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. 2026 Jul 8;12:23779608261465975. doi: 10.1177/23779608261465975

Exploring Barriers to Physical Activity Among Jordanian Patients Suffering From Coronary Heart Disease: A Qualitative Study

Yasmeen Abu Sumaqa 1,✉, Ahmad Rayan 2
PMCID: PMC13346749  PMID: 42428564

Abstract

Introduction

Coronary heart disease (CHD) is a major cause of morbidity and mortality worldwide. Regular physical activity (PA) is a vital component of secondary prevention, yet adherence among patients remains low.

Objective

The study aimed to gain a deeper understanding of barriers to PA among Jordanian patients with CHD.

Methods

A qualitative descriptive design was used. Semi-structured interviews were conducted with 22 patients recruited from outpatient medical clinics, and data were analyzed thematically.

Results

The main theme of the findings was “Barriers to PA of CHD.” Five sub-themes were identified: Psychological and Health-Related Barriers, Motivational Barriers, Lack of knowledge regarding PA, Perceived external obstacles,and Healthcare System-Related Barriers.

Conclusion

Patients with CHD encountered psychological, educational, social, and system-level barriers to PA. Addressing these barriers required culturally tailored active and consistent healthcare counseling, appropriate education, and improved rehabilitation accessibility to increase adherence to PA and promote better secondary prevention outcomes.

Keywords: physical activity, coronary heart disease, barriers, Jordan

Introduction

Coronary heart disease (CHD) is a primary contributor to the worldwide burden of cardiovascular disease of cardiovascular disease and is regarded as a leading cause of morbidity and mortality globally. Globally, around 17.9 million people with CHD die annually, which represents 32% of all global deaths (World Health Organization [WHO], 2023). Although these well-documented advantages, participation in PA among patients with CHD remains suboptimal, highlighting the need to better understand the factors affecting engagement (Molina et al., 2025).

Review of Literature

Both preventing and treating CHD require regular physical activity (PA), which has been shown to lower cardiovascular risk, enhance quality of life, and foster improved mental health (de Keijzer et al., 2024; García-Sánchez et al., 2025; Lönn et al., 2025). Any bodily movement that involves energy expenditure and is performed by skeletal muscle contractions is defined as physical activity (World Health Organization [WHO], 2022). Patients with CHD according to current guidelines, should participate in at least 150 minutes of moderate-intensity PA each week to support cardiovascular health and recovery (Kunutsor & Laukkanen, 2024).

High blood pressure and excess body weight as modifiable risk factors for CHD are significantly decreased in patients who regularly participate in the recommended levels of PA, and thus improvement in physical health outcomes for CHD patients (Ghodeshwar et al., 2023; Kappus & Kowalsky, 2023; Lavie et al., 2019; Nystoriak & Bhatnagar, 2018; WHO, 2022).

Physical activity also stimulates vasodilation, which improves endothelial structure by increasing coronary blood flow and oxygen supply to the heart muscle (Winzer et al., 2018). This physiological adaptation reduces the likelihood of ischemic symptoms and the occurrence of repeated cardiac events, while also enhancing overall cardiac function in individuals with CHD (Kappus & Kowalsky, 2023; Lavie et al., 2019). Consistent physical activity has consistently been associated with reduced psychological distress, such as anxiety and depressive symptoms, as well as an enhanced quality of life (Babu et al., 2021; Wanjau et al., 2023).

While the beneficial health effects of PA are extensively recognized, many people diagnosed with CHD do not engage in exercise, despite participating in organized exercise programs, or rehabilitation programs, due to numerous social, individual ,and environmental barriers (Bennett et al., 2021; Freene et al., 2020; Lear et al., 2017). Around 40–50% of patients diagnosed with CHD might not comply with the recommended PA guidelines even though the fact that PA is recognized to disease burden and mortality (Bennett et al., 2021; WHO, 2022). Most of patients diagnosed with CHD have sedentary lifestyles according to research assessing PA behaviors among patients with CHD (Kambic et al., 2021).

Numerous factors, such as personal factors like low self-efficacy, lack of desire, and negative attitudes toward exercise and health contributing to this low level of PA participation. (Sugiharto et al., 2023). Perceived barriers such as a lack of time, trouble finding safe exercise facilities, and ignorance of the appropriate type, intensity, and duration of physical activity are another significant factor (Joussain et al., 2017).

