Skip to main content

Unfortunately we don't fully support your browser. If you have the option to, please upgrade to a newer version or use Mozilla Firefox, Microsoft Edge, Google Chrome, or Safari 14 or newer. If you are unable to, and need support, please send us your feedback.

Publish with us
Press release

Global study provides new insights into barriers to effective cardiovascular rehabilitation for women and why women are less likely to participate

Philadelphia | September 25, 2023

Canadian Journal of Cardiology study assesses barriers to participation in cardiovascular rehabilitation programs for men and women and provides patients with strategies to mitigate them

Cardiovascular rehabilitation (CR) improves health outcomes and well-being and can reduce death and re-hospitalization rates by 20%. However, programs are underutilized and women are much less likely to participate than men, so they do not reap these benefits. This first global comparative study(opens in new tab/window) into barriers to using CR in men and women assesses the extent of these barriers and discusses ways in which patients can overcome them. It determined that women and men face some common, but also many different barriers, and barriers differ by global region. The study appears in the Canadian Journal of Cardiology(opens in new tab/window), published by Elsevier.

Lead investigator Sherry L. Grace, PhD, CRFC, Faculty of Health, York University and KITE - Toronto Rehabilitation Institute, University Health Network, University of Toronto, explains: “The benefits of cardiac rehab participation are remarkable, plus patients get back their vitality and can return to their meaningful life roles. Unfortunately, women face many structural barriers to attending – from the individual to health system levels. We developed the Cardiac Rehab Barriers Scale (CRBS) almost 25 years ago to better characterize them, and it remains the most widely used and rigorous measurement scale to assess these barriers.”

While the CRBS has been translated into more than 20 languages, before the present study it had never been administered to patients in more than one country at a time and had only been administered in a total of 25 countries. There had only been two studies in which women’s and men’s barriers were compared.

Prof. Grace and co-lead investigator Gabriela Ghisi, PT, PhD, CRFC, also of KITE - Toronto Rehabilitation Institute, University Health Network, University of Toronto, add, “It was time to examine CR barriers on a global comparative basis to help us understand sex differences and women’s main barriers so we can address them, and hence have more women enrolling and fully participating in CR.”

In this cross-sectional study, the CRBS was administered globally via an online survey to over 2,000 patients from 16 countries across all six World Health Organization regions. Members of the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) community helped recruit participants by identifying cardiac inpatients who were eligible for CR and patients who were just starting CR. This is the first international study of CR utilization barriers, including data from all world regions, and presents the first quantitative barrier data from Africa as well as from several Western Pacific and European countries. About 42% of the participants were women.

Caption: Top cardiac rehabilitation (CR) barriers in women according to World Health Organization region. The African region is not shown because there were no female survey respondents from Africa (Credit: Canadian Journal of Cardiology).

The study’s findings show that although female cardiac patients have a somewhat greater burden of barriers in the Western Pacific and Americas than men, men and women have major barriers, which need to be addressed to optimize CR utilization. Women’s barriers were greatest in the Western Pacific and South East Asian regions compared to other regions, with lack of CR awareness as the greatest barrier in both. Men in the Eastern Mediterranean region reported greater barriers than women. Women who were unemployed reported significantly greater barriers than those who were employed.

Among women not enrolled in CR programs, their greatest barriers were not knowing about CR, program not contacting them after referral, cost, and finding exercise tiring or painful. Among women who were enrolled in a program, their greatest barriers to session adherence were distance, travel, family responsibilities, and difficulties in accessing sessions that require attendance in person (i.e., transportation).

Through the study - also for the first time - potential mitigation strategies to help overcome these barriers were provided to participants, such as talking with a healthcare provider about getting to a program or doing a home-based program. Over 70% of women and 40% of men rated the barrier-specific information provided as either “helpful” or “very helpful.” These observations should encourage the application of these types of mitigation strategies, as well as the development of further research on active mitigation strategies to improve adherence to CR programs.

Prof. Grace already has further research underway to test if the strategies to mitigate the main barriers identified can result in more CR participation. “We hope this will lead to more women enrolling in CR, and that would certainly positively impact their health outcomes and well-being.”

She urges, “Patients may have legitimate barriers to attending CR, but we recommend they discuss them with healthcare providers, as there are proven strategies to overcome them. Please help spread the word that CR is available in most countries of the world and saves lives!”

A resource for patients to assess their own barriers along with mitigation suggestions are provided on ICCPR’s website(opens in new tab/window).

