A total of 326 valid questionnaires were collected. The detailed characteristics are presented in
General characteristics of participants (
| Item | Frequency ( |
Percentage (%) | Cumulative percentage (%) |
|---|---|---|---|
| Sex | |||
| Male | 30 | 9.20 | 9.20 |
| Female | 296 | 90.80 | 100.00 |
| Age group | |||
| ≤25 years | 2 | 0.61 | 0.61 |
| 26–30 years | 38 | 11.66 | 12.27 |
| 31–40 years | 217 | 66.56 | 78.83 |
| 41–50 years | 59 | 18.10 | 96.93 |
| 51–60 years | 10 | 3.07 | 100.0 |
| Occupation | |||
| Doctor | 69 | 21.17 | 21.17 |
| Nurse | 257 | 78.83 | 100.00 |
| Professional title | |||
| Senior | 9 | 2.76 | 2.76 |
| Associate senior | 31 | 9.51 | 12.27 |
| Intermediate | 222 | 68.10 | 80.37 |
| Junior | 64 | 19.63 | 100.00 |
| Years of work experience | |||
| 1–5 years | 28 | 8.59 | 8.59 |
| 6–10 years | 86 | 26.38 | 34.97 |
| 11–20 years | 179 | 54.91 | 89.88 |
| ≥21 years | 33 | 10.12 | 100.00 |
Regarding the current status of PR, among 326 surveyed participants, only 204 (62.58%) reported that their departments conducted PR-related work. Further investigation into these 204 participants revealed details about departmental resource allocation and PR effectiveness: 111 (54.41%) indicated that standardized procedures had been developed for these rehabilitation works; in terms of resource allocation, 141 participants (69.12%) stated their departments were equipped with rehabilitation-related equipment (e.g., breathing training equipment, exercise rehabilitation equipment), 129 (63.24%) reported having received special training on PR, and 154 participants (75.49%) noted there were no full-time medical staff dedicated to disease rehabilitation management, while 41 (20.1%) reported 1–2 full-time staff members in their departments. In terms of changes in patients’ symptoms after rehabilitation exercise, 190 participants (93.14%) observed an improvement in patients’ dyspnea, 189 (92.65%) noted an improvement in patients’ fatigue, and 166 (81.37%) reported observing fluctuations in the effectiveness of PR due to altitude differences (
Current status of PR.
| Item | Frequency ( |
Percentage (%) | Cumulative percentage (%) |
|---|---|---|---|
| Implementation of PR | |||
| Whether the department conducts PR-related work for patients with PH? ( |
|||
| Yes | 204 | 62.58 | 62.58 |
| No | 122 | 37.42 | 100.00 |
| Whether standardized procedures have been developed for these PR works? ( |
|||
| Yes | 111 | 54.41 | 54.41 |
| No | 93 | 45.59 | 100.00 |
| Whether the department is equipped with rehabilitation-related equipment? ( |
|||
| Yes | 141 | 69.12 | 69.12 |
| No | 63 | 30.88 | 100.00 |
| Whether having received special training on PR? ( |
|||
| Yes | 129 | 63.24 | 63.24 |
| No | 75 | 36.76 | 100.00 |
| Number of full-time medical staff dedicated to disease rehabilitation management in the department ( |
|||
| 0 staff | 154 | 75.49 | 75.49 |
| 1–2 staff | 41 | 20.10 | 95.59 |
| ≥3 staff | 9 | 4.41 | 100.00 |
| Observed changes in patients’ symptoms after rehabilitation exercise | |||
| Degree of dyspnea ( |
|||
| Significantly improved | 96 | 47.06 | 47.06 |
| Slightly improved | 94 | 46.08 | 93.14 |
| No change | 8 | 3.92 | 97.06 |
| Worsened | 6 | 2.94 | 100.00 |
| Degree of fatigue ( |
|||
| Significantly improved | 100 | 49.02 | 49.02 |
| Slightly improved | 89 | 43.63 | 92.65 |
| No change | 9 | 4.41 | 97.06 |
| Worsened | 6 | 2.94 | 100.00 |
| Whether observing fluctuations in the effect of PR in patients due to altitude differences? ( |
|||
| Yes | 166 | 81.37 | 81.37 |
| No | 38 | 18.63 | 100.00 |
Adjust the content of PR according to the high-altitude environment.