Additionally, decreasing PA involvement among patients with CHD are system-level issues like the lack of structured cardiac rehabilitation and PA programs, logistical obstacles to program accessibility, and low referral rates from healthcare professionals (Sérvio et al., 2019; WHO, 2022).

In Jordan, many people with cardiac disease do not participate in PA (Ahmad & Tawalbeh, 2015; Alsaleh et al., 2016; Shajrawi, Granat, et al., 2021).

Alsaleh and Baniyasin (2023) indicated that 76% of Jordanian patients with CHD were physically inactive (Alsaleh & Baniyasin, 2023). Additionally, only 34.8% of Jordanian patients with CHD engaged in regular walking exercises (Mosleh & Darawad, 2015). Moreover, because of challenges within the healthcare system, patients with CHD in Jordan have restricted access to organized PA programs. The main causes of noncompliance with PA recommendations among many CHD patients are low motivation and self-efficacy. Patients usually only receive brief verbal or written education during hospitalization or follow-up clinic visits because there are no official PA programs in place that might make PA engagement more difficult (Alsaleh & Baniyasin, 2023; Alsaleh et al., 2016; Ammouri et al., 2007; Darawad et al., 2016; Shajrawi, Granat, et al., 2021).

Little is known about how Jordanian CHD patients perceive barriers to PA from their perspectives. Prior research has objectively and statistically described barriers to PA among patients with CHD; several aspects are still not well understood. Gaining insight into the barriers to PA within the Jordanian cultural and healthcare context is crucial for developing tailored interventions to promote PA among CHD patients.

Aim of the Study

This study aimed to explore the perceived barriers to PA among Jordanian patients with CHD from their perspectives.

Methods

Research Design

The study used a phenomenological descriptive design to investigate CHD patients’ experiences of the barriers to physical activity.

Setting and Sample

The study was conducted in the medical outpatient clinics of a governmental hospital in the North of Jordan. A purposeful sampling approach was employed to recruit participants with relevant lived experiences and diverse perspectives on barriers to physical activity. Recruitment continued until thematic saturation was occurred, at which no new themes were identified. A total of 22 participants were involved in the study.

Inclusion and Exclusion Criteria

Potentially eligible participants were initially identified through outpatient clinic medical records in collaboration with healthcare professionals. The principal investigator approached eligible participants during their routine outpatient appointments, gave a detailed explanation of the study objectives, and asked them to participate in the study. In total of 30 participants were screened for eligibility according to established eligibility criteria, which including Jordanian nationality, aged 18–75 years, with a confirmed diagnosis of angina or myocardial infarction. Exclusion criteria included participants with cognitive or communicative impairment, serious medical conditions, that restricted PA or individuals who declined participation. Among these 22 participants were recruited in to the study, whereas eight participants were excluded from the final sample because of not fulfilling the eligibility criteria or refusing participation.

Ethical Considerations

Research Ethics Committee of the Ministry of Health and the hospital where data collection was conducted in Jordan granted their ethical approval. Written informed consent was collected from each participant prior to the interviews. Participants were reassured that participation fully voluntary and they had the right to discontinue participation without explanation. To ensure confidentiality and anonymity participants were identified labeled using numeric codes. Analysis was conducted on anonymized datasets, and audio recordings securely stored on a password-protected computer.

Data Collection

Data were collected through semi-structured, face-to-face interviews conducted by the principal investigator, who has previous expertise in qualitative data collection. Interviews were conducted in a confidential setting within the outpatient clinics to ensure participants’ comfort and privacy. The interviews were conducted between July and October 2025 and ranged in duration from 40 to 85 minutes. All interviews were audio-recorded following the provision of informed consent. A semi-structured interview guide was designed based on a comprehensive review of the literature and consultation with subject matter experts. The guide was evaluated for face and content validity to confirm clarity, relevance, and appropriateness of the questions. The full interview guide was provided as a supplementary file (Supplementary File 1).

All interviews were transcribed verbatim by the principal investigator. They were carried out in Arabic and subsequently translated into English for reporting purposes. To enhance accuracy, an additional bilingual researcher examined both the transcripts and their translations, and any inconsistencies were discussed and resolved collaboratively.

