Pulmonary rehabilitation knowledge and barriers among healthcare professionals in Saudi Arabia

Introduction

Chronic obstructive pulmonary disease (COPD) is a group of lung disorders that leads to breathing problems caused by environmental variables like smoking or dust exposure (1). COPD primarily affects middle-aged and older adults, particularly smokers. The two main disorders comprising COPD are emphysema, where lung air sacs are destroyed, and chronic bronchitis, causing airway inflammation, breathlessness, chronic cough with discharge, and wheezing (2). Among non-transmittable diseases, COPD ranks third globally in disability-adjusted life years (DALY) (3). COPD causes significant chronic morbidity and mortality worldwide, with many patients experiencing relapse and hospitalizations despite treatment advances (4). Patients with COPD typically have concurrent illnesses, mainly due to physical inactivity (5). The major symptoms include breathlessness, chronic cough with discharge, chest infections, and wheezing (6). COPD patients often experience cardiovascular issues and muscle wasting due to insufficient oxygen supply to skeletal muscles (7). Physical inactivity can lead to declining health, increased hospitalization risk, and death (8). Therefore, there is a strong clinical requirement for comprehensive therapies, such as pulmonary rehabilitation (PR), that consider the unique traits and comorbidities of individuals. PR is one of the best treatments for chronic respiratory conditions, such as interstitial lung disease, lung cancer, pulmonary hypertension, bronchiectasis, and cystic fibrosis (9). Patients typically receive PR once their conditions stabilize. PR for COPD typically involves supervised exercise training of the upper and lower limbs, education, collaborative self-management training, and psychological interventions (10). Early intervention in PR after COPD exacerbation is directly associated with better exercise tolerance, higher quality of life, and a lower risk of recurrent hospitalization (11).

PR is a therapeutic approach that has gained global recognition for its effectiveness in enhancing patients’ health-related quality of life (HRQoL) by addressing symptoms, reducing hospitalization rates, and improving exercise capacity (12). PR is an extensive multimodal program that combines multiple therapeutic approaches, such as nutritional therapy, psychosocial support, and strength and endurance training (13). PR is a more comprehensive strategy for managing COPD that helps patients feel better and relies on fewer pharmacological and medical resources (14).

Although PR is a cornerstone of COPD management, its broad use of PR as a routine treatment is restricted by multiple factors (15). The primary obstacles to PR include inadequate positive psychological support, ignorance of symptom management, lack of interdisciplinary coordination with respect to PR as a treatment option, and inadequate education regarding COPD and the prevention of its complications (16). According to a previous study, the most common obstacles to PR were dependence on others, high anxiety levels, inadequate coping with COPD, and restricted access to PR. Additionally, PR programs have limited application due to insurance company coverage and poor healthcare providers’ knowledge of the multidisciplinary components of PR effectiveness (17).

The primary objective of this study was to assess and evaluate the knowledge, attitudes, practices, obstacles, and challenges encountered by healthcare practitioners in integrating PR as a therapeutic option for COPD in Saudi Arabia. The findings suggest that healthcare professionals in Saudi Arabia likely possess moderate to good levels of knowledge and attitudes regarding PR. However, significant obstacles, such as insufficient education, awareness, and institutional support, continue to hinder its effective implementation. This focused examination provides a foundation for identifying areas that require targeted educational initiatives and policy development to enhance PR integration across healthcare settings. We present this article in accordance with the STROBE reporting checklist (available at https://amj.amegroups.com/article/view/10.21037/amj-25-53/rc).

Methods

Study design and recruitment

A descriptive cross-sectional survey was conducted in Saudi Arabia between May and December 2023. The study targeted licensed healthcare professionals currently practicing in the country. Data were collected through both online distribution (via social media and professional networks) and direct visits to healthcare institutions to invite eligible participants. A total of 556 responses were received, of which 328 met the inclusion criteria and were included in the final analysis, giving a qualification rate of 59% (Figure 1).

Figure 1 Flowchart of inclusion and exclusion criteria.

Sampling method

A convenience sampling approach was used to recruit participants across different healthcare sectors and geographic regions (Central, Eastern, Western, Northern, and Southern). This method allowed for broad participation from multiple healthcare disciplines.