Patient adherence to PR exercises (
Regarding the main barriers to implementing PR, the primary reasons cited by 326 participants were insufficient awareness among patients and their families (90.80%), lack of high-altitude PR guidelines (88.04%), and shortage of healthcare human resources (87.42%). In terms of policy support deficiencies, the top three issues identified were insufficient special funding for rehabilitation (84.66%), adaptive rehabilitation equipment not covered by medical insurance (84.66%), and lack of high-altitude compensation standards (82.52%) (
Identified main barrier factors and policy support gaps in PR implementation (multiple responses allowed;
Optimization suggestions focused on developing high-altitude PR guidelines (86.50%), increasing in rehabilitation resources (82.82%), and improvement of patients’ compliance (78.22%). To improve patient adaptability to high altitudes, the most frequently cited approaches were establishing dynamic oxygen therapy standards (93.87%), conducting hypoxia physiology training (91.41%), and develop altitude-specific exercise grading systems (85.89%). Participants noted that technologies such as smart wearable devices (92.33%), electronic medical record sharing systems (88.34%), and AI-generated personalized rehabilitation plans (86.81%) could effectively enhance patient rehabilitation outcomes (
Medical staff recommendations for future improvement of PR programs (multiple responses allowed;
A total of 27 participants put forth suggestions, which were predominantly manifested in the following seven aspects: increasing professional staffing and enhancing their skill sets; establishing standardized and normative operational frameworks; focusing on the upgrading of hardware and technology; strengthening patient management and health education; enhancing awareness at the societal level; advocating for policy and resource support from higher authorities; and developing targeted intervention measures for specific environments and needs. Detailed descriptions are provided in the
A total of 16 participants were interviewed, including 8 doctors and 8 nurses. Detailed results are shown in
Baseline characteristics of interviewed participants.
| Number | Sex | Age (years) | Professional title | Educational background | Work experience (years) |
|---|---|---|---|---|---|
| Doctor1 | Male | 47 | Associate chief physician | Bachelor’s degree | 18 |
| Doctor 2 | Male | 42 | Associate chief physician | Bachelor’s degree | 18 |
| Doctor 3 | Male | 27 | Resident physician | Bachelor’s degree | 5 |
| Doctor 4 | Female | 41 | Associate chief physician | Bachelor’s degree | 17 |
| Doctor 5 | Female | 38 | Attending physician | Bachelor’s degree | 13 |
| Doctor 6 | Female | 37 | Attending physician | Bachelor’s degree | 14 |
| Doctor 7 | Female | 34 | Attending physician | Bachelor’s degree | 12 |
| Doctor 8 | Female | 30 | Resident physician | Master’s degree | 5 |
| Nurse 1 | Female | 51 | Associate chief nurse | Bachelor’s degree | 30 |
| Nurse 2 | Female | 45 | Associate chief nurse | Bachelor’s degree | 20 |
| Nurse 3 | Female | 34 | Supervisor nurse | Bachelor’s degree | 15 |
| Nurse 4 | Female | 30 | Supervisor nurse | Bachelor’s degree | 9 |
| Nurse 5 | Female | 38 | Supervisor nurse | Bachelor’s degree | 14 |
| Nurse 6 | Female | 35 | Supervisor nurse | Bachelor’s degree | 10 |
| Nurse 7 | Female | 43 | Supervisor nurse | Bachelor’s degree | 17 |
| Nurse 8 | Female | 29 | Supervisor nurse | Bachelor’s degree | 8 |
PR measures and implementation characteristics: The current PR measures for inpatients with high-altitude PH primarily include oxygen therapy, breathing exercises, and physical training. However, the implementation of breathing and exercise training remains fragmented, often limited to “verbal instructions followed by low-intensity, self-guided practice”. This approach lacks standardized, individualized assessment based on objective metrics.
High-altitude adaptation adjustment: interventions aimed at adapting to the high-altitude environment are predominantly empirical. For instance, oxygen therapy duration may be extended without unified target oxygen saturation levels, and exercise rehabilitation is primarily guided by the patient’s subjective tolerance.
Management and follow-up mechanism: post-discharge management is mainly conducted through patient WeChat groups. However, the frequency of home-visit follow-ups is low.
Effect evaluation: medical staff have observed improved pulmonary function in patients with good compliance. Nonetheless, the absence of standardized follow-up procedures and systematic data tracking makes it difficult to comprehensively evaluate the effectiveness of home-based PR. Supporting verbatim quotations for these subthemes are provided in
Current status of PR and effects.
