Results from the participant recruitment process are shown in Figure 1. In summary, a total of seven healthcare professionals from seven LMICs, representing South America, Africa, and Asia, were interviewed.
Countries from Asia were Kyrgyzstan and India, from South America was Argentina, and from Africa were Kenya, Malawi, South Africa, and Zimbabwe (Figure 2).
Of the seven interviews, four were conducted on Zoom while three were conducted on Microsoft Teams. On average, each interview lasted for 40 minutes (ranging from 20 to 60 minutes). Five of the participants were physiotherapists (four females), one was a family physician (male), and one was a pulmonologist (female).
Of the five physiotherapists, two were respiratory physiotherapists, one was a sports physiotherapist, one was a public health specialist researching the implementation of PR, and one was a professor of PR. All physiotherapists had PR experience in either a clinical or research context within their respective LMIC. Four physiotherapists had experience in implementing and/or delivering a structured PR programme, while one had practised some aspects of PR as part of their broader cardiorespiratory physiotherapy practice. The pulmonologist was leading an ongoing randomised controlled trial of a PR programme, with their roles including leading the exercise component. The family physician had no prior experience with PR but had previously offered research support as a co-supervisor on a student-led PR research project.
Key themes relating to barriers to PR in LMICs were limited resources, low awareness or recognition, Coronavirus Disease 2019 (COVID-19), and patient-unique access barriers (Table 1). Key themes for enablers were local adaptation, motivated patients, COVID-19, better awareness or recognition, available PR training, and available PR resource support (Table 1).
Table 1: Codes and themes that resulted from the thematic analysis
Barriers
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Code
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Code description
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Theme
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Personnel/staff
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Barriers related to availability and expertise of personnel/staff needed for PR
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Limited resources
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Equipment
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Barriers related to availability and quality of equipment needed for PR
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Awareness or recognition
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Barriers related to level of awareness or recognition of the role of physiotherapy services including PR among patients, healthcare professionals and government
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Low awareness or recognition
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Recruitment
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Barriers to recruiting eligible patients for PR due to COVID-19
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COVID-19
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Face-to-face PR
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Barriers to the feasibility of face-to-face PR due to COVID-19
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Tele-PR
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Barriers to tele-PR due to COVID-19
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Transport
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Patient PR access barrier due to transportation costs
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Patient-specific access barriers
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Commitments
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Patient PR access barrier related to patient work or family commitments
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Fees
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Patient PR access barrier related to patient PR service fee payment
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Enablers
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Code
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Code description
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Theme
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Community-based PR
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Patient PR access enabler related to community-based PR
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Local adaptation
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Local equipment
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PR implementation/delivery enabler related to use of locally available/made equipment
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Local personnel/staff
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PR implementation/delivery enabler related to use of locally available personnel/staff
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Mood
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Patient PR uptake/participation enabler related to motivated patients due to their positive mood
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Motivated patients
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Communication
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Patient PR uptake/participation enabler related to motivated patients due to effective therapist-patient communication
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PR benefits
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Patient PR uptake/participation enabler related to motivated patients due to their gained PR benefits
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CRD burden
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PR implementation/delivery enabler related to increased demand for PR due to increased CRD burden by long COVID-19
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COVID-19
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Tele-PR
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PR implementation/delivery enabler related to increased demand for tele-PR due to hospital COVID-19 restriction for face-to-face PR
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Awareness
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Enabler for PR uptake, referral and resource support among patients, healthcare workers and government, respectively, due to their raised PR awareness
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Better awareness or recognition
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Doctors
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PR referral enabler related to engaging doctors
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Multiple stakeholder engagement
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Local government
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PR resource support/allocation enabler related to engaging local government
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Undergraduate curriculum
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PR implementation/delivery enabler related to provision of PR training to physiotherapists during their undergraduate studies
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Available PR training
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Local personnel/staff
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PR implementation/delivery enabler related to provision of PR training to non-physiotherapist healthcare workers
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Equipment
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PR implementation/delivery enabler due to available equipment
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Available resource support
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Staff/personnel
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PR implementation/delivery enabler due to available staff/personnel
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Funds
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PR implementation/delivery enabler due to available financial support
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Barriers
Theme 1: Limited resources
Participants expressed limited availability of various resources needed to implement and deliver PR as a barrier. The first resource barrier was the shortage of rehabilitation professionals, specifically physiotherapists, who would implement and deliver PR in their setting:
“…there are few physiotherapists doing this practice. It's difficult to find a skilled physiotherapist to do the work.” (Argentina participant)
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Participants also mentioned a lack of PR knowledge or expertise in PR among the healthcare professionals as another barrier:
“… there was nobody who was like you… there was a physio, but they had never heard of pulmonary rehab. So, they did lots of outpatient stuff and parks and all of that, but their respiratory knowledge was next to zero….” (Kenya participant).