Data Analysis

The six-step thematic analysis process developed by Braun and Clarke (2006) was adopted for the systematic analysis of the collected data. The analysis was undertaken by two researchers to enhance methodological robustness and credibility, with each researcher conducting the early phases separately. In the first stage, both researchers became familiar with the data by repeatedly reading the interview transcripts several times, together with reviewing researcher field notes to gain in depth understanding of the data. In the second stage initial coding categories from the data were independently developed by both researchers separately. These codes reflected meaningful units of data related to the study objective. In the third stage (searching for themes), the researchers together analyzed the codes and grouped them into emerging themes by recognizing common patterns and relationships throughout the dataset. In the fourth stage, the initial themes were assessed and refined through collaborative discussion between the two researchers to maintain internal consistency, conceptual coherence, and clear differentiation between themes. In the fifth stage, themes were additional further refined, and named to accurately reflect the underlying meanings. In the sixth stage, the findings were reported, and consensus was achieved on the finalized themes, and illustrative quotations were chosen to exemplify each theme. To ensure credibility and reliability, any differences in coding and theme development were addressed through discussion until agreement was reached. Field notes were used to support data interpretation of the findings and enriched contextual understanding. To enhance trustworthiness, multiple strategies were implemented including peer review, participant validation, and comprehensive documentation of all analysis process.

Results

The final sample included 22 patients with CHD in, north region of Jordan. Participants’ ages ranged between 40 and 75 years, and their educational levels varied from primary school to bachelor’s degree. Analysis of the interviews showed five overarching themes that captured the perceived barriers to PA among Jordanian patients with CHD:

Psychological and Health-Related Concerns, Motivational Barriers, Lack of knowledge regarding PA, perceived external obstacles, and Healthcare System-Related Barriers.

Psychological and Health-Related Concerns

Many participants explained that emotional responses including fear, anxiety, and sadness limited their motivation to participate in PA. Worries regarding deteriorating their cardiac condition or triggering distressing symptoms were related to their unwillingness to participate in PA. Participants reported how fear and catastrophic beliefs influenced their PA behavior. One participant described: “At times, I simply feel depressed. I'm not in the mood or have the energy to go for a walk. My thoughts immediately turn to the worst when I walk quickly—ya Allah, what if the pain flares up again? I would rather sit and keep my heart calm” (P1). Similarly, another participant stated: “After the stent, every heartbeat I feel during exercise scares me. I think, ‘I’ll end up back in Al-Bashir Hospital.’ So, I stop” (P6). Additionally, a participant noted: “Sometimes, I feel as if my heart is weak… I am concerned that if I walk quickly, my condition will deteriorate” (P2). Other participants stated that anxiety caused by the interpretation of minor bodily sensations as warning indicators disrupted activity. One participant stated: “I become anxious when I even slightly lose my breath while climbing stairs. I ask myself, ‘Is this angina?’ as I touch my chest. I wait for it to pass” (P7). Another participant similarly stated: “Quick fatigue makes me feel like I’m not strong enough to continue, so I just give up” (P9). Moreover, psychological distress, mainly fear and anxiety related to symptom exacerbation was identified as a barrier to participation in PA. “When I’m thinking about walking and exercise, I occasionally get really nervous because I keep thinking that I will have severe pain. I'm constantly concerned that if I overdo it, I might wind myself back in the hospital and my heart will stop” (P7). Overall, these findings highlighted that fear of symptom exacerbation, anxiety triggered by bodily sensations, psychological distress, and perceived physical vulnerability collectively acted as interrelated barriers to PA participation.

Motivational Barriers

Many participants indicated that diminished motivation, affective fatigue, and lack of energy as independent barriers to PA, often defined as a sense of emotional heaviness. Participants described lack of motivation and internal challenge to PA. One participant noted: “I remain on the couch due to my depression, despite knowing that walking is beneficial. Before my legs, my mind is tired” (P5). Similarly, another stated, “I lack the motivation to start, so even simple activity feels overwhelming for me.” (P6), while a third stated, “Following the diagnosis, I became disinterested in a number of things, including exercising”. (P7). This was further emphasized by a participant who noted, “I feel so heavy within that it's difficult for me to even think about moving” (P1), and another who described, “I feel like I’m running low not only physically but also emotionally” (P9). Many participants as well stated doubts about PA benefits which resulted to low motivation. One participant said, “Walking won’t make a difference, in my opinion. My heart is already damaged (P1), while another participant mentioned, “I believe it’s too late for me to benefit from exercising” (P6). As one participant expressed,” I don’t think walking will recover my health, even if I try (P5).

