Physical activity recommendations for patients with heart failure
ferences in patients with HF seem, however, to be more
complex and more debated than in healthy people.
Reflecting this, an opposing view was also identified
among healthcare providers, who did not recognize
sex as a discriminating factor with regard to PA in
patients with HF; a fact that was proposed to relate to
the similar effects of the disease on both sexes when
considering the assessed parameters (PA and physical
capacity, barriers and motivations).
The lack of consistency in the observations and be-
liefs of healthcare providers might be due to a lack of
evidence and difficulties related to comparing patients
with HF. This is supported by Rumsfeld & Masoudi
(21), who present 3 possible reasons for sex differences
in cardiovascular disease: “Disparities in care delivery”
(are male and female patients offered the same care?),
“Intrinsic biological differences” (actual biological
differences that give rise to the sex differences), and
“Unmeasured clinical variation” (referring to con-
founding by differences in disease severity, etc.), all of
which were mentioned in the interviews in one way or
another. They further discuss that it is essential to deter-
mine which of these reasons is behind sex differences
in cardiovascular disease in order to decide whether the
solution for eliminating them should be to equalize or
differentiate care (21), further validating the confusion
among healthcare providers when discussing this mat-
ter. Moreover, in the interviews, numerous factors apart
from sex were mentioned as influencing PA, physical
capacity, motivations and barriers and sex differences,
making the subject complex. Studying correlation with
these factors by quantitative means might also be an
interesting approach in future studies.
In the interviews, it was certainly evident that
the healthcare providers faced a conflict in terms of
whether they should equalize or personalize their
care. The opinions on the value of considering sex
when personalizing care were, again, divergent. It
has, however, been shown that a sex-tailored ap-
proach is of importance for adherence and outcome of
interventions (22). In the interviews, adjustments that
were suggested to be of value were mostly related to
different approaches, using sex-specific motivations
and addressing sex-specific barriers, whereas most
interviewees believed that male and female patients
should be given the same advice. As the healthcare
providers found that male and female patients had
different preferences for activities, another proposal
was to offer sex-specific rehabilitation programmes
or groups in order to increase adherence.
It is known that women with HF demonstrate similar
patterns of improvement during cardiac rehabilitation
as men, and even show greater improvements in fitness
and longer-term exercise levels (23). It is therefore of
537
vital importance to enrol female patients in rehabilita-
tion programmes where the focus often is on increasing
PA in the long term. It might, however, be relevant to
tailor activity programmes to the specific needs of men
or women and to vary the design of the interventions in
rehabilitation programmes as proposed in other disease
groups (24). In addition to the differences suggested
in this study, studies carried out on healthy men and
women also identify sex differences in motivations
for and barriers to PA, where men report being more
motivated by “competition”, “strength, “fitting in” and
“avoiding social disapproval from peers” (15).
A strength of this study was the availability of healt-
hcare providers with experience of providing advice
on PA to patients with HF and a 1:1 sex distribution.
We recruited from 2 different centres that had different
profiles, although they were both academic medical
centres. Interviews provided rich data. Additional tri-
angulation of data including observations of healthcare
providers and their patients in practice might have been
preferred, but was not feasible due to language barriers;
for example, patients and healthcare providers commu-
nicating in Hebrew and data collectors being Swedish.
The results, however, provide insight into the chal-
lenges faced by healthcare providers when tailoring
HF care based on sex. To conclude, it may be difficult
to consider sex differences in PA in HF care, and sex
is not a factor that is usually considered when tai-
loring activity advice to patients with HF. Although
some examples of alterations and approaches are
used anecdotally, there is still a lack of evidence on
tailored activity advice and there is a conflict of fear of
discriminating vs the benefits of tailoring and persona-
lizing care. Indeed, one should not instigate healthcare
strategies based on frail evidence. Thus, to assess this
matter fully, more studies are needed on the existence
and reasons for sex differences in patients with HF.
Implications for practice:
• Healthcare providers might not be immune to biases
or perceptions about physical activity based on sex.
• Sex might be considered more often when tailoring
activity advice to patients with HF.
• Sex-specific motivations and barriers can be used to
tailor interventions to improve physical activity to
patients with HF.
ACKNOWLEDGEMENTS
The authors would like thank all the healthcare providers who
gave their valuable time, and to express gratitude to Dr M.
Liljeroos for commenting on the paper.
This work is supported by the Swedish National Science
Council (2016-01390); Swedish National Science Council/
J Rehabil Med 51, 2019