Socioeconomic factors and their association with depressive symptoms and quality of life following cardiac rehabilitation in low-income countries and low-resourced settings

Background Cardiac rehabilitation (CR) is a key part of psychosocial recovery post cardiac events, yet completion rates remain suboptimal. While CR is associated with reduced depressive symptoms and improved quality-of-life, its effectiveness may vary in lower income or low-resourced settings, where financial or structural stressors pose barriers to completion and outcomes. Purpose To identify characteristics of patients more likely to complete CR, and among completers, investigate how self-reported financial worry, age, education and employment were associated with depressive symptoms post-program, changes in depressive symptoms and quality-of-life from baseline. Methods The International Cardiac Rehabilitation Registry (ICRR) data of lower income countries and low-resource areas in high-income countries were used. Patients who provided baseline data at least 6 months before data extraction (November 5, 2024) were analyzed. Outcomes were compared by financial worry, age (≤60 years vs >60 years), education and employment, adjusting for sex using multivariable logistic and linear regressions. Results Among 3,520 patients, 2,190 (62%) completed some components of CR and provided end of program data. Completion was more likely among patients who only worried about finances ‘sometimes’ (45% vs. 40% among non-completers, p<0.001), were male (81% vs. 77%, p=0.004), had more than 12 years of education (57% vs. 44%, p<0.001), were employed full-time (40% vs. 20%, p<0.001), did not pay for medications out of pocket (20% vs. 17%, p=0.009), had definite health-related support (59% vs. 44%, p<0.001), resided in upper-middle-income (37% vs. 20%, p<0.001) or high-income countries (21% vs. 10%, p<0.001), were referred for stable coronary artery disease or angina (33% vs. 23%, p<0.001), had undergone percutaneous coronary intervention (56% vs. 52%, p=0.03), and had no comorbidities (38% vs. 31%, p=0.023). Among completers, those employed full-time/part-time and in modified roles had significantly lower odds of depressive symptoms than those unemployed (OR (95% CI): 0.25 (0.09, 0.70) and 0.223 (0.07, 0.68), respectively). Completers who worried about finances ‘often’ had 3.5-times higher odds (95% CI: 1.56, 7.81) of depressive symptoms than those with ‘no worry’. Younger completers (≤60 years) also had 2.5 times higher odds (95% CI: 1.29, 4.70) of depressive symptoms than those older (>60 years). Full-time employment was associated with worsened depressive symptoms (β (95% CI): 0.23 (0.11, 0.35)) than unemployment, while financial worry with worsened quality-of-life (often vs. no worry β (95% CI): -0.38 (-0.71, -0.05), sometimes vs. no worry: -0.51 (-0.71, -0.31)). Conclusions Financial and employment stressors continue to hinder CR completion and mental health recovery in lower income countries or low-resourced settings. Tailoring CR to address individual socioeconomic barriers may improve completion and overall outcomes.