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Participants attributed this lack of knowledge or expertise to the lack of PR training in their national undergraduate physiotherapy curriculum:
“I don't think they are aware that there's a whole field of rehabilitation, no. I think part of that is because it's not part of the curriculum… I think there's an important gap in the training that's being offered.” (South Africa participant)
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Another resource barrier was limited equipment. Either the equipment was not available or, where available, minimal, or of low quality, or couldn’t be utilised:
“… you can't be saying I'm going to use a treadmill because you may not have one. Or In Zimbabwe's case… you can have that…, but there might be no electricity.” (Zimbabwe participant).
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This equipment barrier was attributed to the lack of financial support needed to purchase it. For example, in Argentina, patients had to donate funds to purchase the equipment:
“… almost all the equipment is donated by the patients… we done collects [donations], so we can purchase some more equipment…. it's hard to have the hospital to buy the equipment…” (Argentina participant)
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Theme 2: Low awareness or recognition
Another barrier expressed by participants was a general lack of awareness or recognition of CRDs, physiotherapy profession and its services including PR. For example, at the patient level, two participants said the following:
“So, the funny part is it is available, but the patients do not know that this is pulmonary rehabilitation. If we ask them, “Have you heard of pulmonary rehabilitation?”, and they would go, “Oh no what is that?” (India participant).
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“… but the people whom you expected to serve don't know what we do. And as a result, they don't understand why we're important.” (Zimbabwe participant).
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At the healthcare professional level, one participant said the following:
“I think many clinicians, especially doctors, are not aware of what the modality of pulmonary rehabilitation is and what it can offer. Typically, if somebody comes with chest problems, the treatment is inhalers and maybe some other medications to open up the airways.” (South Africa participant)
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At the national health policy level, one participant said:
“The national health policy itself has only one word on chronic respiratory diseases that we would want to cover the management for – COPD. And not even all respiratory diseases. It's just COPD…. and there is hardly any mention of rehab in the health policy itself.” (India participant)
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Consequently, this lack of awareness or recognition results in government’s low resource support for physiotherapy services including PR:
“And that then translates to government policy. So, when the people on the ground have no idea who you are, the MP in government has no idea who you are. The Minister of Health does not quite understand why we’re making a fuss about you. So, when it comes to budgeting and they only have ten dollars and they have to split it amongst all the health professions, they’re going to think about their doctors, their nurses and pharmacists, you know. ... So, because people hardly don't understand what we do, we are left on the wayside.” (Zimbabwe participant).
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Theme 3: COVID-19
The restrictions associated with the ongoing COVID-19 pandemic have resulted in low recruitment of eligible patients for PR in LMICs:
“Initially, we were supposed to do a face-to-face intervention. But after COVID set in, we are still not allowed to have a lot of patients in one room because they are at risk of contracting the infection.” (India participant)
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The pandemic has also challenged the expertise of delivering the conventional face-to-face PR. Therefore, some face-to-face PR programmes have been moved to online delivery. However, participants expressed barriers for this delivery model too, including lack of digital access and illiteracy:
“…many patients are illiterate… cannot read or write. A second biggest challenge is they don't have their own smartphones from where we are expecting them to access this web application.” (India participant).
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Theme 4: Patient direct and indirect costs
Finally, participants mentioned patient direct and indirect costs that are barriers to PR access, including transport costs associated with long distance to travel to a healthcare facility to access PR (direct cost), PR service fees (direct cost), and loss of income due to work time lost to attending PR (indirect cost):
“… other people come from far areas… So, transportation costs… can exist as a barrier to participation.” (Malawi participant)
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“So, twice a week you are asking them to forego potential income because Zimbabwe has a 90 percent unemployment rate. So, that means everyone is well just about everyone is self-employed. So, if you don't work, you don't earn money and they're not going to be spending two days a week lining up in a hospital queue to get treatment, that they figure their body will just you know, it will resolve itself.” (Zimbabwe participant).
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“It's not free. So, it's either insurance in Kenya, something called NHIS, or patients have to pay, so that is another issue.” (Kenya participant)
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More participants’ quotes for barriers themes can be found in supplementary material 2.