Inclusion criteria

Inclusion criteria included licensed healthcare professionals (physicians, nurses, physiotherapists, respiratory therapists, and dentists) currently practicing in Saudi Arabia who voluntarily completed the survey. While respiratory therapists and physiotherapists are directly involved in PR, nurses and dentists also contribute through patient education and overall care. Including these professions offered a broader understanding of PR awareness and barriers within the healthcare system.

Exclusion criteria

Exclusion criteria included non-healthcare workers, individuals practicing outside Saudi Arabia, and incomplete or duplicate responses.

Data collection

This study was conducted primarily using an online survey created using Google Forms. The questionnaire was distributed to participants through multiple social media platforms, including email, X™, and WhatsApp™, and person visit to reach healthcare professionals across different regions of Saudi Arabia. Healthcare institutions were selected based on convenience and accessibility to ensure participation from diverse regions and clinical settings, including governmental, private, and teaching hospitals. Participants were informed that their data would be kept strictly confidential and accessed only by the research team. They were also assured that participation was entirely voluntary and that they could withdraw from the study at any time. To ensure inclusivity and ease of understanding, the questionnaire was made available in Arabic and English. Several measures were implemented to ensure response authenticity and data quality. The online survey was configured to prevent duplicate submissions (via Google Forms IP control) and required completion of all mandatory items before submission. As a result, the final dataset contained no missing data, and no imputation methods (e.g., multiple imputation) were required. The main aim of the survey was to evaluate the knowledge, attitudes, practices, and challenges of PR in Saudi Arabia.

Study instrumentation

A structured, self-administered questionnaire was used, following the same validated format developed and used by Dr. Farah et al. [2021] in Lebanon, with permission obtained for use. The reliability and validity of this instrument were verified in that previous study, ensuring that the tool was suitable for assessing healthcare professionals’ knowledge, attitudes, and barriers toward PR. It was translated into Arabic through a validated translation office to ensure linguistic and conceptual equivalence with the original version. The tool comprised three sections:

• Demographic information (e.g., age, gender, profession, years of experience, and region).
• Knowledge domain, assessing participants’ awareness of PR components such as exercise training, education, psychological support, and nutritional counseling.
• Attitudes and practices domain, exploring healthcare professionals’ perceptions and practices regarding PR delivery and referral.

Section 2 responses were categorized as Excellent, Good, Fair, or Poor, while Section 3 used a binary (Agree/Disagree) format as in the original validated tool. No changes were made to the questionnaire format since data collection had already been completed using this structure.

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Ethical consent for the study was obtained from the Institutional Review Board of the Batterjee Medical College (No. RES-2023-0055) and informed consent was obtained from all individual participants. Participants were informed and assured that their participation would be kept anonymous and voluntary. The participants completed the consent forms virtually before they began filling out the survey forms. All collected data were kept highly confidential and were accessible only to the researcher.

Statistical analysis

All statistical data were analyzed using SPSS version 25.0. Statistical characteristics such as frequency, percentage, mean, and standard deviation were used to characterize the data obtained from the survey responses regarding healthcare professionals’ attitudes and levels of knowledge of PR. Differences were considered statistically significant at P<0.05. As this was a descriptive, exploratory survey, no formal power calculation was performed. The sample size was determined pragmatically, targeting at least 300 participants consistent with similar cross-sectional studies. The final sample of 328 exceeded this target.

Results

Demographics of the participants

A total of 556 healthcare professionals initially completed the survey; however, 228 responses were excluded because they did not meet the inclusion criteria (e.g., non-healthcare workers, practicing outside Saudi Arabia, or incomplete responses). The remaining 328 eligible participants were included in the final analysis.

The participant selection process is summarized in Figure 1—participant flowchart. More than half of the participants were male, and most were under the age of 35 years. Nearly 51.2% of the participants belonged to the Western region, and approximately 40.5% of the participants were respiratory therapists. The study showed that 44.8% of the participants had more than eight years of experience. Approximately 77.4% of the participants had graduated from Saudi Arabia. Demographic data of the participants is presented in Table 1.

Knowledge of healthcare professionals about PR

Approximately 30% of participants demonstrated good knowledge of PR, whereas 25.6% had poor knowledge, as shown in Figure 2A. These results represent the overall knowledge level of all included healthcare professionals. Figure 2B presents the distribution of mean knowledge scores across questionnaire domains, illustrating trends in awareness of exercise training, patient education, and psychosocial support.