Moreover, low confidence in PA was stated as a barrier. Similarly, another participant stated “I don't think exercising will help right now because I've had this disease for a while” (P6). Participants doubted their ability to participate in PA, mainly when experiencing fatigue, difficulty breathing, palpitation, or having chest pain. One participant said,

“I have lost my strength. I feel like I can't follow the doctor's instructions. I don't have the motivation to exercise by myself unless someone forces me to” (P8), while another participant said, “I feel physically weakened and absence the motivation to participate in exercise unless someone pushes or encourages me” (P9). Another participant stated, “Following the diagnosis, I lost interest in a lot of things, including exercise. Quick fatigue makes me feel like I'm not strong enough to go on, so I just give up” (P5). Collectively, these findings proposed that low motivation, emotional fatigue, low perceived benefit of PA, and diminished self-confidence as crucial barriers to engage in PA.

Lack of Knowledge and Awareness Regarding PA

Participants’ inadequate knowledge of PA and its role in managing CHD was recognized as a main barrier. Many participants stated not receiving clear instructions about PA from healthcare providers and being advised primarily to take medication, which led them to perceive PA as needless. One participant stated, “I never got any directions about physical activity from the doctor, but he did tell me to take my medications. I therefore thought it wasn't required” (P10), Similarly, another participant indicated the lack of stress on PA was stated by another participant: “Medication was always the chief focus; exercise was not stated.” (P8). Furthermore, some participants perceived PA as non-crucial because of limited clinical guidance, as reflected in the statement, “The doctor have not explained physical activity clearly to me clearly so, physical activity was not important for me” (P7). Other participants also emphasized the lack of structured advice, with one participant explained, “They didn’t provide me a plan or any specific advices about exercise, thus I didn’t consider it part of my treatment” (P12). Furthermore, participants highlighted the uncertainty and inconsistency of advice providing during clinical visits, which added reinforced misunderstanding. On participant said, “The doctor is constantly hurry when I ask them how much walking is okay. They simply express “what you can tolerate”. This confuses me. (P12). Similarly, another participant stated inadequate and unclear post-discharge instructions: “They simply told me to walk a little every day after I left the hospital, but no one explained how much or how safe it is for my heart” (P13). This showed the limited of patient-centered and phase- tailored guidance for PA. Misconceptions about exercise and reliance on sociocultural values consequently leading to lower participating in PA. Many participants showed insufficient understanding of exercise, and regarded it only as vigorous activities such as gym-based exercise or strength training instead of identifying lower-intensity activities such as regular walking as an effective form of exercise. As one participant noted, “I assumed that exercising meant lifting weights or going to the gym… our elders always advise resting for months following heart issues. So, I listen” (P15). Similarly, another noted, “I didn't realize that regular walking could help. I thought they can’t really recover my health” (P9). Moreover, the idea that rest is safer than movement after heart diseases continued among participants, with one stating, “I supposed that after heart disease, it’s safer to rest totally rather than move too much” (P11). Another participant stated: “I avoided exercise since I thought it might put too much stress on my heart”(P19).

Other participants added that cultural factors also played a role in avoiding PA because families frequently advised patients to rest and stay still for fear of causing another heart attack as one participant stated, “No one gave me advice on what to do for exercise once I returned from the hospital. I just sat there since my family keep encouraging me to stay at home and not to become tired and people in our culture think that a patient should not exert himself and should instead rest. My family even forbids me from walking too much since they believe it could make my heart ill” (P10). Family effect also reinforced inactivity, as one participant noted, “After my discharge from the hospital, my family pushed me to rest rather than seeking advice.” (P10).

An additional barrier was the lack of clarity about appropriate exercise prescription. Participants stated uncertainty about the type, duration, and intensity, of PA appropriate for their illness. One explained, “Exercise is said to be beneficial, but I'm not sure how much is safe for me. Should I take a ten- or thirty-minute walk? No one informed me” (P16), while another added, “I'm worried about experiencing pain when I walk or climb stairs. I didn't learn how to begin or how long. They simply instructed me to walk a little each day after I was discharged from the hospital. No one clarified what is safe for my heart, how much, or how quickly” (P13).

