Facilitators of physical activity

The significant influence of parental participation in physical activity (β = 0.42, p < 0.001) corroborates evidence that family lifestyle shapes children’s behaviours.^{Reference Abela1,Reference Andreo, Crespo and Lloret8,Reference Zumpf, Järvinen and Hager21} Parents who engage in physical activity likely model active lifestyles, fostering a supportive environment that encourages participation. This is particularly relevant given the finding that sedentary parental behaviours correlate with reduced activity in children with CHD.^{Reference Apitz2,Reference Murphy, Berrisford and Harris17} Similarly, cardiologist encouragement (β = 0.38, p < 0.001) emerged as a strong predictor, consistent with studies emphasising healthcare providers’ role in alleviating parental fears (Table 3).^{Reference Liem, Bink-Boelkens and Gatzoulis11,Reference Thomas, Barr and Berman14} For instance, Liem et al.^{Reference Liem, Bink-Boelkens and Gatzoulis11} noted that clear medical guidance significantly increases participation by dispelling misconceptions about exercise risks. In Oman, where traditional concerns about exertion in children with medical conditions persist,^{Reference Iommi, Pini and Comastri10} cardiologists’ proactive counselling could bridge knowledge gaps, particularly for parents hesitant due to perceived risks.

Table 3. Relationship between cardiologist encouragement and CHDs (acyanotic vs cyanotic)

* Statistically significant < 0.001.

The higher participation among children living in houses (64%) compared to apartments (34%, p = 0.004) suggests environmental factors play a critical role. Houses in Oman often provide access to private yards or nearby open spaces, facilitating safe, unstructured activities such as walking or cycling. In contrast, apartment dwellers may face constraints such as limited indoor space or unsafe outdoor areas, a finding not widely reported in CHD literature. This aligns with broader research on environmental determinants of physical activity, which highlights the importance of accessible, safe spaces for children with chronic conditions.^{Reference Williams, Hicks and Tuncer12,Reference Chen, Zhao and Yu19} Future studies should explore whether urban planning or community infrastructure (e.g., parks, recreational facilities) could enhance activity levels in this population.

Barriers to participation

The study found that children with acyanotic CHD participated more (66%) than those with cyanotic CHD (45%), though this difference was not statistically significant. Shortness of breath, cited as the primary barrier, underscores the need for tailored activity plans that accommodate varying CHD severities. Notably, concerns about sudden cardiac events were minimal (1%), aligning with evidence that such events are exceedingly rare during exertion in CHD patients but somewhat surprising based on previous studies into kinesiophobia in this population.^{Reference Brudy, Hock and Häcker6,Reference Giannakoulas, Karatzis and Karanasios9,Reference Blake, Gough and Thomas16} For example, Giannakoulas et al.^{Reference Giannakoulas, Karatzis and Karanasios9} and Blake et al.^{Reference Blake, Gough and Thomas16} emphasise that with appropriate medical clearance, most children with CHD can safely engage in physical activity without heightened risk. This finding challenges overprotective attitudes, which remain a significant barrier in Oman, driven by cultural misconceptions about the safety of exertion.^{Reference Iommi, Pini and Comastri10,Reference Charbonnel, Martin and Paillot18}

The predominance of community-based activities (e.g., walking 65%, football 46%) over structured school programmes suggests systemic barriers in educational settings. Although the study did not directly quantify school participation, global research indicates that school sports are often restricted for children with CHD due to policies prioritising safety, lack of tailored programmes, or teachers’ fear of liability.^{Reference Abela1,Reference Williams, Hicks and Tuncer12} In Oman, where physical education may not be fully integrated into school curricula for children with medical conditions, families may turn to community activities as a more accessible alternative. Williams et al.^{Reference Williams, Hicks and Tuncer12} advocate for inclusive school programmes that incorporate medical guidance to ensure safe participation, a strategy that could be adapted in Oman to reduce reliance on informal settings.

Psychological and social implications

Insufficient physical activity may exacerbate psychological challenges in children with CHD, such as impaired physical self-perception and reduced self-efficacy, as noted by Hall et al.^{Reference Hall, Stewart and Varela20} A sedentary lifestyle can lead to social isolation and diminished quality of life, particularly in adolescence when peer interactions are critical.^{Reference Abela1,Reference Brudy, Hock and Häcker6} Structured physical activity, even low-impact options like swimming (34% participation), can improve physical fitness and mental well-being, mitigating these effects.^{Reference Hall, Stewart and Varela20} The low participation rates in team sports like basketball (19%) and volleyball (4%) suggest missed opportunities for social engagement, potentially due to perceived risks or lack of CHD-specific coaching. Interventions should prioritise activities that balance safety with social benefits, fostering both physical and emotional health.

Cultural and policy considerations

Oman’s cultural context, where physical activity is less embedded in paediatric healthcare compared to Western settings, amplifies participation barriers.^{Reference Iommi, Pini and Comastri10} Unlike regions with proactive health-seeking behaviours, Omani parents often prioritise caution, influenced by traditional beliefs about exertion in children with medical conditions.^{Reference Liem, Bink-Boelkens and Gatzoulis11,Reference Charbonnel, Martin and Paillot18} This cultural nuance necessitates targeted, culturally sensitive interventions, such as community-based education campaigns that address specific fears (e.g., sudden cardiac events) with evidence-based reassurance. Charbonnel et al.^{Reference Charbonnel, Martin and Paillot18} and Chen et al.^{Reference Chen, Zhao and Yu19} highlight the efficacy of culturally adapted rehabilitation programmes, which could serve as a model for Oman.

From a policy perspective, the findings underscore the need for systemic changes. Oman’s healthcare system could integrate routine exercise counselling into paediatric cardiology visits, ensuring cardiologists are trained to provide clear, evidence-based recommendations. Schools should adopt inclusive physical education frameworks, supported by medical guidelines, to accommodate children with CHD. Additionally, urban planning initiatives could prioritise accessible recreational spaces, particularly in high-density apartment areas, to address environmental disparities. These strategies align with global calls for comprehensive CHD management that prioritises long-term health and quality of life.^{Reference Tran, Maiorana and Ayer13,Reference Marks, Memon and Pande15}

Limitations

This study has limitations. Telephone interviews may introduce recall bias, as parents may inaccurately report activity levels. The lack of face-to-face interaction risks question misinterpretation, potentially affecting data quality. Excluding children’s and cardiologists’ perspectives limits the findings’ depth. Future studies should use objective measures (e.g., activity trackers) and incorporate diverse viewpoints for greater accuracy.

Future directions

Future research should address this study’s limitations, such as recall bias and the absence of children’s and cardiologists’ perspectives, by incorporating objective measures (e.g., wearable activity trackers) and multi-stakeholder input. Longitudinal studies could explore whether increased physical activity improves clinical outcomes, such as cardiovascular fitness or metabolic health, in Omani children with CHD. Additionally, qualitative research could elucidate cultural barriers, informing the design of effective interventions. Pilot programmes testing educational workshops or school-based initiatives could provide practical insights into scalability and impact.

In conclusion, this study highlights the interplay of familial, medical, and environmental factors in shaping physical activity among Omani children with CHD. By addressing cultural misconceptions, enhancing healthcare guidance, and improving access to safe activity spaces, Oman can foster healthier lifestyles for this vulnerable population, aligning with global standards for CHD care.