www.jcrpjournal.com Barriers to CR in Brazil and Canada / 173 Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. BRIEF REPORT Cardiovascular diseases (CVDs) are the leading cause of mortality worldwide, with more than 80% of CVD deaths occurring in low- and middle-income countries. 1 For instance, in the middle-income coun- try of Brazil (ie, having a gross national per capita income between US$996 and US$12 195), CVDs are responsible for 32% of total mortality. 2 Yet, people with CVDs in such countries have less access to proven treatments, including secondary prevention therapies. 2 Cardiovascular rehabilitation (CR), which is a com- prehensive outpatient program of secondary preven- tion and lifestyle counseling, has been shown to reduce mortality, improve functional capacity, and Gabriela Lima de Melo Ghisi, MSc; Paul Oh, MD; Magnus Benetti, PhD; Sherry L. Grace, PhD Barriers to Cardiac Rehabilitation Use in Canada Versus Brazil ■ PURPOSE: Despite its well-established benefits, cardiac rehabilitation (CR) is greatly underutilized globally. Barriers to its utilization have been identified in high-income countries. Given the growing epidemic of noncommunicable diseases in low- to middle-income countries, the identification of barriers to use of these low-cost interventions is war- ranted. The aim of this study was to describe and compare barriers to CR use in Brazilian and Canadian cardiac outpatients. ■ METHODS: Two cardiac samples consisting of 237 Brazilian (recruited from 2 CR centers in southern Brazil) and 1434 Canadian (recruited from 11 community and academic hospitals in Ontario) outpatients were compared cross-sectionally. Barriers were assessed by using the Cardiac Rehabilitation Barriers Scale, psychometrically validated in English and Portuguese. Mann-Whitney U tests were used to compare barriers between samples. ■ RESULTS: Overall, 139 (58.6%) Brazilian and 779 (54.3%) Canadian respondents were enrolled in CR. The mean total barriers score for Brazilian respondents was 1.71  0.63, and 2.37  1.0 ( P  .01) for the Canadians. For 17 of 21 barriers, Canadians reported significantly greater barriers than Brazilians ( P  .02). As their greatest barriers, Canadians rated already exercising at home or in the community and personal travel, while Brazilians identified distance to and cost of the CR program. ■ CONCLUSION: Despite the significantly lower availability of CR in Brazil and the universal health care system in Canada, cardiac outpatients in Canada perceived significantly greater CR barriers. Arguably, however, these barriers were more modifiable. K E Y W O R D S barriers binational study cardiac rehabilitation enrollment participation Exercise Sciences Department, Faculty of Kinesiology and Physical Education, University of Toronto (Ms Ghisi and Dr Grace), Cardiac Rehabilitation and Secondary Prevention Program, Toronto Rehabilitation Institute, University Health Network (Ms Ghisi and Drs Oh and Grace), and School of Kinesiology and Health Science, York University (Dr Grace), Toronto, Ontario, Canada; and Health Sciences and Sports Center, Santa Catarina State University, Florianopolis, Brazil (Dr Benetti). The authors declare no conflicts of interest. Correspondence: Gabriela Lima de Melo Ghisi, MSc, Cardiac Rehabilitation and Secondary Prevention Program, Toronto Rehabilitation Institute, University Health Network, 347 Rumsey Rd, Toronto, ON M4G 1R7, Canada (Gabriela.meloghisi@ utoronto.ca or Gabriela.ghisi@gmail.com). DOI: 10.1097/HCR.0b013e3182930c9f