Moreover, many participants stated receiving unclear or inconsistent advice during hospitalization and follow-up, such as “walk more” or “stay active,” “just rest,” and “don’t get tired,” which added increased misunderstanding and reduced confidence. One participant noted, “No one states me what’s safe for my heart, but the doctor advised me not to go up the stairs.” (P11). Another described, “One nurse advised to rest for a three-month, and another suggested that I begin walking the following day. I chose not to exercise just to be safe” (P9). Similarly, one participant explained, “The doctor is constantly in a hurry when I ask them how much walking is okay. They simply say ‘what you can tolerate’’. This confuses me” (P12). This absence of clear and consistent guidance was further demonstrated by other participants, with one noting, “They stated me to just stay active, but didn’t clarify what that really means or how much I must do” (P14)., Collectively, limited access to structured rehabilitation programs for cardiac patients within the Jordanian healthcare system and lack of counseling from healthcare providers led to continued deficits in knowledge. This lack of knowledge resulted in reduced confidence and increased avoidance of PA because of lack of clarity, fear of adverse events, and reliance on non-medical advice.

Perceived External Obstacles

Many participants stated that environmental and infrastructural -related barriers substantially restricted their engagement in PA. These involved limited availability of safe walking areas, limited access to exercise facilities, and unfavorable weather conditions such as extremely hot summers and cold winters. Participants highlighted that these factors together limited opportunities for regular participation in outdoor exercise. One participant stated: “It’s too hot to stroll outside in the summer, and it’s cold in the winter. There aren’t any indoor workout facilities in my neighborhood(P1)”, and “There are no sidewalks on our neighborhood streets, and cars make it unsafe to walk” (P2). Furthermore, participants emphasized broader structural barriers as described by one participants “Where I live, there are no parks or specified spaces for walking or exercises ”(P5). while another emphasized that “Mostly if I want to be active, the nearby environment does not encourage activity” (P6). In addition, sociocultural norms played a major role in shaping PA behavior, primarily among women and older adults. Several participants prioritized family responsibilities over personal health needs, demonstrating deeply rooted cultural norms that restrict available time accessibility and participation in PA. One participant reported, “My family is my top priority as a mother. I feel bad for abandoning them to walk. Men are supposed to work and spend time with their families, not walk or exercise in public parks, according to our culture” (P4).

Cultural perceptions of illness also led to physical inactivity, as some participants stated that rest is frequently recommended following a cardiac diagnosis instead of a gradual resumption of PA. One participant noted,” People in my community believe that you should rest rather than move around once you have heart disease (P5). Gender as a barrier were also recognized particularly among women experienced distress participating in PA in public settings because of perceived social judgement, with one participant explained. “I avoid going outside alone because it is difficult for me as a woman, because people might stare or talk, which I dislike it. I wish there were a female-only area” (P6). Lastly, financial constraints and transport-related challenges were recognized as additional barriers limiting participation in structured PA.

Participants stressed the expensive gym membership charges, and restricted access to dependable transportation as main barriers as stated by one participant: “Jordan has very few public places for exercise, and joining a gym is expensive. I would need transportation to get to a center, and that isn't always available. (P7)

Healthcare System-Related Barriers

Participants usually identified structural barriers in healthcare system as an important barrier to PA participation. High patient capacity in public and teaching hospitals led to restricted consultation period, restricting opportunities for in-depth conversation of PA. Many participants reported that physicians were often overburdened to offer in-depth counselling. As echoed by the participant, “The doctor doesn’t have time to discuss exercise because the office is so busy. The doctor just advised me to walk a little at home when I was discharged from the hospital (P1)”, and “Government hospitals are overcrowded. There is no opportunity to inquire about exercise because the doctors see a lot of patients in a short period of time (P2)”. This was consistent with another participant stated, “Appointments was short, usually only a few minutes, so I cannot ask about the safe exercise for me” (P4). Moreover, participants stated getting contradictory advice from multiple healthcare providers. For instance, one participant described: “I see a different doctor every time, and they all say various things regarding activity. which makes me confused and scared to move” (P3).

Inadequate support from nursing staff was as well recognized as a barrier. Participants indicated that nurses frequently had limited time to provide education on PA because of high workload demands as noted by a participant:” Nurses don’t have time to sit down with us and go over physical activities. They simply advise us to rest” (P5). Furthermore, restricted access to designed cardiac rehabilitation (CR) services was a main barrier. Participants reported that these services were mostly concentrated in Amman and are not simply accessible in other areas, which limited their capability to join follow-up programmes as stated by one participant:

“The issue is that there aren’t any cardiac rehabilitation centers in Mafraq close to where we live. I would rather stay home because I would have to make the long and expensive trip to Amman if I wanted to go (P6)”.