| Subtheme | Illustrative |
|---|---|
| PR measures and implementation characteristics | “Guide the patient to, for example, blow a balloon for about 10–15 min after waking up in the morning, as well as perform pursed-lip breathing, diaphragmatic breathing, and use a respiratory training device. There is no fixed duration, just a standard time frame.” (Doctor 7) |
| “Currently, the rehabilitation services provided to patients within the department primarily involve education by doctors and nurses, including activities such as balloon blowing, diaphragmatic breathing, oxygen therapy, and moderate aerobic exercise. The most accessible options at present are balloon blowing and Baduanjin. There is virtually no financial investment required, and these interventions are mainly implemented in the patient’s ward during hospitalization.” (Doctor 8) | |
| “We teach patients breathing exercises, and our department is currently implementing oxygen-carrying exercises, pursed-lip breathing, and abdominal breathing.” (Nurse 1) | |
| High-altitude adaptation adjustment | “Generally speaking, what we do for this is to increase the duration of oxygen therapy, which is 15 h or more. However, we usually do it for more than 15 h, and for some severe patients, it can even reach about 20 h. And this is the exercise, because they already have a heavy lack of oxygen, and coupled with the low oxygen in a high-altitude area, it may be activity. Compared to low altitude areas, the intensity of these exercises is not as high.” (Doctor 3) |
| Management and follow-up mechanism | “But now for our nebulized inhalation medication, we have created a WeChat group, which is a follow-up group. We will actively ask him how he is doing and if he has used up the medication? How have you been these past few days?” (Doctor 6) |
| “There is a WeChat group like this, and before we schedule, we also distribute some compliance with medication and rehabilitation breathing exercises videos, short videos, to the WeChat group.” (Nurse 1) | |
| “In terms of follow-up, our responsible nurse will go home to evaluate the effectiveness after discharge… We have now conducted follow-up on 5 patients.” (Nurse 2) | |
| Effect evaluation | “There is a patient with chronic obstructive pulmonary disease and old pulmonary tuberculosis who also has PH. He has a ventilator at home and a home oxygen therapy device. The drugs he inhales and the targeted drugs he uses to lower pulmonary arterial pressure follow the doctor’s advice very well. His quality of life and survival rate have significantly improved.” (Doctor 4) |
| “There is currently no corresponding evaluation of the effectiveness of existing rehabilitation treatments, they have only been carried out according to requirements. On the other hand, they are not systematic and comprehensive enough, and there is no dedicated person to complete respiratory rehabilitation.” (Doctor 8) | |
| “We only gave him these teachings during his hospitalization, but we do not have any evaluation criteria for how he will perform in the later stages.” (Nurse 1) |
Individual and behavioral factors of patients: Insufficient patient understanding of the disease (e.g., fear of “oxygen dependency”), widespread distrust toward doctors, lack of caregiving support for older adult individuals living alone, and language barriers among some ethnic minority patients collectively contribute to poor compliance.
Geographical and environmental factors: The hypoxic high-altitude environment limits patients’ exercise capacity. Remote locations and inconvenient transportation reduce the frequency of medical consultations and increase the difficulty of follow-up.
Economic burden and cost issues: Financial constraints limit patients’ access to quality medical services, rehabilitation equipment, and medications.
Conflict between culture and belief: Cultural beliefs or practices among some ethnic minority patients can impact healthcare seeking and rehabilitation adherence. For instance, some may turn to a Living Buddha for serious illnesses, and some Tibetan patients prefer Tibetan medicine and treatments.
Insufficient medical resources: Inadequate allocation of healthcare staff and shortages of rehabilitation equipment significantly hinder the delivery of PR.
Shortcomings of existing PR programs: The current PR programs lack standardized procedures. Health education content is delivered in a monotonous format, leading to poor information dissemination. Furthermore, there is an absence of clear quantitative indicators and operational guidelines for high-altitude adaptation, as well as a standardized post-discharge follow-up mechanism. Verbatim supporting quotations for these subthemes are provided in
Barriers for implementing PR.