Figure 2 Knowledge of pulmonary rehabilitation in the KSA. (A) Level of knowledge regarding pulmonary rehabilitation. (B) Content areas of knowledge related to pulmonary rehabilitation. KSA, Kingdom of Saudi Arabia; PR, pulmonary rehabilitation.

Attitude of healthcare professionals towards PR

There were four questions regarding the participants’ attitudes toward PR, as shown in Table 2. A total of 150 (45.7%) participants strongly agreed that patients who were stable could be enrolled into PR. However, the opinions of healthcare professionals were divided with respect to the effectiveness of the PR program conducted in Kingdom of Saudi Arabia (KSA). Nearly 83 (25.3%) of the healthcare professionals agreed that the PR in KSA was effective, while approximately 69 (21%) disagreed with the statement. Additionally, around half of the participants 153 (46.6%) strongly agreed that access to an outpatient center is an added value in the country. Finally, more than half of the participants 201 (61.3%) strongly agreed that the quality of treatment would improve if patients were enrolled in PR as shown in Table 2.

Practice of healthcare professionals regarding PR

The questionnaire included six questions regarding the general practices of the PR program in the KSA. The first question asked when to refer a patient to the PR program, to which 199 (60.7%) participants responded that they preferred to start PR while the patients were still in the hospital setting. Nearly 225 (68.6%) participants preferred to select patients with COPD as most suitable for rehabilitation after their discharge from the hospital, as shown in Table 3. Nearly 46% of the participants agreed that healthcare professionals should initiate the PR programs in the country. Nearly 59% of the participants showed strong concerns over the difficulty of patient referral to the PR program.

Barriers to PR

The questionnaire included seven questions on the main barriers to PR. Absence of awareness and education was the most selected barrier to PR among the list of barriers presented to the participants. Nearly 80.5% of the participants agreed that they faced multiple barriers to referring patients to the PR program. Most participants (85.7%) mentioned that there was a lack of specialists or therapists to successfully run and expand the PR program for COPD patients. The economic point of view also influenced the effectiveness of the PR program, as 72.7% of the participants responded that the high cost associated with PR was also a primary barrier to its expansion of the PR program as mentioned in Table 4.

Support from healthcare professionals to different types of PR include

The fourth section of the questionnaire included questions on the support required for PR programs in different settings. Most participants (88.4%) indicated a dire need for more support from the government and concerned authorities for the expansion of outpatient PR programs. Approximately 83.8% of the participants responded that there was a need for support in the development of home-based pulmonary tele-rehabilitation as shown in Table 5.

Discussion

COPD is characterized by restricted airflow, which can result in symptoms like breathing problems, coughing, wheezing, and decreased ability to exercise (1). COPD is the fourth leading cause of death in the USA and has shown an accelerating trend in KSA (18). Although there have been astonishing advancements in the fields of medicine and pharmacology, COPD still cannot be treated completely and often relapses in patients, leading to rehospitalization and, in some cases, death. The failure of pharmacological treatments in COPD patients opens the door to non-pharmacological treatments (19).

PR is a comprehensive, non-pharmacological intervention designed to improve exercise performance and quality of life in individuals with COPD (20). Although PR offers numerous advantages over other pharmacological treatments, its use is limited in KSA. PR is restricted in KSA, mainly because of a shortage of skilled and well-trained personnel, scarcity of PR facilities, and the requirement for close supervision by qualified medical personnel. The lack of knowledge about PR as well as the lack of referral authority among medical professionals is hindering its broad adoption and having an effect on the nation’s COPD care (21).

This study evaluates the knowledge, attitudes, practices, and challenges faced in the application of PR in KSA. The findings of this study show that knowledge among healthcare practitioners was sufficient to conduct PR programs. Moreover, knowledge among Saudi Arabian healthcare professionals has increased because the Saudi government supports the development of the healthcare infrastructure and, more importantly, human resources (22). This includes scholarships for Saudi healthcare professionals studying at prestigious medical institutions. These scholarships are provided by the government of KSA to ensure that the best scholars have the chance to acquire knowledge that enables them to conduct PR efficiently in KSA (23).

The results of the study showed that most participants acknowledged that they were familiar with PR and the major components of PR programs. The participants had prior knowledge of the PR issue, with up to 72.6% stating that they had at least medium-level knowledge of PR. Furthermore, PR is a basic treatment method used to treat respiratory diseases and alleviate their symptoms. PR is considered the cornerstone and gold standard non-pharmacological practice for COPD treatment (24). The awareness of PR and national and international guidelines regarding it allow health workers to treat and manage COPD and other lung illnesses in a more effective manner (25).