Financial difficulties increased these barriers. In spite of being covered by public health insurance many participants noted that CR services, physiotherapy, and private fitness facilities were not involved in insurance coverage and continued financially unreachable. In addition, travel-related costs, and challenging life responsibilities additional limited access to care. As clarified by one participant:” Exercise and rehabilitation programs are not covered by health insurance, and I can’t afford the high cost of private gyms or private centers with my low pension, and I have family obligations.” (P7).

Discussion

Coronary heart disease is a significant public health issue in Jordan and continues to be one of the leading causes of morbidity and mortality worldwide (Al-Ajlouni et al., 2024; Petrkova et al., 2024). Although many patients find it difficult to adopt and sustain recommended levels of PA, regular PA is widely acknowledged as the cornerstone of cardiac rehabilitation and secondary prevention (Dibben et al., 2021; Fu et al., 2019). This study explored the CHD patients’ experiences with the barriers to PA they experienced. Findings consisted of five main themes: Psychological and Health-Related Barriers, Motivational Barriers, Lack of knowledge regarding PA, Perceived external obstacles, Healthcare System-Related Barriers.

Psychological and Health-Related Barriers

This study highlighted the significant influence of psychological distress and motivational barriers on PA engagement among Jordanian patients with CHD. Many participants stated experiencing fear, anxiety, and sadness, which created hesitation toward exercise. This could be explained as patients in Jordan frequently associated exercise with possible danger rather than benefits because they viewed it through the prism of their heart disease. Participants reported a heightened perceived vulnerability, indicated by fear-driven cognitive and emotional responses regarding PA, which lowered their confidence and promoted avoidance behavior.

Psychological distress and motivation play a crucial role in shaping PA behaviors among patients with CHD (Yaqoob et al., 2024; Zanatta et al., 2024). Raised levels of fear, anxiety, and depressive symptoms often weaken patients’ willingness to participate in regular exercise, as psychological distress might increase perceptions of vulnerability and fear of symptom exacerbation (Yakut Ozdemir et al., 2023; Zhang et al., 2025; Çakal et al., 2022). This was congruent with the findings of earlier studies, which found that psychological distress is considered a barrier to PA among patients with CHD (Bertolín-Boronat et al., 2025; Cohen et al., 2015; Khalifeh et al., 2026; Ljubic et al., 2006; Peterson et al., 2014; Rao et al., 2020). Bermudez and colleagues (2022) found that depression and anxiety were associated with reduced exercise capacity (Bermudez et al., 2022). This was congruent with a prior study that found that psychological distress is associated with poor physical performance and low exercise tolerance, such as poor walking distance and mobility in ischemic heart disease patients in CR outpatients (Sakamoto et al., 2022).

Motivational Barriers

Participants experienced low self-efficacy and motivations that were associated with decreased physical activity. This was in line with the findings of Mulyanti et al. (2024), who found that a lower level of self-efficacy was associated with low levels of PA among patients with CHD (Mulyanti et al., 2024). This might be explained as people with high levels of self-efficacy and motivations will have the confidence to manage their behavior to improve their health and maintain a healthy lifestyle like PA, regular exercise (Han & Won, 2022; Lu et al., 2020; Siegmund et al., 2017).

Moreover, PA behavior was shown to be significantly correlated with social support (Teleki et al., 2022; Won & Son, 2017). In contrast to our findings, a study reported that mild depressive symptoms were linked to a 40% increase in the chance of maintaining PA (Wang et al., 2020). The majority of participants stated that their family members had anxiety and fear when they attempted to engage in PA due to cultural beliefs were shown to associate illness with PA, especially heart disease, with the need for rest rather than exercise. This was consistent with the findings of previous studies, which found that anxiety, fear, and discouragement of patients’ families about patients’ exercise (Bäck et al., 2020; Birtwistle et al., 2022; Shajrawi, Granat, et al., 2021). This could be explained by family was the primary decision-maker in Jordanian culture when it comes to daily activities and health, and family members frequently exhibit protective behaviors and misconceptions as a result of their anxiety, fearing that PA would cause chest pain, dyspnea, or possibly another cardiac attack for their patients.

