Why Don't More Women Participate in Cardiac Rehabilitation?

Marilynn Larkin

October 03, 2023

The biggest barrier to enrollment and participation in cardiac rehabilitation (CR) among women globally is lack of awareness, an international cross-sectional study suggests.

That barrier prevented even women referred to CR from participating, according to the study, which included 2163 patients (42% women) from 16 countries across all World Health Organization regions. Other major barriers for referred women who did not participate included the program's failure to contact them after referral, cost, and finding exercise tiring or painful.

The researchers also found that among women who did enroll in CR after referral, the greatest barriers to session adherence were distance, travel, family responsibilities, and difficulties in accessing sessions that require attendance in person.

Sherry L. Grace, PhD

"We tested some mitigation responses for each barrier in this study, and patients —particularly women — rated them as highly useful," study author Sherry L. Grace, PhD, professor at York University and University Health Network, Toronto, Ontario, Canada, told Medscape Medical News. "We have further research, a randomized trial, underway now to test if this can actually result in more CR participation."

The study was published online September 24 in the Canadian Journal of Cardiology.

Significant Regional Differences

The investigators administered the English, Simplified Chinese, Arabic, Portuguese, or Korean version of the Cardiac Rehabilitation Barriers Scale (CRBS, a 5-point Likert scale, with higher scores indicating more barriers) to 2163 patients indicated for CR from October 2021 to March 2023. Members of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) community facilitated participant recruitment. Mitigation strategies were offered and rated.

Globally, there was no sex difference in total CR barriers or subscales. But there were significant differences in total barriers in women regionally. Women’s barriers were greater in the Western Pacific (mean CRBS score, 2.6) and South East Asia (mean CRBS score, 2.5). Lack of CR awareness was the greatest barrier in both regions. The Eastern Mediterranean region was the only region in which men reported greater total barriers.

In Brazil, women reported significantly greater barriers related to logistical factors and comorbidities or functional status, compared with men. Brazilian women reported fewer barriers related to work or time conflicts. The findings were similar for the Western Pacific region.

In the Eastern Mediterranean (the region with lowest gender equality), women had significantly fewer barriers related to perceived need or healthcare access, logistical factors, and comorbidities or functional status, compared with men. In Europe (the region with the greatest gender equality), women had significantly fewer barriers than men related to logistical factors and comorbidities or functional status.

Women who were unemployed reported significantly greater barriers than those who were working. "At first, I was surprised that unemployed women had greater barriers, given they would not have work conflicts impeding participation," Grace said. "This probably reflects that these women have high domestic responsibilities and do not have money or coverage for CR services through an employer benefit plan."

Overall, nonreferred women had somewhat higher CRBS scores than those who were referred.

Among nonenrolling women, the greatest barriers were not knowing about CR, the program's failure to contact them after referral, cost, and finding exercise tiring or painful. Among enrolling women, the greatest barriers to session adherence were distance, travel, family responsibilities, and difficulties in accessing sessions that require attendance in person (that is, transportation).

Mitigation strategies suggested in the study include automatic CR referral through electronic health records, bedside encouragement, and education of women. Post referral, strategies to support women’s enrollment and adherence include providing choice in the mode and timing of CR delivery to address transportation barriers and time constraints, and women-focused CR.

Overall, 71.8% of women and 42.1% of men rated the barrier-specific information provided as either "helpful" or "very helpful."

"Based on the ICCPR’s initial Global Audit, approximately 700 programs in less than 50 countries globally offer some form of women-focused CR," wrote the authors. "Resources are available to feasibly support programs to offer some women-focused programming, even in low-resource settings."

Generalizability Limited

The authors advised caution in interpreting the study results. The generalizability of the findings is limited because the cohort was made up of a convenience sample of in- and outpatients from centers with a CR program across a few countries in every region. Furthermore, there were no women participants from Africa, and all participants from the Americas and from South East Asia were from a single country each.

In addition, they wrote, prudence is also warranted because of sex differences in sociodemographic characteristics in the sample that could affect barriers. For example, women were more likely to be older, members of minorities, and unemployed than men.

Gabriela Lima de Melo Ghisi, PT, PhD

Nevertheless, "cardiac rehab is available in most countries and saves lives," lead author Gabriela Lima de Melo Ghisi, PT, PhD, also of University Health Network, commented. She urged clinicians to discuss barriers with their patients and provide strategies to overcome them.

Patients can assess their own barriers on ICCPR’s website, which also provides additional mitigation strategies, she told Medscape Medical News.

"We have also developed some materials to support clinicians in making a referral, including a free, brief, evidence-based CME-approved course on promoting CR at the bedside and scripts for the bedside that include talking points specifically for women," said Grace.

'Emphasize the Benefits'

Commenting on the study for Medscape, Martha Gulati, MD, president of the American Society for Preventive Cardiology and director of preventive cardiology at the Smidt Heart Institute at Cedars-Sinai Medical Center in Los Angeles, California, said, "Access to CR is a real issue" in the US, as well. CR programs are often in urban, not rural, areas, and "if you can’t get to it, or it is too far, you won’t attend. CR is three times a week for 12 weeks. It isn’t that easy to drive far for this." Gulati was not involved with the research.

Dr Martha Gulati

"In the US, we also do not have universal healthcare, so the costs are very much also an issue for women," she noted. "Even with insurance, heavy copays are a great burden to many patients and make them not attend. Imagine a copay for every one of those 36 visits. Copayments can vary from $10 to as high as $100."

Virtual CR started during the pandemic, "but now it is likely not even going to be reimbursed," she said. "It is also work intensive for a CR team in its [current] format, and with little reimbursement, it will be unsustainable. The low reimbursement reflects the [low] value given to CR, despite it being an essential therapy."

"Physicians are essential to getting a patient to CR," she added. "When physicians emphasize the need for CR and provide the reason why they are referring, patients are more likely to attend. For our women patients, we need to emphasize the benefits of CR, because women will not be there to care for their family if they die as a result of their underlying cardiac issue."

The study was conducted without funding, and the authors and Gulati report no relevant financial relationships.

Can J Cardiol. Published online September 24, 2023. Full text.

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