Development and validation of the Brazilian Portuguese version of the Cardiac Rehabilitation Barriers Scale.

Abstract

Cardiovascular diseases show high incidence and prevalence in Brazil; however, participation in Cardiac Rehabilitation (CR) is limited and has been poorly investigated in the country. The Cardiac Rehabilitation Barriers Scale (CRBS) was developed to assess the barriers to participation and adherence to CR.
To translate, cross-culturally adapt and psychometrically validate CRBS to Brazilian Portuguese.
Two independent initial translations were performed. After the reverse translation, both versions were reviewed by a committee. The new version was tested in 173 patients with coronary artery disease (48 women, mean age = 63 years). Of these, 139 (80.3%) participated in CR. Internal consistency was assessed by Cronbach's alpha, test-retest reliability by intraclass correlation coefficient (ICC) and construct validity by factor analysis. T-tests were used to assess criterion validity between participants and non-participants in CR. The applied test results were evaluated regarding patient characteristics (gender, age, health status and educational level).
The Brazilian Portuguese version of the CRBS had Cronbach's alpha of 0.88, ICC of 0.68 and disclosed five factors, most of which showed to be internally consistent and all were defined by the items. The mean score for patients in CR was 1.29 (SD = 0.27) and 2.36 for ambulatory patients (SD = 0.50) (p <0.001). Criterion validity was also supported by significant differences in total scores by gender, age and educational level.
The Brazilian Portuguese version of CRBS has shown adequate validity and reliability, which supports its use in future studies.

Full text

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Development and Validation of the Brazilian Portuguese Version of
the Cardiac Rehabilitation Barriers Scale
Gabriela Lima de Melo Ghisi1,2, Rafaella Zulianello dos Santos4, Vanessa Schveitzer4, Aline Lange Barros4, Thais
Lunardi Recchi4, Paulo Oh2, Magnus Benetti4, Sherry L. Grace2,3
University of Toronto - Faculty of Physical Education and Health - Department of Exercise Sciences1; Toronto Rehabilitation Institute - Cardiac
Rehabilitation and Prevention Program2; York University and University Health Network3, Toronto, ON, Canada; Universidade Estadual de
Santa Catarina. Centro de Ciências da Saúde e do Esporte4, Florianópolis, SC – Brazil
Abstract
Background: Cardiovascular diseases show high incidence and prevalence in Brazil; however, participation in Cardiac
Rehabilitation (CR) is limited and has been poorly investigated in the country. The Cardiac Rehabilitation Barriers Scale
(CRBS) was developed to assess the barriers to participation and adherence to CR.
Objectives: To translate, cross-culturally adapt and psychometrically validate CRBS to Brazilian Portuguese.
Methods: Two independent initial translations were performed. After the reverse translation, both versions were reviewed
by a committee. The new version was tested in 173 patients with coronary artery disease (48 women, mean age = 63 years).
Of these, 139 (80.3%) participated in CR. Internal consistency was assessed by Cronbach’s alpha, test-retest reliability by
intraclass correlation coefficient (ICC) and construct validity by factor analysis. T-tests were used to assess criterion validity
between participants and non-participants in CR. The applied test results were evaluated regarding patient characteristics
(gender, age, health status and educational level).
Results: The Brazilian Portuguese version of the CRBS had Cronbach’s alpha of 0.88, ICC of 0.68 and disclosed five
factors, most of which showed to be internally consistent and all were defined by the items. The mean score for patients
in CR was 1.29 (SD = 0.27) and 2.36 for ambulatory patients (SD = 0.50) (p <0.001). Criterion validity was also
supported by significant differences in total scores by gender, age and educational level.
Conclusion: The Brazilian Portuguese version of CRBS has shown adequate validity and reliability, which supports its
use in future studies. Arq Bras Cardiol. 2012; [online].ahead print, PP.0-0)
Keywords: Cardiovascular diseases / rehabilitation; patient compliance; treatment outcome; patient participation;
questionnaires.