According to this study, nearly 91% of healthcare workers in the KSA were assured that they had sufficient PR knowledge and were capable of being involved in PR therapy programs and providing care to patients.

This study was designed to investigate the knowledge, attitudes, and skills of healthcare workers involved in PR practices in KSA. Studies have shown that PR is not well covered in KSA and data are limited, supporting this study. This study examines the attitudes of workers in the Saudi Arabian healthcare sector. The aim was to obtain a background on the attitudes of healthcare workers regarding PR. In most cases, the attitude of healthcare workers impacts the way patients recover from certain diseases (26).

The results of the study showed that 91.7% of the participants agreed that patients can undergo rehabilitation treatment only if their condition was stable. Approximately, 39.6% agreed that the Saudi Arabian healthcare system was effective in providing PR. However, 24% of participants lacked confidence in the current system.

The vast majority 84.1% of the study participants had a strong conviction that providing access to an outpatient facility would add value to the country in terms of dealing with the number of patients who required treatment. In other studies, healthcare workers have attributed the cost of running such programs to the unavailability of resources (27).

This study showed that 94.2% of the healthcare workers agreed that PR would increase the quality of treatment provided to patients with respiratory diseases. Thus, the healthcare workers had a positive attitude toward PR. In most cases, when a patient is referred to for PR, they must have serious health conditions that cause dyspnea (28).

The diseases that led to referrals are COPD, cystic fibrosis, bronchiectasis, and idiopathic pulmonary hypertension, and post thoracic surgeries(15). These diseases affect lung capacity and ability of an individual to breathe properly. In this study, approximately 68.6% of the selected COPD patients started PR after discharge from the hospital because PR is deemed to be one of the most effective courses of treatment for COPD in terms of increased exercise capacity and increased HRQoL (29).

Nearly 60.7% of the caregivers preferred to offer rehabilitation programs to patients discharged from hospitals. Among the obstacles listed, lack of awareness of PR was considered a major barrier (89.3%) to starting PR. This lack of awareness makes it difficult for patients to seek PR in hospitals. In other studies, the lack of awareness among COPD patients about the benefits of PR was the major obstacle for seeking PR (30).

Moreover, the scarcity of specialists and PR centers in the KSA presents a significant challenge to the effective implementation of PR programs (31). The study’s findings, which indicate low awareness and infrequent referrals to PR, align with both regional and international research. In KSA, a study has identified the shortage of PR centers and specialists as a primary barrier to the successful execution of PR initiatives (32). Different obstacles have been observed in low- and middle-income countries, such as constrained resources and a lack of sufficient professional awareness (33). These patterns echo global evidence showing that despite strong guideline support for PR, referral and participation remain low due to environmental, knowledge-based, and systemic obstacles (34). The participants also listed high cost of care as the lowest factor preventing them from receiving PR because of free healthcare in KSA.

Limitation

This study has several limitations. No formal power calculation was performed; instead, the sample size was determined pragmatically, with 328 participants exceeding the intended target. Convenience sampling and broad recruitment may have affected representativeness, and the exclusion of incomplete responses (41%) could have introduced nonresponse bias. Including multiple professional groups may have contributed to variation in perspectives, as knowledge can differ by profession, age, and region. Additionally, physician specialty was not collected, which limits the ability to compare PR knowledge specifically among different physician groups. Furthermore, the structure of the dataset did not allow for multivariate or stratified subgroup analyses. Future studies should use stratified analyses to address these differences. Despite these factors, the study provides valuable insight into current knowledge and barriers to PR among healthcare professionals in KSA.

