The prevalence of cardiovascular mortality in Denmark and comparable countries has decreased during recent decades, but cardiovascular disease (CVD) remains a dominant cause of morbidity and mortality in many countries [1, 2]. Elimination of modifiable risk factors including unhealthy lifestyle allows for prevention of 80% of CVD cases [3], and individuals with desirable lifestyle factors (not smoking, physically active, healthy diet, BMI < 25) are expected to have a 67–72% lower risk of developing heart failure [4], However, actual implementation and maintenance of preventive measures, e.g. lifestyle change, has proven difficult [5‐7]. Experiencing barriers to lifestyle change has been shown to prevent successful change of low exercise levels, unhealthy nutrition and/or smoking status among at-risk groups as well as in general populations [8‐13].

Inability to maintain changes may be explained by limited structural resources (e.g. available time, or lacking financial resources, and influence by partner) or more personal challenges (e.g. habits, taste, and previous experience) [14]. Which types of barriers one perceives may, however, differ across population groups. In particular socio-economic factors might make a difference, but few studies have as yet systematically compared barrier perceptions across socio-economic strata. If specific barriers to lifestyle change can be identified and linked to specific population groups, it may be beneficial to approach lifestyle changes through targeted or individually tailored messages boosting self-efficacy and coping abilities, rather than using traditional and more generalized risk messages addressing mainly negative consequences of given lifestyles.

A recent survey of 40–60 year old Danes demonstrated that the vast majority of the study population expressed a preference for lifestyle changes instead of lifelong medication to prevent a hypothetical heart disease [15]. At the same time the respondents expressed doubt that they would be able to maintain the changed lifestyle for an extended period of time [16]. The present article is based on the same study population but focuses on disclosing group differences in perceived difficulties for maintaining specific lifestyle changes including exercise, diet, and smoking. The study explores whether perception of barriers commonly identified in the literature differs between socio-demographic groups and groups with different health status, different weight and different levels of physical activity.

In particular, the present study aims at investigating whether middle-aged Danes from different socio-economic backgrounds and with different health status vary in their perception of

Socio-economic characteristics of the 962 respondents who accepted the intervention and preferred life style changes are listed in Table 2. This subsample did not differ from the entire group of respondents (n = 2099) based on gender, age distribution, health status, household income, educational attainment, or occupational status. Moreover, for the age strata used, our sample of respondents was representative of the Danish population in terms of household income, educational attainment, and occupational status (data not shown).

The present study indicates that the part of the population at increased risk for CVD (either BMI > 25, or those physically inactive) more often report the specified barriers to lifestyle change than population segments at lower risk for CVD. Even though creating time for physical activity/exercise or ensuring room in the budget to buy healthier food may be seen as a prioritization issue, our study clearly demonstrates that structural factors, such as low income and being out of the work force are associated with stating that low fat foods are too expensive and that it is too costly to use fitness centers to support lifestyle changes. Similarly, previous studies have shown that being unemployed or having low income and low socioeconomic position is associated with lower participation in and higher drop-out from cardiac rehabilitation programs [17, 18]. Thus, social inequality exists not only in the delivery and offering of health care services, but also in the ability to take appropriate preventive measures through lifestyle changes to stay healthy. This finding underlines the challenge of social inequality even in an otherwise fairly homogeneous Danish population with apparently equal and cost-free access to health care.

Among the barriers most commonly reported were those relating to cost and time. This may raise the question as to whether some respondents might claim these as barriers because they are aware that they have a health issue needing personal investment (time, money, convenience), but doubt their own ability or true intention to act on it [16]. This could be a kind of coping mechanism transforming the challenge of lifestyle change from being a personal issue to a more societal or structural issue related to costs and lack of time. Testing subgroup differences in perception of specified physical activity barriers, which had been identified as relevant in prior studies, may unintendedly have prompted some respondents to think only of fitness centers rather than of incorporating 30 min physical activity as a part of everyday life (walking or cycling to work) or without incurring much additional cost by jogging/running in the neighborhood).

Besides structural barriers, we considered more personal barriers related to habits and preferences. Not being used to exercise/physical activity, not liking low fat food, or for smokers having a partner who smokes were each regarded as a barrier to maintaining lifestyle change by at least 10% of the respondents. This is in accordance with the literature reporting that attitude towards and experience with physical activity/exercise, unwillingness to change diet, and family support are important determinants for maintaining initiated lifestyle changes [14, 17].