Mailing Address: Gabriela Lima de Melo Ghisi •
35 Charles Street West – Yorkville - M4Y 1R6 – Toronto – ON - Canada
E-mail: gaby_melo@hotmail.com, gabriela.ghisi@gmail.com
Manuscript received July 22, 2011; revised manuscript received July 22,
2011; accepted December 01, 2011.
(system) features10,11. Among them we can mention: the process
of referral to CR programs11-14, patients’ psychosocial and personal
factors10,13,15, logistic factors16, patients’ perception10,15, sex10,16-18,
age10,16,19,20, functional status and associated comorbidities10,21,
socioeconomic level10,21 and smoking10,22.
Brazil has a peculiar health system, of which cardiac
rehabilitation programs may be public or private. The fact that
this feature is different from countries where barriers to CR were
studied, associated with lack of knowledge in the area, makes it
necessary to have instruments to assess barriers, allowing better
planning of programs, improvement of clinical training and
increase participation and adherence of patients.
A literature search showed three scales (psychometrically
validated) that evaluate barriers both in participation and adherence
to CR: an English one (Beliefs on Cardiac Rehabilitation)23, an
Australian one (CREO - Cardiac Rehabilitation Enrollment
Obstacles)24 and a Canadian one (CRBS - Cardiac Rehabilitation
Barriers Scale)25. The scale that assesses the beliefs23 incorporates
only some barriers identified by the literature and is applied only
to adherence, and not to participation in CR. The scale that
assesses the obstacles24, in addition to having low validity, was
tested with a sample of patients after percutaneous coronary
Introduction
Cardiovascular diseases are the leading cause of death
worldwide, in addition to significantly contributing with high
morbidity rates1 and high governmental health costs2. Cardiac
Rehabilitation (CR) – a multidisciplinary treatment program that
focus on secondary prevention3 – effectively decreases cardiac
risk, significantly reduces the recurrence of cardiac events,
increases the quality of life of patients4 and reduces mortality by
25%5. Although these benefits are known, cardiac rehabilitation
is not widely used, with patient participation ranging between
7.5% and 29%6-7 with low adherence and dropout rates ranging
between 40% and 55%8-9.
The reasons for the low participation and adherence to CR
programs are described in the literature as barriers and may have
personal (patient), professional (multidisciplinary team) or public

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Development and Validation of the CRBS in Brazilian Portuguese
intervention, and therefore its use in other groups of patients
with coronary disease has not been tested and is not known.
The Cardiac Rehabilitation Barriers Scale (CRBS) was
developed in Canada and validated in two languages (English25
and French26), in order to assess the barriers to participation and
adherence to CR programs in relation to the patient, healthcare
professional and health system factors. The CRBS can be used
to assess the reasons why patients with heart problems do not
to use RC, even when such treatment is indicated by health
professionals25.
The aim of this study was to translate, culturally adapt and
validate the CRBS to Brazilian Portuguese.
Methods
Participants
The participants were patients of both sexes, with any disease/
comorbidity that required cardiac rehabilitation treatment, who
participated or not in these programs. The following exclusion
criteria were used in the study: 1) age younger than 18 years;
2) illiterate individuals; 3) any visual, cognitive or psychiatric
condition that would prevent the individual from answering the
instrument.
Data were collected between March and June 2011 and
patients were selected from cardiac rehabilitation programs and
outpatient clinics, both public and private, in the metropolitan
region of the city of Florianópolis, state of Santa Catarina,
Brazil. The instrument was applied through monitored self-
administration. The researchers maintained a neutral stance
during the administration, answering questions about the research
and encouraging participants to answer all questions.
Participants were categorized according to gender, age,
health status (diagnosis, associated comorbidities, acute events
and surgical procedures performed), educational level and type
of treatment (cardiac rehabilitation and outpatient clinic, public
and private). The characteristics were collected after patients had
given their consent, through their medical records.
