There are few studies of CR barriers outside of western high-income settings [27], and none to our knowledge quantitively assessing sex differences in these barriers using a validated scale in a less gender-equal society. In this first such study in a relatively large sample of Iranian non-enrollees, key barriers were quite consistent with what is reported in the broader literature, and sex differences were numerous.
To our knowledge, the CRBS and CR Enrolment Obstacles scales are the only validated measures of CR barriers [28]. And following a rapid review of the literature, we could only identify one other study using one of these measures to assess sex differences in CR barriers, which was undertaken in Canada. There the context is different: they are ranked 19th in Global Gender Gap Index [29], and CR is fully reimbursed, including widely-available home-based services [30]. In that study, there was no significant difference in total CR barriers, but similar to this study, there were significant sex differences for individual barrier items, with some greater in women and some in men. For instance, in both studies [29], men rated already exercising at home or in the community greater than women. While men are generally more physically active than women [31], we must educate all patients that CR is more than just exercise [6], and that the benefits are great.
In that study as well [29], women’s top barriers were not logistical as they were herein, but instead not knowing about CR (this item was not included in the translation; [23]) or being encouraged by their physician (this item was somewhat differently worded in the translation) were top; however, finding exercise tiring or painful and already exercising at home were also greater barriers in both studies. This suggests that in a lower-resource setting logistical barriers are paramount as is poor health for women. The majority of women were unemployed (hence why work responsibilities were a greater barrier in men than women) and therefore had no independent income, thus the costs of CR sessions, and indirect costs such as transportation to the CR center were formidable barriers. Women lacked financial independence to pay for transportation, or to have a personal vehicle. And in the province there is only this one CR center, so distance is an issue.
Indeed, similarly between studies [29], women rated transportation, but also perceiving exercise as tiring or painful and comorbidities higher than men. Many studies have documented women’s lower functional capacity upon CR entry, as well as their musculoskeletal [32] and other comorbidities which they perceive prevent them from fully participating in CR [33, 34], but in most cases are actually also ameliorated by it.
But in the Canadian study and others[35], women also rated family obligations higher than men. One of the possible reasons for the lack of difference in this barrier between men and women in this study may be that many men were retired and thus spend more time on household responsibilities and family care [36]. Another reason for this difference may be that women’s children had grown, and as they were not working, they perceived fewer conflicts related to this life role.
A review of women’s CR barriers and associated solutions sheds light on potential strategies to overcome these barriers [37]. Many of the solutions focus on the referral process itself and automating it including an encouraging discussion with patients, which is in place at this center but could be bolstered. A recent update of the Cochrane review on interventions to increase CR utilization also suggests home-based models could work [5]. Indeed, a home-based model has been initiated since the COVID-19 pandemic, via phone with free follow-up monitoring. Offering “women-focused” CR may also increase utilization [38], and that is already offered at the center under study (i.e., it is women-only), although more tailoring to better meet women’s needs may be warranted [39]. For instance, the recent International Council of Cardiovascular Prevention and Rehabilitation clinical practice guideline [39] on this matter recommends careful attention to comorbidities as well as feelings of pain and fatigue when developing, initiating and progressing women’s exercise prescriptions.
Finally, in an effort to move the field from assessment of barriers to mitigation of them, the CRBS is now available online in several languages for patients to complete, and strategies to address their top-rated barriers are provided (https://globalcardiacrehab.com/For-Patients). We are now testing the value of the responses and seeking to optimize them to be applicable across a broad range of settings, and then will test impact on utilization. Ultimately however, we must tackle all levels at play: not just the patient level, but increasing capacity (i.e., health system level), ensuring referral (i.e., physician level), and optimizing accessibility of programs (i.e., center level).
Study limitations
The present study was undertaken in a single center, such that generalizability to other centers, including those in lower-resource, gender-unequal, Muslim settings is not known. Future research in other such settings is warranted. Moreover, it is unknown whether selection bias is at play, as a convenience sample was used.