Barriers and enablers to centre-based pulmonary rehabilitation for patients with chronic obstructive pulmonary disease in low- and middle-income countries: a systematic review.

Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and morbidity in low- and middle-income countries (LMICs). Despite the proven benefits of pulmonary rehabilitation (PR) for patients with COPD, its referral, uptake, and completion rates remain low. This systematic review aimed to identify the barriers and enablers to centre-based PR among patients with COPD in LMICs. Methods: We searched PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and Scopus databases from their inception to September 2023 and updated in May 2025. Studies involving patients with COPD, their caregivers, and healthcare professionals (HCPs), were included if they reported barriers or enablers to centre-based PR in LMICs. Data were extracted based on the socio-ecological model of health behaviour, and a narrative synthesis was conducted. Results: Five articles met the inclusion criteria, comprising four quantitative and one qualitative study, involving 1544 patients with COPD, 11 caregivers, and 84 HCPs, which were conducted in Iran, China, Colombia, and Brazil. The most frequently identified barrier to PR was personal financial constraints. Other frequently reported barriers included symptom severity of COPD, lack of family and social support, inadequate competency of HCPs, and logistical challenges. Enablers to PR included higher proficiency of HCP, higher personal and family income, higher educational levels, better patient awareness of PR, and awareness programmes. Conclusions: Barriers and enablers to PR referral, uptake, and completion in LMICs were identified at multiple levels: intrapersonal, interpersonal, organisational, community, and policy. Some factors were common to both LMICs and high-income countries, such as frequency of hospitalisation, social support, HCP knowledge and skills, logistical challenges, and awareness programmes, but personal financial constraints were a unique barrier to LMICs. To improve existing PR services or to effectively implement new PR programmes, these factors need to be considered. Registration: PROSPERO: CRD42024528467.