The research was carried out according to the standards
required by the Declaration of Helsinki and was approved by
the Ethics and Research Committee of Instituto de Cardiologia
de Santa Catarina (#020/2011), in accordance with CNS
Resolution #196/96. All subjects were informed about the
research objectives, data confidentiality and signed the free and
informed consent form.
Cardiac Rehabilitation Barriers Scale (CRBS)
The CRBS assesses patients’ perception of barriers in relation to
the personal level (patient), professional (healthcare professional)
and institutional (system) that affect participation and adherence
to CR programs. One example of the patient’s level is the item:
“Because I find exercise tiring or painful”; of the professional
level: “Because my doctor did not feel it was necessary”, and of
the system level: “Because I think I was referred, but the rehab
program didn’t contact me”. The scale can be applied to patients
in outpatient consultations, to inpatients or those participating
in CR programs.
The scale is based on a pilot study that resulted in a
revised version with 21 items, psychometrically validated by
Shanmugasegaram e cols. 25 in English. The items are divided
into four subscales, each related to a group of barriers: perceived
needs / health care factors (9 items), logistic factors (5 items),
conflicts with work schedule/time (3 items), and comorbidities/
functional status (4 items)25.
Participants in studies involving the CRBS are asked to rate
their level of agreement with the items through a 5-point Likert
scale ranging from 1 = strongly disagree to 5 = strongly agree.
High scores indicate strong barriers to the participation or
adherence to CR programs25.
Translation and cultural adaptation
The initial process - translation and cultural adaptation
- was carried out to provide the CRBS for the Brazilian
population, as equivalent to cultural differences. This step
of the translation of the scale from English to Portuguese
followed strict norms approved by the author and was
based on the protocol proposed by Guillemin et al27: initial
translation, back translation and review by a committee of
experts.
The initial translation of the scale (in English) to the target
language (Brazilian Portuguese) was performed by two
independent health professionals, both fluent in English,
whose mother tongue is Brazilian Portuguese. The translators
were aware of the objectives and concepts underlying the
study and sought to detect ambiguities and unexpected
meanings in the original items.
After the two translations had been performed, the
researchers met to create the first version of the instrument. In
the second phase, the first version was retranslated into English
by a native translator, blinded to the initial objectives of the
study and the original version, generating the second version.
After this process, an evaluation committee, consisting of
bilingual researchers in the field, evaluated the second version
and the original instrument in order to verify the semantic,
idiomatic, cultural and conceptual equivalence. Through this
process the third version was created and submitted to the
next stage of validation, being applied to study participants.
Psychometric Validation
The SPSS - Statistical Package for Social Sciences - release
17.0 was used for storing, sorting and analyzing data. The level
of significance for all tests was set at 0.05. When more than 20%
of the items were not completed by the participant, their data
were excluded from the analysis.
Psychometric analyses were performed to assess the validity
(of the construct and the criterion), the internal consistency and
reliability of the Brazilian Portuguese version of CRBS.
The construct validity was assessed through exploratory
factorial analysis. Kaiser-Meyer-Olkin (KMO) and Bartlett
Sphericity tests were performed to indicate the degree of
susceptibility data to factorial analysis. The factor extraction was
performed using the method of main components, considering
only those with eigenvalues greater than 1.0. After the factors
were selected, a correlation matrix was generated using the
method of varimax rotation with Kaiser normalization, which

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Development and Validation of the CRBS in Brazilian Portuguese
showed the relationships between items and factors, by means
of factorial loads, considering those > 0.328,29.
To estimate the internal consistency, Cronbach’s alpha of the
scale and subscales was calculated. In this analysis, Alpha values
greater than 0.60 were considered acceptable, reflecting the
correlation of the items among themselves and with the total
score of 28,29.
Reliability was assessed using the intraclass correlation
coefficient (ICC) using a test-retest with an interval of two and
a half months between applications in 17 study participants.