Conclusions

This study tested the knowledge, attitudes, and skills of healthcare workers with reference to PR The findings from this study indicate that knowledge and practice among KSAn healthcare practitioners about PR were high. This finding will pave the way for more PR referrals and improve the general health of the Saudi population. However, a lack of awareness about PR, and fewer PR centers and specialists have led to fewer PR referrals. The results of this study align with existing evidence, affirming that PR is a critical component of the management of COPD. This highlights the imperative to enhance healthcare professionals’ knowledge, strengthen referral systems, and increase the availability of PR programs to improve clinical practice and patient outcomes in KSA.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://amj.amegroups.com/article/view/10.21037/amj-25-53/rc

Data Sharing Statement: Available at https://amj.amegroups.com/article/view/10.21037/amj-25-53/dss

Peer Review File: Available at https://amj.amegroups.com/article/view/10.21037/amj-25-53/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://amj.amegroups.com/article/view/10.21037/amj-25-53/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Ethical consent for the study was obtained from the Institutional Review Board of the Batterjee Medical College (No. RES-2023-0055) and informed consent was obtained from all individual participants. Participants were informed and assured that their participation would be kept anonymous and voluntary. The participants completed the consent forms virtually before they began filling out the survey forms. All collected data were kept highly confidential and were accessible only to the researcher.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Agustí A, Vogelmeier C, Faner R. COPD 2020: changes and challenges. Am J Physiol Lung Cell Mol Physiol 2020;319:L879-83. [Crossref] [PubMed]
2. Kahnert K, Jörres RA, Behr J, et al. The Diagnosis and Treatment of COPD and Its Comorbidities. Dtsch Arztebl Int 2023;120:434-44. [Crossref] [PubMed]
3. Joshi Y, Saklani S, Bisht S. Prevalence of chronic obstructive pulmonary disease: a global review. Res Dev Pharm Sci 2021;2:51.
4. Bhatt SP, Agusti A, Bafadhel M, et al. Phenotypes, Etiotypes, and Endotypes of Exacerbations of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2023;208:1026-41. [Crossref] [PubMed]
5. Castillo SS, Smith L, Suárez AD, et al. Association between physical activity and comorbidities in Spanish people with asthma-COPD overlap. Sustainability 2021;13:7580.
6. Vogelmeier CF, Román-Rodríguez M, Singh D, et al. Goals of COPD treatment: Focus on symptoms and exacerbations. Respir Med 2020;166:105938. [Crossref] [PubMed]
7. Fiorentino G, Esquinas AM, Annunziata A. Exercise and Chronic Obstructive Pulmonary Disease (COPD). Adv Exp Med Biol 2020;1228:355-68. [Crossref] [PubMed]
8. Divo M, Celli BR. Multimorbidity in Patients with Chronic Obstructive Pulmonary Disease. Clin Chest Med 2020;41:405-19. [Crossref] [PubMed]
9. Choi JY, Kim KU, Kim DK, et al. Pulmonary Rehabilitation Is Associated With Decreased Exacerbation and Mortality in Patients With COPD: A Nationwide Korean Study. Chest 2024;165:313-22. [Crossref] [PubMed]
10. Paolucci T, Pezzi L, Bellomo RG, et al. Tailored patient self-management and supervised, home-based, pulmonary rehabilitation for mild and moderate chronic obstructive pulmonary disease. J Phys Ther Sci 2022;34:49-59. [Crossref] [PubMed]
11. Zhang D, Zhang H, Li X, et al. Pulmonary Rehabilitation Programmes Within Three Days of Hospitalization for Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis. Int J Chron Obstruct Pulmon Dis 2021;16:3525-38. [Crossref] [PubMed]
12. Spruit MA, Singh SJ, Garvey C, et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013;188:e13-64. [Crossref] [PubMed]
13. Stavarache IE, Buculei I, Cernomaz A, et al. Role of pulmonary rehabilitation in chronic obstructive pulmonary disease - a historical perspective. Med Pharm Rep 2022;95:475-85. [Crossref] [PubMed]
14. Yohannes AM, Dryden S, Casaburi R, et al. Long-Term Benefits of Pulmonary Rehabilitation in Patients With COPD: A 2-Year Follow-Up Study. Chest 2021;159:967-74. [Crossref] [PubMed]
15. Lahham A, Holland AE. The Need for Expanding Pulmonary Rehabilitation Services. Life (Basel) 2021;11:1236. [Crossref] [PubMed]