Lack of Knowledge Regarding PA

The findings of this study indicated inadequate knowledge and understanding among patients with CHD related to the role, type, and exertion level of PA in disease management. Participants often stated that they had unclear or inadequate instructions about exercise following discharge from hospital, which left them confused, and reliant on their cultural norms, and this led to a decrease level in their participation in PA. This might be explained by a lack of clarity and fear of movement were the results of discharge education that was primarily viewed as unclear, inconsistent, or insufficient (Keessen et al., 2020).

This finding indicated that a lack or unclear discharge information are associated to patients’ confusion and fear, which subsequently decreases their engagement in PA. This interpretation was consistent with the findings of earlier studies, which found that insufficient information regarding PA was associated with decreasing engagement with PA (Alsaleh et al., 2016; Reid et al., 2012; Sabouret et al., 2022; Vooturi et al., 2023; Wang et al., 2020). This was in line with the findings of Pitta et al. (2022), who found that the educational program yet be an effective intervention in increasing PA and self-efficacy among patients with CHD (Pitta et al., 2022).

This barrier is compound by Jordan’s cultural context. Participants indicated that after a cardiac event, family beliefs frequently prioritized rest on activity. This was indicative of a larger societal emphasis on convalescence as opposed to a progressive recovery through safe PA (Kanan et al., 2021). Therefore, one crucial element of the PA programs offered to patients with CHD should be increasing awareness of the physiological advantages of PA.

Perceived External Obstacles

The findings of the current study highlighted that patients with CHD perceived external barriers significantly restricted PA engagement. Participation in PA among patients with cardiac diseases is often restricted by environmental and infrastructure barriers, including a limited availability of safe walking areas, limited access to exercise facilities, and adverse weather conditions (Galdas et al., 2012; Shajrawi, Granat, et al., 2021; Wang et al., 2025). This was similar with Barghouti et al. (2015), who found that Jordan lacks parks and open places, which Jordanians prefer over sporting facilities for engaging in PA (Barghouti et al., 2015).

Views regarding PA were also identified as being substantially affected by sociocultural norms. Many participants, primarily women, reported that they gave priority to their family before their own needs, reflecting of deeply rooted social norms the Jordanian cultural context, and this consequently limited their participation in PA. This finding was consistent with Abu et al. (2021), who found that some patients felt selfish if they chose to spend their leisure time with themselves rather than their loved ones (Abu et al., 2021). Thus, it is advised that family members support and encourage the patient more.

The majority of participants reported difficulty participating in outdoor activities because of the severe seasonal circumstances in Jordan due to hot summers and cold winters. These environmental restrictions were made worse by the scarcity of affordable gyms, especially for women who expressed discomfort in exercising in public spaces because of cultural sensitivities.

This was consistent with Firoozabadi and colleagues, who found that women prefer home-based CR rather than CR programs. Some participants mentioned that the high cost of gym memberships and the problems of transportation to get to exercise facilities as financial and transportation constrains for PA (Dhaliwal et al., 2017; Jin et al., 2014; Rangel-Cubillos et al., 2022; Rogerson et al., 2012; Xie et al., 2022).

Healthcare System-Related Barriers

Many participants in this study constantly highlighted structural barriers within the healthcare system that hindered their engagement in PA following cardiac events. Public and teaching hospitals were frequently overcrowded, which left doctors with limited time to offer individualized PA counseling. This aligned with the findings of previous studies, which found that high patient loads, short consultation times, and limited communication and inconsistent advice contribute to restricted physicians’ ability to provide education about PA, which in turn undermines patients’ confidence to engage in PA (Boyde et al., 2015; Hayek et al., 2025; Mentrup et al., 2020; Niksadat et al., 2023).

Additionally, the majority of participants stated that nurses were unable to offer structured PA guidance, which was as a barrier to engage in PA, and this might be attributed to staffing shortages and workload pressures (Elzyen et al., 2023). This was in line with the findings of Ahmed et al. (2022), who found that the shortage of nursing staff members, and nursing workload left little time for them to engage in education about PA, and this was a barrier for patients to engage in PA (Ahmed et al., 2022).

Lack of access to structured CR programs was another significant barrier to many of the participants. This might be explained as CR programs are largely centralized in Amman limits participation because travel is costly and time-consuming for patients from other governorates (Al-Duhoun et al., 2025; Alsaleh & Baniyasin, 2023). This was consistent with the findings of previous studies that found the unavailability of CR programs, cost of transportation, and time constraints might add to the unwillingness to travel long distances (Fraser et al., 2022; Iyngkaran et al., 2024; Syed et al., 2013; Zhang et al., 2024). Despite many participants were covered by public health insurance, physiotherapy and CR programs were frequently not covered making access difficult for patients to afford these services, including the expense of private cardiac rehabilitation centers or gyms was unaffordable, which aligns with global findings emphasizing the economic burden associated with cardiac rehabilitation (Ragupathi et al., 2017; Resurrección et al., 2019).