To assess the criterion validity of the CRBS, t tests verified
differences between the means of the total scores of the
scale and subscales in cardiac rehabilitation participants and
nonparticipants.
To verify the results of applying the scale in relation to patient
characteristics (gender, age, health status and educational level)
we used one-way analysis of variance and chi-square test, after
confirming the normal distribution of data (p> 0.1) using the
Kolmogorov-Smirnov test28,29.
Results
Characteristics of the participants
The sample comprised 173 patients, of which 48 were
women. Regarding treatment, 139 were participants in cardiac
rehabilitation programs and 34 were outpatients. Age ranged
from 38 to 85 years (mean = 63.01, SD = 9.5). In relation to
health status, 50.9% had a diagnosis of coronary artery disease
(CAD), 31.2% had had a previous acute myocardial infarction
(AMI) and 28.9% had undergone Percutaneous Coronary
Angioplasty Procedure (PTCA) .
Regarding the degree of schooling, it was observed that the
majority of the sample had finished College/University (54.3%).
When evaluated regarding the treatments, 65.4% of the patients
undergoing cardiac rehabilitation have a university degree and
58.8% of the outpatients had only elementary education.
The questionnaire took between 15 and 20 minutes to be
completed and the characteristics of participants are shown
in Table 1.
Table 1 – Participants’ characteristics
CharacteristicCategory
CharacteristicSample
(n = 173)
Rehabilitation
(n = 139)
Ambulatory
(n = 34)
n %(total)n %(total)n %(total)
Gender Male 125 72.3%10776.9% 18 52.9%
Female 4827.7% 32 23%1645%
Health status* CAD88 50.9% 88 63.3%0-
AMI5431.2% 47 33.8%720.6%
CHF7 4%32.1%4 11.8%
SAH 7744.5% 6345.3% 1441.2%
DM4425.4%3928%5 14.7%
Dyslipidemia 4626.6% 4431.6%25.9%
Arrhythmias2011.6%107.2%10 29.4%
COPD21.2%21.4%0-
PVD63.5%6 4.3%0-
Obesity105.8%96.5%1 2.9%
Angioplasty 5028.9%47 33.8%3 8.8%
MR3419.7%2920.9%5 14.7%
Degree of schooling Illiterate7 4%1 0.7%617.6%
Incomplete Grade
School
26 15%6 4.3%2058.8%
Complete Grade School63.5%2 1.4%411.8%
Incomplete High School 42.3%4 2.9%0-
Complete High School 2916.8% 2820.1%12.9%
Incomplete College/
University
74%75%0-
Complete College/
University
9454.3% 9165.4%38.8%
*CAD - Coronary Artery Disease; AMI - Acute Myocardial Infarction; CHF - Congestive Heart Failure; SAH - Systemic Arterial Hypertension; DM - Diabetes Mellitus;
COPD - Chronic Obstructive Pulmonary Disease; PVD - Peripheral Vascular Disease; MR - Myocardial Revascularization .

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Development and Validation of the CRBS in Brazilian Portuguese
Translation and cultural adaptation
During the process of translation and cultural adaptation,
it was observed that all questions could be used for the
Brazilian context, and the Portuguese version of the CRBS
also consisted of 21 items. Table 2 shows the items of CRBS
translated into Portuguese.
Psychometric Validation
Construct validity was assessed by means of exploratory
factorial analysis. The significance values of Bartlett’s Sphericity
(< 0.0001) and KMO (0.845) tests were appropriate for the
use of factorial analysis in data processing. Through varimax
rotation with Kaiser normalization, five factors were obtained,
extracted by the method of main components. These factors,
considered together, account for 63% of the total variance and
factor 1 is responsible for 36% of the variance. All factors were
defined by items and three were considered internally consistent
(Cronbach’s alpha > 0.6)28. The first factor reflects items related to
comorbidities and functional status (Alpha = 0.876). The second
factor includes items related to perceived needs (Alpha = 0.812).
