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Study Explores Barriers to COPD Pulmonary Rehabilitation


This study is one of only a handful to explore barriers to pulmonary rehabilitation in Iran for patients with chronic obstructive pulmonary disease (COPD).

A qualitative descriptive study published by BMC Health Services Research has shed light on some of the barriers facing patients with chronic obstructive pulmonary disease (COPD) from receiving comprehensive pulmonary rehabilitation (PR) treatment.

By some estimates, around 80 million people suffer from COPD in the world. An unknown number of those affected live in Iran, though a previous study on prevalence in multiple provinces reported a population rate of 4.9%. PR seeks to help patients return to functionality and regain their agency in society by addressing physical complications and improving quality of life.

The study was conducted between January 2019 to October 2020 at the Comprehensive Respiratory Clinic of Khorshid hospital, Isfahan, as well as the lung care wards of Al-Zahra and Khorsid hospitals in Iran. Of those surveyed, 19 were patients with COPD, 12 were health care providers, and 11 were family caregivers. To be qualified for the study, patients needed to have a stage 2-4 COPD diagnoses for 1 year or greater, and have no hearing impairments or cognitive disorders.

Semi-structured personal interviews between 30-90 minutes in length were conducted. Locations and times were of the participants’ preference. The interviews were transcribed and reviewed, then screened for key words assigned meaning units. These were then grouped by similarity and relevance into broader subcategories.

Principally, the authors found 3 main barriers to PR: inappropriate organizational context for PR, barriers related to patients and family caregivers, and the overall inefficiency of PR services in Iran. A number of subcategories within these 3 groups were elaborated on and highlighted with quotes from the interviews. Each category had 4 subcategories which covered a wide range of concerns.

For example, on top of a general lack of knowledge among patients and their families, limited access to PR services and a lack of patient-centeredness were noted. The complexity, chronicity, and heavy financial burden of COPD presented additional large obstacles to overcome for the afflicted.

In terms of medical care provided at facilities, a pronounced lack of coordination, professional competence, effective planning, or access to holistic approaches existed in the Iranian PR staff compared to ideal standards. Inadequate insurance for PR services was available, leading to the shouldering of costs for care, treatment, and medications by the patients and their families.

Prominently, impairment of sexual function was considered a notable factor. Conversations around sex are considered a cultural taboo in Iran. This inhibits rehabilitation team members with limited knowledge of COPD-related sexual impairment from discussing it with patients and family members, who are themselves hesitant to speak of their experiences and concerns. The authors feel more research should be done into this topic, and that PR health teams should show active initiative to address the topic in order to provide care allowing for the continued sexual performance and satisfaction of COPD sufferers.

These and other factors led to Iranian patients’ overall frustration and discontinuation of PR and care. The authors reinforced the need for reform and an improvement in financial support for patients to avoid accruing greater personal and social costs.

Studies on barriers to PR in Iran have been largely quantitative so far. The authors emphasized the importance of qualitative studies such as theirs that could represent conditions in different cultures, in order to offer a deeper understanding of treating COPD.

The wide demographic range of surveyed patients with COPD, their caregivers, and medical staff was cited as a strength of the study, with variances in education level, occupation, gender, and age.

A limitation on the study’s generalization was cited. The unique structural conditions of medicine in Iran involve different access to resources and practices, which the authors considered “radically different” compared to conditions in other parts of the world.

Overall, more strategies for improving the quality and effectiveness of PR in Iran are needed to mitigate barriers to aiding those with COPD. The authors summarized their consensus by saying, “These findings imply that the barriers to PR for patients with COPD are personal, familial, social, financial, organizational, and governmental.”


Sami R, Salehi K, Hashemi M. et al. Exploring the barriers to pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a qualitative study. BMC Health Serv Res. Published online August 17, 2021. doi.org: 10.1186/s12913-021-06814-5

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