Cardiovascular diseases are among the leading causes of morbidity worldwide [1]. Persons with cardiovascular disease require long-term management if recurrent events and other complications are to be postponed or prevented. Cardiovascular outcomes are largely dependent on gains in cardiometabolic fitness [2, 3]. Daily exercise is a fundamental and modifiable contributor to cardiometabolic fitness. Guidelines recommend patients accumulate 30 to 60 min of moderate-to-vigorous intensity aerobic exercise on most, but preferably all, days of the week for secondary prevention [4].

Although cardiovascular rehabilitation programs are successful in ensuring patients initiate and engage in exercise, long-term maintenance of exercise remains a challenge [5–9]. Among patients who complete cardiovascular rehabilitation, less than 50 % continue to meet exercise recommendations thereafter [10]. Safe and appropriate facilities are therefore needed to promote exercise maintenance [11, 12]. However, there is insufficient capacity in existing cardiovascular rehabilitation programs for graduated patients to continue exercise, as many programs cannot even meet the demand for new patients. While some cardiovascular rehabilitation programs offer Phase IV, or maintenance programming, at a cost to patients, these programs may be unaffordable, inconveniently located in terms of travel time and distance, and the limited class dates and times available for maintenance programming may be inconvenient for patients. Moreover, there is scant research addressing degree of use of Phase IV rehabilitation, and therefore it is not known whether there are sufficient services and whether they are meeting patient needs.

Availability of low-cost and accessible exercise facilities in the community therefore represents a more feasible approach to encouraging continued exercise in cardiac rehabilitation graduates. Indeed, in the World Health Organization’s Global Action Plan on the Prevention and Control of Non-Communicable Diseases 2013–2020, they specifically recommend “increased availability of safe environments in […] recreational spaces to encourage physical activity” (p. 51) [13]. However, previous research has shown that cardiovascular rehabilitation graduates perceived instructors in the community as having limited knowledge and skills in relation to supervision of exercise in people with their condition, and they can feel like an “outsider” in relation to young, healthy attendees [14]. Thus, there is a need to broadly offer safe, accessible exercise environments for patients with cardiovascular, among other, chronic diseases.

The Heart Wise Exercise™ model (heartwise.ottawaheart.ca; HWE) was consequently developed. HWE developers identified and encouraged existing community-based exercise programs to build capacity for serving patients with chronic disease, with the goal of broad delivery of safe and appropriate exercise classes for stable outpatients with chronic disease. This is achieved by working with interested facilities to ensure they meet specific safety criteria, educating their exercise leaders, and then providing HWE materials to these facilities to market their Heart Wise Exercise sessions to clients. The six specific criteria programs must meet to be recognized as “Heart Wise” are: (1) encouraging daily aerobic exercise; (2) incorporating a warm-up, cool down and self-monitoring; (3) allowing participants to exercise at a safe level and offering options to modify intensity; (4) accepting participants with chronic health conditions; (5) offering health screening for all participants; and, (6) having a documented emergency plan that is known to all fitness leaders (who have current cardiopulmonary resuscitation certification), phone access to local paramedic services and having an automated external defibrillator (AED) on-site.

Models similar to HWE have been developed in other jurisdictions [15, 16]. However, there is a dearth of formal evaluation of these models from the lens of the exercise facility and the participants. Therefore, the objectives of this study were to evaluate: (1) whether HWE programs were meeting the six criteria for safety; (2) whether HWE programs are being used by persons with chronic health conditions as intended; and, (3) the perceptions and experiences of these persons with the HWE program.

This was a cross-sectional study using mixed-methods. Audits of HWE programs and survey results from HWE program participants are presented. The study protocol was approved by York University’s Office of Research Ethics (e2014 - 376). The Ottawa Health Sciences Network Research Ethics Board granted an ethics approval exemption for this study.

This study was the first to formally evaluate the HWE program, which seeks to identify a wide range of safe and appropriate community programs for those with, or at risk for, cardiovascular or other chronic conditions, and systematically connect patients exiting cardiovascular rehabilitation to nearby facilities for life-long exercise. Findings revealed that HWE-designated exercise sessions were generally delivered in accordance with the six criteria, reached persons with chronic health conditions but not necessarily cardiac rehabilitation graduates, and participants were highly satisfied with HWE sessions.

There is an epidemic of non-communicable diseases globally. Our findings are not only applicable to communities in Ontario, Canada, but also communities worldwide. The World Health Organization's 2015 World Report on Ageing and Health emphasizes that “older people's participation in physical activity is increasingly linked to the environment in which they live” (p.194) and that policy-makers should create environments that promote physical activity [17]. Our evaluation demonstrates that HWE is an effective model to support communities in providing access to safe exercise environments for adults, those with chronic disease and/or those recovering from acute health events.