The third factor reflects personal and family problems (Alpha =
0.625). The fourth factor refers to items that address travel and
conflicts with work schedule (Alpha = 0.554). The fifth and last
factor corresponds to the items related to access (Alpha = 0.567).
Table 3 shows the factor loading of each question in the five
raised factors, whereas factor loadings < 0.3 are not significant28.
Cronbach’s alpha was also used to estimate the internal
consistency of the instrument, and value was calculated at 0.88.
The intraclass correlation coefficient (ICC) was extracted to
assess the reliability of the instrument in Brazilian Portuguese,
through test-retest, with a two and a half-month interval
between applications on 17 study participants. The ICC found
was 0.68.
Criterion validity was assessed through the differences
between the means of the total scores of the scale and
subscales between cardiac rehabilitation participants and
nonparticipants. Regarding the means of the total scores,
the barriers to cardiac rehabilitation were significantly higher
among outpatients than among patients already in CR (p <
0.001), as expected13,14,16,25. Furthermore, outpatients had
statistically higher mean scores (p < 0.001) in four of the five
factors of CRBS in Portuguese (comorbidities/functional status,
perceived needs, family/personal problems, travel/conflicts
with work schedule), when compared with the CR group.
These results are shown in Table 4.
When the means of the items are analyzed according to
the groups (patients in cardiac rehabilitation and outpatient
treatment), there were significant differences in all items, and
Table 2 – CRBS Items in Brazilian Portuguese
ItemsI do not attend a cardiac rehabilitation program, or if I do attend, I missed some sessions because:
1 of the distance (e.g., the program is located too far from where I live);
2 of the cost (e.g., gas, parking, bus tickets);
3 of transportation problems (e.g., I do not drive, I have nobody to drive me and public transportation is inaccessible or deficient);
4 of family responsibilities (e.g., I have to take care of grandchildren, children, spouse, housework);
5I didn’t know about cardiac rehab (e.g., doctor didn’t tell me about it)
6I don’t need cardiac rehab (e.g., feel well, heart problem treated, not serious);
7I already exercise at home, or in my community;
8 bad weather;
9 I find exercise tiring or painful;
10travel (e.g., holidays, business);
11I have little free time (e.g., too busy, inconvenient rehabilitation time);
12 of work responsibilities;
13I don’t have the energy;
14other health problems prevent me from going (specify:___________)
15I am too old;
16 my doctor did not feel it was necessary;
17many people with heart problems don’t go, and they are fine;
18I can manage my heart problem on my own;
19 I think I was referred, but the rehab program didn’t contact me;
20 it took too long to get referred and start the program;
21I prefer to take care of my health alone, not in a group;
22Other reason (s) for not attending a cardiac rehabilitation program:

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Table 3 – Factorial structure of the instrument
Components
Itens
Factor 1
Comorbidities/
functional status
Factor 2
Perceived Needs
Factor 3
Personal / family
problems
Factor 4
Travel/ work
appointments
Factor 5
Access
9 .843
15 .795
13.793
21.777
14.721
17 .530
8 .360
5 .810
6 .705
16 .675
3 .644
11.638
4.723
7.625
18.592
12 .793
10 .792
2 .638
1 .494
19 -.474
20-.337
Table 4 – Validity of Criterion of CRBS in Brazilian Portuguese (n = 173)
Cardiac Rehabilitation (n = 139)Ambulatory (n = 34)
p
Mean SD MeanSD
Scores Totals 1.290.27 2.36 0.50<0,001
Factor 1 1.400.56 2.981.12<0,001
Factor 21.33 0.30 3.300.89<0,001
Factor 30.890.211.490.65<0,001
Factor 40.95 0.421.480.66 <0,001
Factor 50.830.470.670.29 0,06
SD - Standard deviation.
the group of patients undergoing outpatient treatment had
the highest means (or, as described, the biggest barriers).
Table 5 shows the results of the means of the scores of each
item in the overall sample and in the groups.