16. Gushken F, Degani-Costa LH, Colognese TCP, et al. Barriers to enrollment in pulmonary rehabilitation: medical knowledge analysis. Einstein (Sao Paulo) 2021;19:eAO6115. [Crossref] [PubMed]
17. Sami R, Salehi K, Hashemi M, et al. Exploring the barriers to pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a qualitative study. BMC Health Serv Res 2021;21:828. [Crossref] [PubMed]
18. Alyami MH, Naser AY, Alyami HS, et al. Prevalence and Knowledge of Respiratory Symptoms Among the General Public in the Southern Area of Najran, Saudi Arabia: A Cross-Sectional Health Survey Study. Int J Gen Med 2023;16:4077-90. [Crossref] [PubMed]
19. Alshabanat A, Otterstatter MC, Sin DD, et al. Impact of a COPD comprehensive case management program on hospital length of stay and readmission rates. Int J Chron Obstruct Pulmon Dis 2017;12:961-71. [Crossref] [PubMed]
20. Rehman AU, Hassali MAA, Abbas S, et al. Pharmacological and non-pharmacological management of COPD; limitations and future prospects: a review of current literature. J Public Health 2019;28:357-66. Available online: https://doi.org/10.1007/s10389-019-01021-3
21. Alanazi AM, Almutairi AM, Aldhahi MI, et al. The Intersection of Health Rehabilitation Services with Quality of Life in Saudi Arabia: Current Status and Future Needs. Healthcare (Basel) 2023;11:389. [Crossref] [PubMed]
22. Al Saffer Q, Al-Ghaith T, Alshehri A, et al. The capacity of primary health care facilities in Saudi Arabia: infrastructure, services, drug availability, and human resources. BMC Health Serv Res 2021;21:365. [Crossref] [PubMed]
23. Almeshari MA, Alshehri Z, Alqahtani JS, et al. The Status of Respiratory Care Education in Saudi Arabia: A National Survey of Program Directors. Adv Med Educ Pract 2022;13:619-28. [Crossref] [PubMed]
24. Perumal SD. Renewed vision on pulmonary rehabilitation service delivery for chronic obstructive pulmonary disease management beyond COVID-19. Chronic Dis Transl Med 2021;7:107-16. [Crossref] [PubMed]
25. Hurst JR, Buist AS, Gaga M, et al. Challenges in the Implementation of Chronic Obstructive Pulmonary Disease Guidelines in Low- and Middle-Income Countries: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2021;18:1269-77. [Crossref] [PubMed]
26. Khan MU, Shah S, Ahmad A, et al. Knowledge and attitude of healthcare workers about Middle East Respiratory Syndrome in multispecialty hospitals of Qassim, Saudi Arabia. BMC Public Health 2014;14:1281. [Crossref] [PubMed]
27. Hoffman M, Mellerick C, Symons K, et al. Pulmonary rehabilitation for interstitial lung disease: Referral and patient experiences. Chron Respir Dis 2021;18:14799731211046022. [Crossref] [PubMed]
28. Cox NS, Oliveira CC, Lahham A, et al. Pulmonary rehabilitation referral and participation are commonly influenced by environment, knowledge, and beliefs about consequences: a systematic review using the Theoretical Domains Framework. J Physiother 2017;63:84-93. [Crossref] [PubMed]
29. Dong J, Li Z, Luo L, et al. Efficacy of pulmonary rehabilitation in improving the quality of life for patients with chronic obstructive pulmonary disease: Evidence based on nineteen randomized controlled trials. Int J Surg 2020;73:78-86. [Crossref] [PubMed]
30. Augustine A, Bhat A, Vaishali K, et al. Barriers to pulmonary rehabilitation - A narrative review and perspectives from a few stakeholders. Lung India 2021;38:59-63. [Crossref] [PubMed]
31. Aldhahir AM, Alqahtani JS, Alghamdi SM, et al. Physicians’ Attitudes, Beliefs and Barriers to a Pulmonary Rehabilitation for COPD Patients in Saudi Arabia: A Cross-Sectional Study. Healthcare (Basel) 2022;10:904. [Crossref] [PubMed]
32. Bickton FM, Shannon H. Barriers and Enablers to Pulmonary Rehabilitation in Low- and Middle-Income Countries: A Qualitative Study of Healthcare professionals. DOAJ (DOAJ: Directory of Open Access Journals). 2022. Available online: https://doaj.org/article/69a70022ebe04d17b1d9a8e168ae394b
33. Qin H, Jia P, Yan Q, et al. Barriers and facilitators to pulmonary rehabilitation in COPD: a mixed-methods systematic review. BMC Pulmonary Medicine 2025;25:314. [Crossref] [PubMed]
34. Alahmadi FH. Optimizing Pulmonary Rehabilitation in Saudi Arabia: Current Practices, Challenges, and Future Directions. Medicina (Kaunas) 2025;61:673. [Crossref] [PubMed]