Cardiac rehabilitation: what's hindering access for women?

By Dr. Liji Thomas, MDSep 27 2023Reviewed by Benedette Cuffari, M.Sc.

After a major cardiac event, proper attention and care must be given if the individual is to recover as much function and good health as possible. A new paper in the Canadian Journal of Cardiology discusses the potential factors impacting women’s participation in cardiac rehabilitation (CR) programs.

Study: Women’s cardiac rehabilitation barriers: results of the International Council of Cardiovascular Prevention and Rehabilitation’s first global assessment. Image Credit: Elnur / Shutterstock.com

Introduction

Cardiovascular disease (CVD) is a leading killer among both men and women. Women are at an increased risk of CVD after menopause, as the protective effects of estrogen on the heart and vascular system weaken.

CR is a crucial secondary prevention approach that aims to prevent the further deterioration of patients with CVD and promote their health. These programs, which are designed to operate in outpatient clinics, have provided positive effects on women with CVD.

Nevertheless, there remains a global gap in the usage of CR by both sexes, predominantly in women, as compared to the need. In fact, even when provided referrals by their physicians, women are often reluctant to enroll in or complete CR programs. This could be the secondary effect of gender discrimination towards women, as egalitarian countries like Sweden report greater use of CR than other Western countries.

To date, only two studies have examined differences in availing CR between the sexes using an accepted scale. One study was performed in Canada, where women reported some barriers impacting their access to CR more than men despite the liberal culture of this nation. The other study was conducted in Iran and reflected a universally greater level of difficulty in CR access among women.

The current study was conducted in China, Korea, Portugal, and the Middle East. The aims included identifying the major CR barriers in women, differences in CR barriers by sex, differences in women’s CR barriers by social characteristics, the relative importance of the various women’s barriers, and evaluating various counter-strategies.

The patients who were considered eligible for CR were identified by members of the International Council of Cardiovascular Prevention and Rehabilitation. All study participants were given questionnaires in the locally appropriate language between March 2021 and March 2023

What did the study show?

Over 2,000 patients from 16 countries in six World Health Organization regions were included in the study, about 40% of whom were women. The mean age of the study cohort was 62 years.

Women did not generally report that they faced greater barriers to participating in CR programs. However, sex differences were observed in Brazil and the Western Pacific.

The greatest obstacles were observed in the Western Pacific and Southeast Asia, wherein patients were not aware of the availability or need for CR programs. Unemployed women also faced difficulty in accessing such programs.

Conversely, men were underserved in the Eastern Mediterranean region and reported issues with transportation, less access to CR, and difficulties posed by other illnesses or low physical function. This difference could be because more workers outside the home are men, which accounts for time/work conflicts with CR.

Likewise, in Europe, men reported more barriers than women in logistical and health- or functional status-related areas. Logistical and function-related difficulties were more prominent for women in Brazil as compared to men, while issues related to working hours or lack of time for the program were less impactful.

A lower proportion of women received CR referrals at 40% as compared to over 70% of men. Women who were referred for CR were less likely to report barriers than those non-referred. Less than half of referred women eventually enrolled in the program.

Among those referred, women who were unemployed or previously sedentary were more likely to experience barriers to CR participation than physically active or employed women. Women who did not exercise routinely before they were diagnosed with CVD needed CR the most; however, these women reported more barriers.

These barriers included poor access to CR programs, transportation issues, family or workplace responsibilities, health/functioning status issues, CR-related pain or fatigue, low sense of need or poor healthcare utilization, weather-related costs, and personal opinions and preferences.

The most notable barriers among women not enrolled in CR included ignorance of the existence of CR and the failure of the program coordinators to contact patients. The cost of the program and fatigue or pain following the initial exercises also reduced CR participation in women. In enrolled women, logistics and family responsibilities interfered the most with CR.

Various factors interact to create barriers to CR use by men and women. Among women, those who were retired or on disability were most likely to be enrolled in CR. The lowest participation rates were reported among women who were out of work who also reported the greatest barriers.

What are the implications?

In each of the four barrier categories of logistics, health issues/low functional status, other work/time commitments, and lack of interest or perceived need for CR, both sexes reported more barriers in at least one region.

The study findings demonstrate the crucial need for CR programs with automatic enrollment for women who have suffered cardiac events. Plans to reduce the barriers preventing unemployed women from utilizing these programs are also urgently needed.

Unlike earlier studies, the scientists did not find age, educational level, or ethnic origin associated with barriers to CR. Thus, the individual’s sex alone appears to account for much of the disparity in CR participation rates.

It is the association of social and economic determinants of health as they relate to use of CR that is important. CR barriers—men’s and women’s—vary significantly according to region, necessitating tailored approaches to mitigation.”