Barriers and Facilitators to Pulmonary Rehabilitation Adherence in Patients With Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Mixed Methods Systematic Review

BACKGROUND: Pulmonary rehabilitation (PR) is a key nonpharmacological intervention that significantly improves prognosis and health outcomes in patients experiencing acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Despite its proven benefits, PR adherence among this population remains low, with multiple factors influencing participation and completion. OBJECTIVE: This mixed-methods systematic review aims to analyze and synthesize current evidence on the barriers and facilitators affecting PR adherence in patients with AECOPD. DESIGN: A systematic search was conducted in MEDLINE, PubMed, and Web of Science to identify studies examining PR adherence in patients with AECOPD. Studies published in English from 2014 to 2024 that involved adult patients with AECOPD participating in PR programs were included if they reported on adherence to PR and its influencing factors. Excluded were review articles, case reports, editorials, conference abstracts, and studies without accessible full text. Articles were extracted and analyzed using the convergent integrated approach. RESULTS: Eight studies met the inclusion criteria, including four quantitative studies, three qualitative studies, and one mixed-methods study. The methodological quality of the included studies ranged from moderate to high. Thematic analysis revealed the barriers and facilitators of PR adherence: (1) personal motivation and education, (2) physical and psychological health, (3) family and social support, and (4) transportation and economic challenges. CONCLUSION: Multiple and interrelated factors affect PR adherence in patients with AECOPD. The present findings indicate that future intervention research should test the effectiveness of developing individualized PR plans based on disease severity, addressing psychological barriers, and implementing motivation-enhancing interventions. Likewise, intervention studies are needed to verify that involving family members in the rehabilitation process and expanding the role of health care professionals in providing proactive, continuous support improve long-term adherence and patient outcomes.