Enablers
Theme 1: Local adaptation
Despite barriers, participants felt that PR implementation and delivery in their respective LMIC was possible if the intervention could be adapted to their local context. This included use of a community-based PR model to address the transport barrier:
“… actually, there wouldn't be anything stopping a hospital team going to a community health centre once a week and doing it there. And I think that might be better than making the patients pay for transport.” (Kenya participant)
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Local adaptation also meant the use locally available staff and equipment:
“Community health workers could be trained to guide people in this and be involved with community rehabilitation or pulmonary rehabilitation… it doesn't have to be a physiotherapist in my mind… If you can have services in the community, people will be more likely to access it.” (South Africa participant)
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“… looking at the equipment for exercise therapy, we manufactured them locally using the locally available resources…for strength training, we actually had to hire a tailor from the village, and he brought his own machine and we just had to go to kaunjika (market) and buy zitenje (cloth) and cut them off into pieces that can accommodate 1kg, 1/2 kg, 2kg, 3kg up to 8kg using sand.” (Malawi participant)
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Theme 2: Motivated patients
Participants also described increased motivation of their patients to participate in PR as a facilitator. Several factors contributed to patient motivation including good therapist-patient relationship:
“… it's patients’ mood… patients were really, really enthusiastic and really interested to take part in this study…. It was really easy to communicate with patients…. before the trial, we ask for consent from patients and also ask them what time is more convenient for them when they can participate in our PR trial… So, it was discussed with patients, and they feel themselves really comfortable for this and they find it convenient.” (Kyrgyzstan participant)
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Some specific components of components of the PR programme and associated benefits also contributed to patient motivation to participate:
“I think the facilitators for patients is that they feel well, they notice that they feel well. And that made that they want to continue to the program with the program… group effect of the sessions…, the dynamic of the session. We try to do a diversity… We don't do unique training method; we try to use other methods in the programs that the patient feel that they do not do a routine training…” (Argentina participant)
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Theme 3: COVID-19
Although COVID-19 was perceived as a barrier to PR, also it was also perceived as a facilitator. Specifically, long COVID-19 is an extra CRD burden, thereby increasing the demand for PR, especially tele-PR:
“I've got a friend that's got long covid that's affected her lungs. At this stage, she is using her cell phone to message her children because she gets tired of speaking. She is in desperate need of pulmonary rehab. It's not available to her…. She’s got to use the Internet…. I think we can use technology. We are having this conversation on two different continents so pulmonary rehabilitation can be done by video conference. I can’t see why not. I think training videos can be made.” (South Africa participant)
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Theme 4: Better awareness or recognition
Participants suggested several ways to improve public awareness and recognition of physiotherapy services such as PR, including public awareness campaigns:
“I suppose this would involve a lot of public campaigns… to just enable the public to understand the role of physiotherapy in general and then the role of cardiopulmonary rehabilitation in improving health outcomes.” (Zimbabwe Participant).
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Such better awareness could potentially increase patient referral for PR among health practitioners:
“… medical practitioners and other practitioners know what it entails and what it can offer patients, I think they'd be more likely to prescribe it and to make it to get services running.” (South Africa participant)
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Theme 5: Multiple stakeholder engagement
Participants also hinted the importance of engaging and seeking support of multiple stakeholders to successfully implement PR. These included various members of the multidisciplinary team, such as doctors, and local governments:
“… we work together with the doctor that refers the patient with an order of pulmonary rehab. They send the patient with a spirometry (as a minimum), cardiological studies (investigations) so that the patient is able to do the training sessions.” (Argentina participant)
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“So, it actually needs some advocacy and rehabilitation practitioners to engage with governments and provincial decision makers. Those that allocate resources.” (South Africa participant)
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Theme 6: Available PR training
Participants also expressed the need for formal training in PR for both physiotherapists and healthcare workers of other cadres including community healthcare workers, doctors, and occupational therapists:
“I think also at a training level, the physios need more training… because there's no point foreigners delivering it. That's just silly.” (Kenya participant)
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“… if the physiotherapist leaves, then it's a program that needs to be run by occupational therapist to maybe even one of the doctors or somebody else that needs to initiate it and get things going. So, in low- and middle-income countries, transdisciplinary practice is actually not an option. It's something we have to build into our curriculum and training… Community health workers could be trained to guide people in this and be involved with community rehabilitation or pulmonary rehabilitation… it doesn't have to be a physiotherapist in my mind.” (South Africa participant)
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Theme 7: Available resource support
Wherever participants had been able implement and deliver PR successfully, it was because they had resource support in the form of equipment, funds, and staff:
“… they help us with the equipment because, you know, we are a developing country. So, we don't have much money for… yes, financial support for this. So, they give us support, there is a room, there is corridors… our room is already equipped… So, we have enough staff, actually, who really want to participate, to work, to take a salary.” (Kyrgyzstan participant)
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More participants’ quotes for enabler themes can be found in supplementary material 3.