Regarding the characteristics of the participants
according to the means of the total scores, there were
significant differences between the categories of age (p
= 0.01), schooling (p < 0.001) and sex (p < 0.001).
The elderly had significantly higher barriers than younger
individuals. Patients with low levels of education also had
higher barriers to participate in CR. Women had significantly
lower barriers than men, which may be related to the
low perception of their health status as shown in certain
studies17,18.

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Discussion
The process of translation and validation of an instrument in
the health area requires a greater effort than simply idiomatic
and semantic analysis. It is necessary to adapt the language
from the cultural and conceptual points of view, aiming at
bringing it as close as possible to the reality of the target
population30. In Brazil, particularly, regional, social and cultural
differences make this task somewhat even more difficult31.
These aspects were all considered in this study.
This study sought to validate the CRBS scale assessing
barriers to participation and adherence to cardiac rehabilitation
programs, on multiple levels, and can be applied to subjects
participating in these programs or not. The factorial analysis
revealed five factors, called comorbidities/functional status,
perceived needs, personal/family problems, travel/ conflicts
with work schedule and access. All factors were defined
by items and three were considered internally consistent
(Cronbach’s alpha > 0.6)28. The scale scores were significantly
related to participation or not in CR programs, so that the
criterion validity was established. Finally, the instrument’s
internal consistency was established (alpha = 0.88) and
instrument reliability was verified by test-retest.
In addition to the Portuguese language, the CRBS has been
validated in English (original validation25) and translated into
French and Punjabi. However, this was the first study in which
the scale was applied outside Canada and, in addition to being
translated and psychometrically validated, the instrument was
adapted to the Brazilian culture.
The results of this study are consistent with those presented
in the original validation25, particularly in relation to the
number of items (21 in each version) and criterion validity
(the biggest barriers cited by those not participating in CR).
Also, the reliability of the CRBS in English was demonstrated
by an ICC of 0.64.
The original validation25 had four factors (perceived
needs / health care factors, logistic factors, conflicts with
work schedule/ time and comorbidities / functional status).
However in our study five factors were identified, which
were described earlier. The difference between the number
of factors may be associated with different realities between
the countries where the original validation (Canada) and the
Brazilian Portuguese one (Brazil) were performed. According to
Daly et al10, the social environment, the traditions, mean and
sociodemographic variables of each region and their health
Table 5 – Mean of scores of each item, in the general sample and in the groups
Items
General
(n = 173)
Cardiac Rehabilitation
(n = 139)
Ambulatory
(n = 34)
p*
Mean (SD)Mean (SD)Mean (SD)
11.80(1.4)1.45(1.1)3.21(1.7)0.00
22.24(1.5)2.15(1.4) 2.59(1.7) 0.00
3 1.47(1.1)1.07(0.3) 3.12(1.7)0.00
41.45(0.9)1.34(0.9)1.91(1.2) 0.00
5 1.69(1.4) 1.17(0.7)3.79(1.6)0.00
6 1.31(0.8)1.02(0.1) 2.47(1.2)0.00
7 1.22(0.6)1.05(0.3)1.91(1.2) 0.00
8 1.23(0.6)1.13(0.5)1.62(0.7)0.00
91.65(1.2) 1.35(0.9)2.88(1.6)0.00
102.24(1.3)2.42(1.4) 1.50(0.5) 0.00
11 1.45(0.9) 1.28(0.7)2.15(1.2) 0.00
121.76(1.2)1.74(1.2)1.85(1.2) 0.00
13 1.57(1.2) 1.19(0.7)3.12(1.5) 0.00
141.56(1.1) 1.24(0.8) 2.88(1.5)0.00
151.23(0.5)1.07(0.2)1.88(1.0)0.00
16 1.60(1.3)1.06(0.4) 3.76(1.4)0.00
171.29(0.6) 1.13(0.4)1.94(1.0)0.00
181.32(0.8) 1.08(0.3)2.29(1.3)0.00
191.07(0.4) 1.00(0.0)1.35(0.9)0.00
20 1.08(0.4)1.04(0.3)1.24(0.7)0.03
211.27(0.8)1.05(0.2) 2.18(1.5)0.00
SD - Standard deviation. * p - comparison between means of patients in cardiac rehabilitation and ambulatory treatment.