| Subtheme | Illustrative |
|---|---|
| Individual and behavioral factors of patients | “The patient’s compliance is not good, and there are very few who can persist in doing mouth breathing and health exercises……For example, in terms of oxygen therapy, whether it’s a nasal cannula mask or a ventilator, they always feel that they become dependent on it after wearing it for a long time and will not be able to remove it in the future, so they may use it during acute exacerbations. I think it’s more likely to have a higher level of cultural awareness, and I do not think his own understanding of this disease is enough. They adjust the duration of their oxygen therapy according to their own wishes……I think it’s the patients who have decreased their trust in the hospital and doctors. Some patients and their families are not particularly cooperative, so they may have a big discount on compliance, or they may not trust the doctor’s words very much……It is indeed possible that our hospital is in Chinese, and there are few translations of Tibetan language. They do not know how to write, and even with Tibetan language, they do not know it. They only know this language. Therefore, cultural knowledge has an impact on ethnic minorities in remote areas.” (Doctor 1) |
| “The old man was alone at home and could not take care of himself, so he had to procrastinate until his children came back to pick him up and take him to the hospital. So the life cycle of these patients is shorter. If there is someone at home to take care of them, their lifespan will also be longer.” (Doctor 2) | |
| “Inhalation of medication is a long-term chronic treatment. Some patients may not be able to persist and may stop taking medication because they feel better. Many patients give up halfway due to improper use of medication or incorrect inhalation methods, resulting in poor treatment outcomes.” (Doctor 4) | |
| “I think it’s related to cognition, which is about these Tibetan and Hui pastoral areas. They believe in Buddhism and their own beliefs.” (Nurse 8) | |
| Geographical and environmental factors | “Especially in pastoral areas, there is still a part that is mainly based on grazing, and his place of residence is not fixed, so his compliance may be poor.” (Doctor 5) |
| “After the patient returns, the medicine will not be used for a long time, especially because their reason is that it is too far away and we cannot get through.” (Doctor 6) | |
| “I think this is related to our altitude. Overall, the patient population for pulmonary hypertension is still… the acceptance rate is relatively high among rural and pastoral patients.” (Nurse 2) | |
| Economic burden and cost issues | “There are some patients who do not have their own source of income. Sometimes he cannot hold off until the end because he cannot take it anymore or borrow money (for medical treatment)” (Doctor 6) |
| “We (the patients here) buy very few oxygen concentrators, and the conditions at home are indeed very poor. Most of us are poor people here, who are very sick and have to wait for a long time before coming and then getting on a ventilator.”(Nurse 8) | |
| Conflict between culture and belief | “(Patients) will make major decisions, they will go to the living Buddha to decide whether to seek medical treatment or further treatment.” (Doctor 2) |
| “Some Tibetan patients find it difficult to receive Western medicine treatment due to their beliefs or customs, and it is also difficult to follow medical advice for corresponding rehabilitation.” (Doctor 8) | |
| “Regarding their culture, faith, and beliefs. I think this is because we also have more Hui people and people who believe in Buddhism.” (Nurse 8) | |
| Insufficient medical resources | “As for our department, although we have 55 beds, we have a maximum of six non-invasive breathing machines in our general practice, and then add four high flow ventilators.” (Doctor 1) |
| “The reimbursement ratio in Qinghai is still relatively low, mainly because the reimbursement ratio for patients is 60%, plus some threshold fees, he may only be able to report 40%.” (Doctor 2) | |
| “The second one is this rehabilitation exercise. Currently, some of these equipments sometimes cannot keep up.” (Doctor 3) | |
| “The personnel are indeed quite busy. The respiratory department is quite busy, and in the afternoon, there is a bit of tension. The personnel are really limited because our number of people is really not enough.” (Nurse 4) | |
| Shortcomings of existing PR programs | “There are no specific standards. There is no specific plan given to him, only verbal preaching without a specific implementation process……The publicity is relatively poor. The overall publicity, including our hospital and even the government’s publicity efforts, is not enough, and patients’ understanding of the disease is also insufficient……There is still a lack of clear quantitative indicators and operational norms for adjusting the PR needs and intervention measures of patients at different altitudes……The amount and level of activity that patients engage in must be different. It is necessary to reduce the frequency according to the altitude……There is no complete management plan or standardized follow-up mechanism.” (Doctor 2) |
| “There is a process that we drafted ourselves, but this is something we drafted ourselves, and it cannot be said to be completely right or wrong.” (Nurse 7) |
Optimization of intervention content: It is recommended to develop individualized and differentiated exercise plans based on the patient’s disease severity and tolerance. Long-term home oxygen therapy and early respiratory rehabilitation exercises should be emphasized, alongside strengthened nutritional guidance, psychological support, health education.
Technical tools and methods: Utilize a variety of tools for health education, including brochures, videos, WeChat groups, and instructional videos. However, WeChat group management must be enhanced to ensure information is accurate and practical. Wearable devices like smart wristbands can be widely adopted to provide dynamic feedback for rehabilitation through real-time data monitoring.
