Feasibility and effects of an eHealth intervention to support patients with a low socioeconomic position during their waiting period preceding cardiac rehabilitation 113 6 6.1 Introduction Cardiac rehabilitation (CR) is a multicomponent lifestyle intervention that includes information and coaching on healthy behavior and supervised exercise training (Nederlandse Vereniging voor Cardiologie, 2011; Piepoli et al., 2016). CR is crucial for cardiac patients to prevent secondary health problems and decrease mortality rates. It has been shown to improve patient outcomes like physical fitness and health-related quality of life (Eijsvogels et al., 2020). However, the effectiveness of CR is not uniformly experienced. Specifically, individuals with a low socioeconomic position (SEP) often show lower participation rates in these programs and drop out more frequently (Ades et al., 2022; Harlan et al., 1995; Valencia et al., 2011). This disparity can be attributed to various barriers to participation (Shanmugasegaram et al., 2013), such as stressful life situations (Marmot, 2005), environmental accessibility issues (Coupe et al., 2018), inadequate social support (Moroshko et al., 2011), stigma and distrust in healthcare (Armstrong et al., 2007), and low health literacy (Paasche-Orlow & Wolf, 2007). Due to these disparities, CR is not fully benefitting patients with a low SEP, underscoring the need for solutions to make CR more inclusive and accessible. Our previous research highlights an opportunity to address the barriers faced by cardiac patients, especially those with a low SEP, during the waiting period between hospital discharge and the start of CR(Faber et al., 2023a). This waiting period lasts, on average, six weeks (Fell et al., 2016). It is marked by emotional vulnerability and uncertainty, as patients often leave the hospital with unmet informational needs about their condition and self-care (Barnason et al., 2012; Keessen et al., 2022; Mai Ba et al., 2020; Sunamura et al., 2017). The absence of adequate guidance during the waiting period, exacerbated by the initial shock of diagnosis or surgery, leads to a passive patient attitude (Lie et al., 2012; Neubeck et al., 2012; Timmins & Kaliszer, 2003) and a disjointed transition between healthcare settings (Coleman et al., 2006). Patients with a low SEP feel this lack of guidance more strongly. Their additional challenges increase their vulnerability and uncertainty during the waiting period (Liao et al., 2022). As a result, this group is less likely to adopt the necessary “readiness” to successfully engage with CR. This leads to lower participation and higher dropout rates during CR (Clark et al., 2012; Rao et al., 2020). eHealth interventions are a promising strategy to overcome barriers that arise during the waiting period. They can better prepare cardiac patients with a low SEP for CR. For example, these interventions can fill the existing information and guidance gap by leveraging online information platforms (Keessen et al., 2022) and goal-monitoring tools (Su & Yu, 2021). Due to rising healthcare costs, addressing these needs through face-to-face sessions during the waiting period may not be feasible (Goryakin et al., 2020;
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