabilitation (Thomas et al., 2019). The participants reported significant improvement in weight, lipids, blood pressure, and tobacco use following an eight-week home-based CR (Thomas et al., 2019). However, the results were influenced by adherence to the 8-week home-based CR (Thomas et al., 2019). Nonetheless, no significant difference was reported in weight management and blood pressure level in home-based CR and other possible alternatives (Buckingham et al., 2019).

Preference for home-based CR over center-based CR was reported in a quantitative   study, involving a randomized controlled trial. The study findings indicated that 57% of the participants preferred home-based cardiac rehabilitation, while 43% were in favour of centre-based CR (Wingham et al., 2018). Additionally, NICE and European guidelines recommended home-based cardiac rehabilitation due to high participation, resulting in behaviour change. A large prospective cohort study, including 151 centers that were conducted in the US indicated patients’ reference to home-based cardiac rehabilitation over center-based CR. Compliance with COVID-19 guidelines has increased the rate of home-based CR and the use of virtual education. The clinical benefits of home-based CR and virtual education, including enhancing exercise training, dietary education, medication adherence, and smoking cessation were reported in Long et al. (2019). A diagram indicating the benefits of virtual education-supported interventions, including enhancing exercise training, dietary education, medication adherence, and smoking cessation is included in the appendices.

Findings

            This review aimed to evaluate studies on the use of virtual education in cardiac rehabilitation during the COVID-19 pandemic. The selected quantitative studies were reviewed to collect data on virtual education in CR during the COVID-19 pandemic. The reviewed quantitative studies provided evidence on various virtual education interventions, including exercise training, dietary education, medication management, and smoking counseling. The study findings indicated that virtual education interventions, including exercise training, dietary education, medication management, and smoking counseling resulted in increased physical activities, healthy eating, medication, adherence, and smoking cessation, resulting in better management of cardiovascular diseases during and after the pandemic.

            The reviewed quantitative studies indicated a significant increase in home-based and use of virtual education during and after COVID-19 pandemic. This trend was associated with COVID-19 guides requiring people to maintain social distance to limit transmission of the coronavirus. Additionally, most CVD patients prefer home-based cardiac rehabilitation over center-based due to its convenience and cost-effectiveness. Upon comparing home-based to center-based CR, 57% of the participants preferred home-based cardiac rehabilitation, while 43% were in favour of centre-based CR, indicating high demand for home-based CR and virtual education during the pandemic.

Discussion

            The selected quantitative studies reported a dramatic increase in home-based cardiac rehabilitation during and after the pandemic. This trend is associated with COVID-19 guidelines, which require people to avoid highly populated places and maintain social distance to reduce the risk of being exposed to coronavirus. Consequently, CVD patients are discouraged from enrolling in center-based CR but rather embark on home-based CR. This trend lowers the risk of contracting the virus among CVD patients whose affinity for the virus is relatively high than the general population. Additionally, most CVD patients prefer home-based cardiac rehabilitation over center-based due to its convenience and cost-effectiveness. As result, the compliance rate for home-based cardiac rehabilitation is higher than center-based. Thus, evidence-based interventions for CVD management, including exercise training, dietary education, medication management, and smoking counseling result in positive health outcomes.

The effectiveness of virtual education interventions in enhancing exercise training, dietary education, medication adherence, and smoking cessation is supported by previous studies on this study topic. First, studies indicated the effectiveness of virtual education dietary programs in controlling patients’ nutritional needs. According to Yu et al. (2018), reducing excess calories and improving dietary composition play a significant role in preventing primary and secondary cardiovascular incidents. Secondly, the studies supported the appropriateness of exercise training via virtual education. Sari and Wijaya (2021) reported that virtual education in CR programs contains various exercise components, including aerobic training, strength/resistance exercise, posture, flexibility, coordination, and balance, which results in the desired exercise results. The efficacy of virtual education in medication management education has been reported in previous studies.  Schwartz et al. (2019) reported that pharmacological management in CVD patients controls cardiovascular risk factors and comorbidity, including hypertension, dyslipidemia, obesity, and diabetes. In another study, Gallucci et al. (2020) supported the effectiveness of virtual education in smoking counseling, resulting in smoking cessation, which reduces the risk of heart attack events among CVD patients.

The result findings imply healthcare policy and practice. Regulatory measures should be introduced to facilitate home-based CR to reduce CVD morbidity and mortality rates. The policy will significantly enhance the management of CVD and comorbidities, especially during the pandemic when access to healthcare services for CVD patients is limited following COVID-19 guidelines. Additionally, the policy will reduce the cost of home-based CR, enabling all CVD patients to engage in this program, improving their cardiac functioning, quality of life, and overall wellbeing.

Strengths and Limitations

This review has strengths and limitations. The most significant strength of this review involves collecting data from quantitative studies. Highly reliable and credible data was collected from these studies, allowing the application of the study findings in clinical practices. On the contrary, data was collected from a small sample population (12 quantitative studies), limiting the generalizability of the study findings. Additionally, studies in the reviewed sources were conducted among participants with various demographic features, including age, gender, and ethnicity, limiting the generalizability of the study findings.

Recommendations for Future Research and Implication in the Practice

The review has focused on virtual education in cardiac rehabilitation during the pandemic. However, more information is needed in other areas related to this topic, including virtual education in cardiac rehabilitation among paediatric patients or virtual education in home-based care for cancer patients during the pandemic. Therefore, future scholars should focus on these topics to create a wider knowledge-based that will enhance clinical practices, quality and safety of care, and patient health outcomes. The study findings indicated that virtual education in CR during the pandemic has enhanced exercise training, dietary education, medication adherence, and smoking cessation, preventing disease progression. Therefore, healthcare organizations should support virtual education among CVD patients to achieve positive health outcomes.

Conclusion

            Significant improvement in physical activities, dietary habits, medication adherence, and smoking habits was indicated by CVD patients who engaged in home-based CR with virtual education after their access to healthcare services was compromised by COVID 19 guidelines. Hence, incorporating virtual education in cardiac rehabilitation is an evidence-based intervention that should be adopted in clinical practices to improve physical activities, dietary habits, medication adherence, and smoking habits, preventing adverse health outcomes among CVD patients such as increased disabilities rates, high morbidity and mortality rates, many years of life lost, and disability-adjusted life years. However, further studies should be conducted to assess the impact of incorporating virtual education in cardiac rehabilitation among paediatric patients or in home-based care for cancer patients during the pandemic. The results of these studies will inform the clinical practices, enhancing the quality of care and health outcomes in these patient populations.

References

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Appendix A: Cardiovascular disease management activities

Appendix B: Intervention and Targeted Behavior