Physical activity recommendations for patients with heart failure
respondent said: “Men often surrender somehow. And
women usually fight. I see that very often in patients
with heart failure. Women are more fighters than men.”
(R1) In contrast, others claimed that women were less
driven to do PA, saying: “They [female patients] have
more difficulties, they need more encouragement. It’s
different, you really have to push them. I mean, it seems
like they are less motivated.” (R2).
Meanwhile, lack of time, fear, lack of self-esteem
and physical inactivity prior to HF were described
as being particularly challenging for female patients.
Apart from being motivational, external appearance
was also mentioned as a female barrier: “… when you
come regularly to a place and you don’t really like the
way you look because you have an oedema, ascites or
shortness of breath. Or for some reason or another, to
any extent, then I guess it would be less attractive or
less feminine. A woman might regard it as a limitation
to engage in a sport.” (R1). Related to this, female
patients were thought to have more barriers than male
patients. One of the respondents said: “You’ve heard
women with heart failure? They have a lot of explana-
tions and excuses. One hundred excuses.” (R2).
“Barriers to and motivations for PA in male HF pa-
tients’ refers to the motivations and barriers stated to be
more important to male patients, several of which could
be linked to societal expectations. While expectations
on men to be strong and active could work as a motiva-
tion, shame of showing weakness was mentioned as a
potential barrier to seeking help. Similarly, work was
mentioned as a barrier in terms of limiting time, but
getting back to work and being able to provide was also
mentioned as a male motivation. Additional observa-
tions included male patients being more competitive,
giving them the motivation to work harder in cardiac
rehabilitation. Some healthcare providers argued that
male patients with HF were more motivated to perform
PA than female patients, saying: “It may well be that
men want to do more because they are, you know, they
see themselves as, in general, as more active to start
off with and so they will want to try to get back to that
as much as possible. Whereas women, particularly if
they weren’t very active beforehand, they may have less
drive to push themselves and do it.” (R12).
Factors related to differences in physical activity
and physical capacity between male and female
patients with heart failure
Participants described several factors related to dif-
ferences in barriers, motivations, PA and physical
capacity between men and women. The category
“Factors influencing PA and physical capacity” des-
cribes independent factors, such as age, socioecono-
535
mic status, an outdoor lifestyle, physical background,
training and disease. The participants also described
factors affecting the existence and extent of sex dif-
ferences in PA and physical capacity. Sex differences
in PA were suggested to be strongly related to different
generations, where women from the older generation
were said to be less physically active than those from
younger generations. Societal views were also thought
to contribute to sex differences. For example, one nurse
said: “So, the mentality I think of the parents and all the
community. The boys have to do something physically,
some physical activity. From the base. For the women,
the maximum you can do is you can dance.” (R4).
In the category “Factors influencing barriers and sex
differences in barriers to PA”, several aspects were
mentioned, including generation, age, religion, culture
and marital status. Experiencing more barriers was
associated with the older generation (not knowing the
importance of PA), with middle-aged people (preoc-
cupation, lack of time) and with religious people and
certain cultures (societal views, not having the habit).
Moreover, middle-aged women were perceived to have
more barriers than middle-aged men due to having to
balance work and family, whereas such differences
were believed to decrease with age. Being more pro-
found in religious societies and in certain cultures,
traditional gender roles were mentioned as being a
barrier for women to be physically active.
“Impact of healthcare provider on sex differences
in PA” refers to the role of the healthcare provider in
patient motivation. It was said that: “It depends on you
as a doctor. How you explain and how you motivate…
I think that if you cause motivation you shouldn’t
have an extreme gender difference. But I think that
we have a bias and we encourage women less.” (R2).
Moreover, although some of the healthcare providers
disagreed, the sex of the healthcare provider was said
to affect interaction and patient adherence and could
be particularly problematic with patients from certain
religions and cultures. One of the healthcare providers
said: “… if I have the ability with a very religious guy
to tell my other co-worker to do the treatment and not
me – I do it. Because he will react better to men.” (R9).
Heart failure has a greater impact on physical
activity and physical capacity than patient sex
An opposing position was identified during the inter-
views reflecting a lack of differences between male
and female patients with HF regarding PA and physical
capacity. The healthcare providers felt that male and
female patients with HF experience the same levels and
types of barriers and motivations, performing equally
physically. One interviewee said: “I can’t think off the
top of my head of any major differences between men
J Rehabil Med 51, 2019