The two HWE criteria which should be improved upon were encouraging daily aerobic exercise and instructing participants how to self-monitor exercise intensity. Only 71 % of the fitness leaders encouraged daily aerobic exercise. Because the site audits were conducted at a single point in time, it is possible that the fitness leaders frequently encourage daily aerobic exercise, but it was not observed during the audited class specifically. With regard to the latter, there are several practical methods for self-monitoring exercise intensity that are routinely presented in the HWE Training Program for fitness leaders, including heart rate monitoring, the Borg Rating of Perceived Exertion and the Talk Test [18–20]. Audit findings were provided to the facilities, and therefore it is hoped that this feedback will result in improvements in these areas. Providing more or perhaps better examples of how to incorporate these tools into a fitness class and having opportunities to practice delivery of these methods during the workshop may encourage the fitness leaders to use these tools consistently in every session.

HWE programs generally reached highly and consistently active, older females, many of whom had arthritis or osteoporosis. It was surprising how few cardiac rehabilitation graduates were accessing the HWE sessions. In our survey of cardiac rehabilitation graduates in regions where the HWE program is available, almost half of graduates intended to exercise at a community facility post-program [21]. One year post-cardiac rehabilitation, almost two-thirds of graduates reported exercising in the community, of which one-third reported exercising at a HWE facility specifically [21]. However, most respondents reported exercising at home rather than in the community [21]. A similar model has been implemented in Australia following cardiac and pulmonary rehabilitation, and results showed that 60 % attended at least once, and one-third attended at least six sessions (i.e., just over half of those who attended at least once) [16]. In another study of cardiac rehabilitation graduates, many intended to join community-based programs but most discontinued after five or fewer sessions, citing lack of confidence in their ability to exercise without medical supervision and lack of support for their transition as causal factors [14]. As suggested by participants in the latter study, perhaps a better linkage between the community-based program and rehabilitation program should be made prior to program completion.

Awareness and use of the HWE classes could be improved by ensuring greater visibility of session offerings at reception of the community facilities, and on their websites. The HWE developers are currently working to increase awareness of the program, so that it is more highly accessed by chronic disease patients, including those with cardiovascular disease. There is also room for improvement in terms of ensuring staff working at the reception desks of these exercise facilities are aware of the HWE program and what it offers. We also recently partnered with a provincial health and fitness society to offer the HWE fitness leader training to a wider audience.

Our findings show that HWE fitness leaders were confident and knowledgeable instructors in the area of exercise in chronic disease. Recently adapted to allow a more flexible delivery, using a combination of in-person and online modules, the training program has clearly been successful. To date, more than 1,150 fitness leaders have completed the HWE Training Program. Our findings show that HWE fitness leaders are confident and knowledgeable instructors. With the increase in participants with, and at risk for, chronic conditions, having instructors able to meet the needs of these participants, and provide meaningful exercise and social encounters for them will be essential to helping them remain high-functioning and independent. While the exercise leaders were eager to participate in further training, it does appear that the HWE model speaks to some of the suggestions raised by cardiac rehabilitation graduates exercising at non-specific community exercise facilities [14]. In the Training Program, fitness leaders are also informed about chronic disease management programs available for participants who come to their classes but may not have accessed them yet (e.g., cardiovascular rehabilitation, diabetes educators, chronic obstructive pulmonary disease clinics). This ensures participants with chronic disease will know how to exercise safely in the community setting.

Several limitations of the current study must be conceded. Firstly, this was a cross-sectional study with no control or comparison group (e.g., patients not going to HWE or who discontinued attending HWE sessions) and therefore caution is warranted in interpreting or over-generalizing the findings. Second, the current study was conducted using a convenience sample of HWE participants and HWE programs, so the results may have limited generalizability and selection bias may be at play. For example, male participants were under-represented in the participant surveys, and hence the findings are likely less generalizable to male than female exercisers. Third, the HWE contact may have informed the exercise leader of the audits, hence leading to a Hawthorne effect. Replication is warranted in a representative sample using a randomized controlled design before causal conclusions regarding the impact of the HWE model on the delivery of exercise for patients with chronic disease in the community can be drawn. The further limitation pertains to measurement. The audit forms and participant surveys were investigator-generated and not validated. Therefore, there could have been some measurement error. Finally, exercise leaders and exercise session participants self-reported their characteristics and perceptions. Self-report is often biased by recall failure and socially-desirability, leading to an overestimation of physical activity levels.

This study was the first to evaluate the HWE model which seeks to identify and promote a wide range of safe and appropriate community programs for patients with, or at risk of, chronic disease. HWE programs appear to be safe and appropriate for persons with varying chronic health conditions. The exercise sessions were generally delivered in accordance with the six criteria. The HWE training program should more greatly emphasize that exercise leaders regularly encourage self-monitoring of exercise intensity and daily aerobic exercise among participants. Participants were satisfied with and intend to continue attending their HWE classes. Future efforts should be directed at increasing awareness of HWE offerings among referring health care professionals and participants at risk of, or with, chronic conditions.

Written informed consent was obtained from the fitness leaders and participants for publication of this original manuscript. A copy of the written consent is available for review by the Editor of this journal.