Policy and institutional safeguards: Healthcare institutions are advised to establish dedicated respiratory rehabilitation centers equipped with professional rehabilitation devices and to create positions for clinical nutritionists. At the policy level, it is recommended to expand the scope of health insurance coverage and increase reimbursement rates to alleviate the financial burden on patients. Efforts should also promote directing resources toward primary care, implementing disease-specific management for target populations, and ensuring the implementation of relevant clinical guidelines in high-altitude areas. Verbatim supporting quotations for these subthemes are provided in
Optimization suggestions.
| Subtheme | Illustrative |
|---|---|
| Optimization of intervention content | “For those with lung problems in high-altitude areas, we definitely recommend long-term home oxygen therapy.” (Doctor 1) |
| “Compared to low altitude areas, I think for oxygen therapy, in our high-altitude region, the oxygen inhalation time may be longer and equipped with this kind of oxygen related equipment.” (Doctor 5) | |
| “Compared with low altitude areas, it may be necessary to comprehensively consider the economic conditions of patients and provide them with economical and efficient respiratory rehabilitation guidance…It may be necessary to increase psychological intervention. Many patients have anxiety, depression, or sleep problems, which are currently a weakness.” (Doctor 8) | |
| “Many patients cannot intervene if they cannot tolerate it. Some lie in bed and some stand up, depending on the patient’s condition.” (Nurse 3) | |
| “Do a good job in evangelism. Go home and stick to oxygen therapy, then have regular outpatient visits, and after that, take medication according to the doctor’s advice. The inhaled medication is basically not stopped. In Tibetan areas, people do not pay attention to their diet because they already eat a lot of beef and mutton, so they need to pay attention to their diet.” (Nurse 6) | |
| Technical tools and methods | “WeChat groups will invite patients to join, and corresponding professional technicians will answer your questions every day.” (Doctor 1) |
| “In terms of technical tools, we can now use portable devices such as oxygen saturation monitoring and heart rate monitoring, like wristbands, to dynamically observe patients’ rehabilitation.” (Doctor 3) | |
| “For example, recording a video… You can send it to his phone and watch it for a long time when he goes back. Follow this video to practice together.” (Doctor 4) | |
| “Actually, we also add some WeChat accounts for patients and their families now. They can always tell us anything, just like playing the role of a family doctor. If there is a dedicated platform and personnel to manage this aspect, it may be better……With the help of remote or Internet, or the small brochures, we can follow up outside the hospital.” (Doctor 5) | |
| “But this is because if this group becomes bigger and bigger, he will send it to you all day and night, and it’s not good if there is no one to manage it.” (Nurse 1) | |
| “Join the WeChat group or make a phone call. If they are older, they play with their phones less, and then family members can tell them.” (Nurse 6) | |
| “The video may be the simplest. The most commonly used Tiktok or Kwai video, which he may brush while watching, will definitely pay attention to.” (Nurse 7) | |
| Policy and institutional safeguards | “Whether it’s oxygen concentrators or ventilators, if the country can keep up with the support, it will definitely be a good thing for lung rehabilitation.” (Doctor 1) |
| “Also, there is a rehabilitation specialist specifically for patients with pulmonary hypertension who can provide them with training……The policy of prevention as the main focus, as well as the Healthy China policy, mainly targets many chronic diseases. If we start managing and gradually promoting them from the grassroots level, it may have a certain effect.” (Doctor 3) | |
| “We can also provide some equipment, such as specialized respiratory training devices. It depends on the patient’s wishes, and then, how convenient they are, which one they are willing to choose, and then provide them with the corresponding equipment.” (Doctor 4) | |
| “I think our respiratory patients need to have a nutritionist.” (Doctor 5) | |
| “Guidelines and expert consensus related to high-altitude areas need to be implemented, and public welfare publicity needs to be strengthened.” (Doctor 8) | |
| “I hope we can have a rehabilitation department, so that all of us older adult patients with pulmonary heart disease can go to the department for more comprehensive and professional rehabilitation training.” (Nurse 8) |
The integrated quantitative and qualitative findings collectively delineate the current landscape, barriers, and potential optimization pathways for PR in high-altitude regions.
Regarding the current state of PR practice, the quantitative data (62.58% of participants reported PR implementation in their departments) and qualitative descriptions (characterizing the measures as being in a “fragmented stage”) jointly indicate insufficient penetration and systematization of PR within clinical practice. Both methodological approaches revealed significant gaps in departmental resource allocation.
Concerning high-altitude adaptation adjustments, the quantitative result (55.39% of participants reported making adjustments to PR content) and qualitative finding (that these are “primarily based on empirical adjustments”) mutually corroborate each other. This convergence demonstrates that while adaptation practices are common, they lack standardization.
In terms of implementation barriers, the top-ranked obstacles identified in the quantitative survey—such as insufficient patient awareness, lack of specific guidelines, and inadequate resources—were richly elaborated and contextualized through specific examples and detailed explanations provided in the qualitative interviews.
Pertaining to optimization pathways, a high degree of consensus emerged from both research methodologies. The core needs expressed by quantitative participants—for developing high-altitude-specific guidelines and increasing resource allocation—directly correspond to the recommendations derived from qualitative analysis, which emphasized addressing the lack of standardized procedures and optimizing the configuration of human resources and equipment.