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systems can modify the identification and organization of the
barriers to participation and adherence to CR programs. In
this study, although two factors are not considered internally
consistent, the solution of five factors was considered
adequate, as it showed greater internal consistency among
the items.
When validating the CRBS in Portuguese, the factor
“comorbidities and functional status” had a greater number
of items (n = 7) compared to the original instrument.
Studies show that patients with more comorbidities and
lower functional status are less likely to participate in CR21,32,
particularly when they generate high costs for hospitals and
health systems33. The factor “access” was created to supply
certain items of logistic factors encompassing the barriers of
public character (system). The factor “personal and family
problems” was created to encompass factors directed at
family and personal matters, such as the item “Because I can
manage my heart problem on my own.” The factor “perceived
needs” was differentiated from the original instrument’s
“perceived needs/healthcare factors”, with the healthcare
items distributed in the factor “comorbidities and functional
status.” Also differentiated was the factor “travel and conflicts
with work schedule,” called in the original instrument of
“conflicts of work schedule/ time.”
Regarding the characteristics of the participants, we
observed differences between the means of scores by gender,
age and educational level. Although the participated less
often in CR programs, overall women have a low perception
of barriers to participate in these programs, when compared
to men17,18. Moreover, the nature of their barriers differs,
especially among non-participants17. Regarding age, the
fact that elderly patients are less aware of the benefits of
CR and have other complaints and comorbidities result in
more barriers to the treatment19,20. The level of schooling -
characterizing the socioeconomic level in this study – showed
to be related to participation in CR programs, as described
in other studies. Individuals with higher levels of education
had lower mean scores and higher participation in CR
programs10,34.
One of the consequences of using CRBS in research,
although its construction and validation have research
purposes, is its use for clinical and political purposes, as
described in the original validation25. The use of this scale
may facilitate the identification of barriers between different
regions and different health organizations, and works as a
“dairy”, describing different barriers in different stages of
patient care.
The limitations of this study are related mainly to the
characteristics of the studied population: higher number of
patients in cardiac rehabilitation programs and higher degree
of schooling. Another point is the fact that patients were
reporting barriers not only of a personal level, but at the
professional and system levels, which can generate errors.
Also, when they are evaluated, it is important to describe at
what stage of treatment the patients are, in order to identify
the period in which barriers are acquired. As in the original
instrument, this study was conducted in a specific region
(southern Brazil) and these results generalize only patients
from this area and it is necessary to perform further studies in
other regions of the country.
Although the objective of this study is the validation of the
instrument into Brazilian Portuguese, future researches are
suggested in order to compare the barriers to participation
and adherence to CR programs with different socioeconomic
levels and stages of treatment.
Conclusions
Although there are other scales to assess barriers to
participation and adherence to CR programs, the CRBS is the
first that evaluates these barriers at multiple levels (personal,
professional and public) in participants and nonparticipants of
these programs. The results presented here indicate that the CRBS
in Brazilian Portuguese has adequate indices of reliability and
validity. Its use allows the identification of barriers that can be used
to establish strategies to increase participation and adherence to
CR programs, focusing on the actual needs of patients.
To access the instrument and obtain more information,
visit the electronic address: http://www.yorku.ca/sgrace/
crbarriersscale.html.
Potential Conflict of Interest
No potential conflict of interest relevant to this article was
reported.
Sources of Funding
There were no external funding sources for this study.
Study Association
This study is not associated with any post-graduation
program.
References
1. World Health Organization. Cardiovascular diseases. 2010; Disponível em:
<http://www.who.int/mediacentre/factsheets/fs317/en/index.html>.
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