CR is a chronic disease management program where patients are supported by a team of healthcare professionals over several months through medical risk factor management, structured exercise, as well as patient education and counseling.


Notes for editors

The article is “Women’s Cardiac Rehabilitation Barriers: Results of the International Council of Cardiovascular Prevention and Rehabilitation’s First Global Assessment,” by Gabriela Lima de Melo Ghisi, PT, PhD, CRFC, Won-Seok Kim, MD, PhD, Seungwoo Cha, MD, Raghdah Aljehani, MD, Mayara Moura Alves Cruz, PT, PhD, Luiz Carlos Marques Vanderlei, PhD, Garyfallia Pepera, PhD, Xia Liu, RN, PhD, Zhimin Xu, MD, Lela Maskhulia, MD, PhD, AFAMEE, Elio Venturini, MD, Hung-Jui Chuang, MD, Danielle Gomes Pereira, PT, PhD, Patricia Fernandes Trevizan, PT, PhD, Evangelia Kouidi, MD, Ladislav Batalik, PT, PhD, Mahdieh Ghanbari Firoozabadi, PhD, Ivana Burazor, MD, PhD, Mariya Prakash Jiandani, PT, PhD, Ling Zhang, RN, PhD, Nidal Tourkmani, MD, and Sherry L. Grace. PhD, CRFC ( in new tab/window)). It appears online ahead of the Canadian Journal of Cardiology, volume 39, supplement (November 2023) published by Elsevier.

The article is openly available at in new tab/window).

Full text of the article is also available to credentialed journalists upon request. Contact Eileen Leahy at +1 732 238 3628or [email protected](opens in new tab/window) to obtain copies. Journalists wishing to speak to the study’s authors should contact Emina Gamulin, York University, at +1 416 554 9567 or [email protected](opens in new tab/window).

About the Canadian Journal of Cardiology

The Canadian Journal of Cardiology(opens in new tab/window) is the official journal of the Canadian Cardiovascular Society(opens in new tab/window). It is a vehicle for the international dissemination of new knowledge in cardiology and cardiovascular science, particularly serving as a major venue for the results of Canadian cardiovascular research and Society guidelines. The journal publishes original reports of clinical and basic research relevant to cardiovascular medicine as well as editorials, review articles, case reports, and papers on health outcomes, policy research, ethics, medical history, and political issues affecting practice. in new tab/window)

About the Editor-in-Chief

Editor-in-Chief Stanley Nattel, MD, is Paul-David Chair in Cardiovascular Electrophysiology and Professor of Medicine at the University of Montreal and Director of the Electrophysiology Research Program at the Montreal Heart Institute Research Center.

About the Canadian Cardiovascular Society (CCS)

The CCS(opens in new tab/window) is the national voice for cardiovascular clinicians and scientists, representing more than 2,300 cardiologists, cardiac surgeons and other heart health specialists across Canada. We advance heart health for all by setting standards for excellence in heart health and care, building the knowledge and expertise of the heart team, and influencing policy and advocating for the heart health of all Canadians. For further information on the CCS visit in new tab/window).


The International Council of Cardiovascular and Prevention and Rehabilitation (ICCPR) brings together Societies around the world dedicated to the secondary prevention of heart diseases. Central to their mission is promoting high quality cardiac rehabilitation services where they are needed most. Learn more at in new tab/window).

About Elsevier

As a global leader in scientific information and analytics, Elsevier helps researchers and healthcare professionals advance science and improve health outcomes for the benefit of society. We do this by facilitating insights and critical decision-making with innovative solutions based on trusted, evidence-based content and advanced AI-enabled digital technologies.

We have supported the work of our research and healthcare communities for more than 140 years. Our 9,500 employees around the world, including 2,500 technologists, are dedicated to supporting researchers, librarians, academic leaders, funders, governments, R&D-intensive companies, doctors, nurses, future healthcare professionals and educators in their critical work. Our 2,900 scientific journals and iconic reference books include the foremost titles in their fields, including Cell Press, The Lancet and Gray’s Anatomy.

Together with the Elsevier Foundation(opens in new tab/window), we work in partnership with the communities we serve to advance inclusion and diversity in science, research and healthcare in developing countries and around the world.

Elsevier is part of RELX(opens in new tab/window), a global provider of information-based analytics and decision tools for professional and business customers. For more information on our work, digital solutions and content, visit

Media contact


Eileen Leahy


+1 732 406 1313

E-mail Eileen Leahy