When perceived barriers are not equally distributed across socio-demographic strata, it underpins the need for a targeted or an individualized approach to CVD prevention through lifestyle changes. Further, it opens for a discussion on the dilemma between a societal wish to promote healthy lifestyles and the existence of population groups unwilling or unable to engage in smoking cessation or in losing weight despite being overweight or obese. In that way, our observations align with previous findings of a discrepancy between what people intend to do if at risk, and what individuals at risk actually do to prevent CVD.

The single most frequently reported barrier to lifestyle changes, stated by 25% of our respondents, was finding ½ an hour extra time to do daily exercise. Demographically these respondents were younger, in the work force, had higher household income and a higher educational attainment. The last three determinants were positively associated with lack of time as perceived barrier for physical exercise, but the associations with age were more complex. Thus, what characterizes this barrier to lifestyle change is diversity, which may also be part of the explanation why only some but not all previous studies have found lack of time or time stress to be a barrier to lifestyle changes [6, 14].

Unlike the barriers on diet and physical activity, we found no statistically significant sociodemographic/socioeconomic gradients for perceived barriers to smoking cessation. For educational attainment and health status this may be due to the reduced sample size.

In the present study, the respondents were presented with a limited number of suggested barriers to consider as well as a free text option. This may be seen as a limitation, since it might direct the respondent’s attention to the barriers suggested in the questionnaire which might lead to underestimation of the overall number of barriers perceived by people trying to change their lifestyle. However, the purpose of the present study was not to explore the overall number and range of possible barriers, but to test subgroup-specific differences in barriers which had been identified as the most relevant ones in the literature [14, 17, 19]. Further, examining the free text option in the questionnaire did not reveal any major topics not already covered by the themes. Nevertheless it is possible that the specification of only 2 to 3 specific options, because of cognitive availability, acquiescence bias or conformity processes, may have led to higher endorsement of these barriers at the expense of other, non-listed choices. We do multiple comparisons and therefore have an increased risk for type I errors. We have handled this by focusing on differences that are both relevant in size and having p-values below 0.005. Another important limitation may be that our respondents were asked to state their intentions and beliefs referring to a hypothetical risk situation, rather than to a real-life CVD risk. However, the subsample of our population reporting either to have a heart disease themselves or having family members with heart disease (in total 28% of our respondents) gave similar responses to barriers for lifestyle changes as the majority of our respondents with no prior experience with heart disease. As the present study population is extracted from a representative population sample based on criteria on willingness to change lifestyle and avoid medication, we cannot expect the chosen sample to be fully representative of the entire population. However, from previous data from Statistics Denmark we have previously reported that within the present age group the average household income is appr. 100,000 USD, 28% have less than 12 years schooling, and 7% have a University degree [20]. Thus, despite that our group is a subpopulation based on the above mentioned criteria; they appear fairly representative of the general population regarding these sociodemographic characteristics. Further strengths of the study were the solid sample size of 962 respondents, the high participation rate (91%) among those accessing the website for the study, that respondents were not informed about the specific risk scenarios before entering the survey, and that the questionnaire was thoroughly tested before being used.

An important observation from our study is the considerable heterogeneity between different social groups in the population regarding a number of barriers to lifestyle change, an issue, which has so far not been given sufficient attention. Thus, traditional generalized preventive efforts based on ‘one size fits all’ may not be optimal. A recent review concludes that prevention is cost-effective and should be delivered at the general population level by promoting healthy lifestyle behavior, and at the individual level by tackling unhealthy lifestyles (e.g. poor-quality diets, physical inactivity, smoking) [7]. This is in accordance with our study, suggesting to change or supplement traditional general public campaigns to counter CVD by using individualized and targeted initiatives directed at the groups at highest risk.

We observed a considerable heterogeneity between different social groups in the population regarding a number of barriers to lifestyle change. Our study demonstrates that social inequality exists in the anticipated ability to take appropriate preventive measures through lifestyle changes to stay healthy. While our study is based on a hypothetical scenario and any conclusions are therefore tentative, the findings suggest that it may be worth wile to consider supplementing traditional public campaigns to counter cardiovascular disease, for instance by using individualized and targeted initiatives directed at the groups at highest risk.