Lastly, participants indicated receiving with inconsistent and unclear PA advice, including being advised to resume walking immediately or avoid all physical activity. inconsistent discharge advice reduce self-efficacy and engagement in recommended PA, which was a global issue that was evidenced by insufficient of standardized structured phase-based recommendations (Aleksova et al., 2025; Muliantino et al., 2024; Sevilla-Cazes et al., 2018).

Implications for Practice

This study shed light on the critical role of nurses in enhancement PA among patients with CHD. Nurses should offer culturally appropriate education, addressing patients’ fears and misconceptions, incorporating motivational counseling and psychological assessment into patients’ care, and include family members to reinforce support and adherence. Furthermore, nurses might work with interdisciplinary teams and advocate for accessible cardiac rehabilitation programs to address system-level barriers. Future research should emphasis on assessing culturally tailored nursing interventions, investigating nurses’ roles in encouraging PA, and to assess the long-term effects on patient adherence and cardiovascular health outcomes.

Strengths and Limitations

A primary strength of this study was the use of a qualitative phenomenological design , which facilitated rich understanding of personal experiences of Jordanian adults with CHD concerning barriers to PA. Moreover, participants of a diverse sample in terms of age and education were selected, which better data richness and strengthened the trustworthiness of the findings. This study has some limitations. The study sample might limit the transferability of the findings. In addition, the findings were derived from participant-reported experiences, which might be impacted by memory-related bias. The study was also performed in a single setting, which might decrease the generalizability of the findings in different settings.

Conclusion

This study indicated that Jordanian patients with CHD face multiple barriers that hinder their engagement in PA. The study findings indicate the diverse nature of factors influences on engagement to PA, including both individual fears and misconceptions to wider social and systemic barriers. To promote PA participation, interventions ought to be culturally sensitive, provide comprehensive education about safe exercise participation, and overcome psychological concerns. Healthcare professionals, specifically physicians and nurses, have a key role in delivering individualized counseling and incorporating family support. At the health care system level, improving access to CR services, particularly in rural areas is crucial to reducing disparities. Overcoming these barriers collectively might enhance adherence to PA and ultimately lead to improve secondary prevention outcomes for Jordanian patients with CHD.

Supplemental Material

Supplemental material - Exploring Barriers to Physical Activity Among Jordanian Patients Suffering From Coronary Heart Disease: A Qualitative Study
sj-pdf-1-son-10.1177_23779608261465975.pdf (72.8KB, pdf)

Supplemental material for Exploring Barriers to Physical Activity Among Jordanian Patients Suffering From Coronary Heart Disease: A Qualitative Study by Yasmeen Abu Sumaqa, Ahmad Rayan in Sage Open Nursing

Acknowledgments

We wish to express our gratitude to all participants who willingly agreed to contribute to this study and share their experiences during interviews.

Author’s Contribution: YA contributed to conceptualization, data curation, formal analysis, investigation, methodology, project administration, resources, visualization, and writing – original draft and writing – review & editing. AR contributed to formal analysis, methodology, supervision, validation, and writing – review & editing.

Funding: The authors of this study did not receive any funding for the research, manuscript preparation, and publication of the article.

The authors of this study stated no conflicts of interest in relation to manuscript preparation, and publication of the article.

Supplemental Material: Supplemental data for this article is accessible online.

ORCID iD

Yasmeen Abu Sumaqa https://orcid.org/0000-0003-2367-3569

Ethical Considerations

IEC clearance: This manuscript was granted ethical approval from the Institutional Review Board (IRB) at the Ministry of Health (MOH) in Jordan with approval number (16449) on 1 /7/ 2025. This study was undertaken consistent with institutional regulations, national research ethics guidelines, the ethical principles of the Declaration of Helsinki. Verbal informed consent was secured before participation, consistent with IRB-approved exemption. Written informed consent was obtained from all participants before enrollment in the study. This research adheres to the principles outlined in the Declaration of Helsinki.

Consent to Participate

Oral and written informed consent were secured from the participants before conducting the interviews.

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