Cultural factors facilitating cardiac rehabilitation participation among Canadian South Asians: A qualitative study

Barriers and Facilitators of Center-Based Cardiac Rehabilitation Utilization in South Asian Ethnic Minorities: A META-SYNTHESIS

AIM

The aim of this review was to synthesize literature on the perceptions of South Asian ethnic minorities of the barriers and facilitators to center-based, phase II cardiac rehabilitation (CR).

METHODS

A meta-synthesis approach was used, and findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was conducted from database inception dates to July 2022 using the following databases: MEDLINE, EMBASE, APA PsycINFO, Cochrane Database of Systematic Review, CINAHL, Scopus, and Web of Science. The inclusion criteria were studies that examined the barriers and/or facilitators of structured center-based CR among South Asian adult ethnic minorities. Critical appraisal of the included studies was conducted using the Mixed Methods Appraisal Tool. Findings were synthesized using a thematic synthesis approach.

RESULTS

Among the 7110 records initially retrieved only nine studies conducted in the United Kingdom or Canada met the inclusion criteria. More barriers than facilitators were studied and reported. Key barriers were the English language difficulty, fatalistic beliefs, previous bad interactions with and negative perception of health care professionals, transportation problems, work schedule conflict, safety issues, and long-distance CR centers. The facilitators included patient-preferred environment, presence of family members during exercise, family and friends support, and encouragement to change lifestyle and enroll in a CR program.

CONCLUSION

The review findings revealed that South Asian ethnic minorities encounter various barriers and facilitators to enroll and complete CR. The findings can inform researchers and clinicians in the development of interventions that are tailored to their cultural needs.

PRACTICE IMPLICATIONS

The findings can be valuable to health care professionals and policy makers in designing customized CR programs for South Asian minorities.

Ethnic Minorities' Experiences of Cardiac Rehabilitation: A Scoping Review

Cardiac rehabilitation (CR) can improve cardiovascular risk factors, decrease cardiac mortality, and promote healthy lifestyle behaviours. However, services remain underutilized by groups of ethnic minorities. The purpose of the study was to identify patients' personal CR experiences to identify the differences CR makes towards minorities' lifestyle. An initial electronic search was performed in 2021 for papers ranging from 2008-2020 across specific databases, including PubMed, EMBASE, APA PsycINFO, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Medline. Google Scholar was also used to supplement the search process and to identify studies performed within grey literature. A total of 1230 records were screened, of which 40 were assessed for eligibility. The final sample consisted of seven qualitative design studies that were identified for inclusion in this review. Based on patient personal experiences, this review identified that ethnic minorities continue to remain disadvantaged when accessing healthcare interventions, primarily as a result of cultural behaviours, linguistic barriers, socioeconomic status, religious and fatalistic beliefs, and low physician referral rates. More research is needed to elucidate this phenomenon and address these factors faced by ethnic minorities.

Patient-Centered Care Experiences of First-Generation, South Asian Migrants with Chronic Diseases Living in High-Income, Western Countries: Systematic Review

BACKGROUND

First-generation migrants from South Asia account for a considerable proportion of the immigrant populations in high-income, western countries and are at a high risk of developing complex, chronic diseases such as cardiovascular disease and diabetes. Yet, previous systematic reviews have not synthesized information about the healthcare needs and preferences of such migrants and the best ways for health services to provide them with appropriate, culturally sensitive, patient-centered care. The aim of this study is to systematically review the international evidence about first-generation, South Asian migrants' healthcare experiences from the patients' perspectives.

METHODS

Five databases were searched for qualitative, quantitative, and mixed methods studies published between January 1990 and April 2020. Fourteen thousand, six hundred and forty-four papers were retrieved and screened using pre-determined eligibility criteria. Sixty-one papers were included in this narrative synthesis. Relevant qualitative findings from the included papers were thematically analyzed, and quantitative findings were summarized.

RESULTS

Five themes emerged from findings: 1) Healthcare services engaged; 2) the language barrier; 3) experiences and perceptions of healthcare advice; 4) the doctor-patient relationship; and 5) the role of patients' families in supporting access and delivery of healthcare.

CONCLUSION

The findings indicate that communication barriers reduce the cultural and linguistic appropriateness of healthcare. Potential solutions include employing healthcare staff from the same cultural background, training healthcare professionals in cultural competence, and proactively including first-generation, South Asian migrants in decision-making about their healthcare. Future research should explore South Asian migrants' experiences of multimorbidity management, continuity of care, interdisciplinary collaboration, the formation of treatment plans and goals as little to no data were available about these issues.

Motivational Strategies and Concepts to Increase Participation and Adherence in Cardiac Rehabilitation: AN INTEGRATIVE REVIEW

INTRODUCTION

Low participation and adherence to cardiac rehabilitation (CR) leads to ineffective care and increased risk of cardiac complications. There is a need to identify effective motivational strategies and concepts to increase participation and adherence to CR.

PURPOSE

The aim of this review was to synthesize and integrate the current knowledge about motivational strategies and concepts to increase participation and adherence to CR.

METHODS

A literature search was performed using five electronic databases: CINAHL, Medline via PubMed, Scopus, Embase, and Rehabilitation & Sports Medicine Source. The search was limited to peer-reviewed studies, written in English, and publications from 2010 to 2019. A matrix and narrative synthesis were employed to organize and synthesize the findings, respectively.

RESULTS

Eight of 522 articles met the inclusion criteria. Four articles used motivational interviewing (MotI) and counseling strategy, three articles investigated the autonomy, competence, and relatedness of self-determination theory (SDT) concepts, and one article used a reinforced motivational strategy. Use of MotI led to improving the CR completion rate from 14% to 39%. The number of sessions attended/patient improved from 12 to 20 when the staff was provided attendance feedback and a reward. Autonomy, competence, and relatedness motivated patients to participate in and adhere to CR.

CONCLUSIONS

Motivational interviewing and counseling, motivational and reinforcement strategies, and the autonomy, competence, and relatedness of SDT concepts should be utilized to promote participation and motivation for CR. The effects of these techniques on long-term CR require further research, including combining the identified methods to investigate the efficacy of these techniques on CR adherence.

First call, home: perception and practice around health among South Asian migrants in Melbourne, Australia

The socio-cultural context of populations has a significant effect on health outcomes across every stage of life. In Australia, South Asian migrants have a comparatively higher incidence of chronic disease and less use of health services. Often overlooked are community views of health, cultural traits and belief systems. This study aimed to explore the factors that influence health perception and practice of South Asian migrants. The study used a mixed method approach with both a survey and interviews. A total of 62 participants between the age of 18 and 64 years were surveyed and 14 participants completed interviews. Data were analysed descriptively and thematically. South Asians share a common perception and practice around health and illness. This paper highlights two key findings. First, these groups take a broad view of health encompassing physical, mental, emotional, social and economic aspects of life. Second, these cultural groups do not seek medical help as their first choice, but have a high level of trust in family for providing health advice and share a belief in the effectiveness of home remedies for managing health conditions. Participants shared their expectation that the Australian health system should consider their socio-cultural construct to make services culturally safe and engaging to enhance service utilisation.

Regional Variability in the Access to Cardiac Rehabilitation in Poland

Equitable access to cardiological rehabilitation services is one of the important elements in the effectiveness of the treatment of cardiovascular diseases as cardiological rehabilitation is an important part of circulatory system disease prevention and treatment. However, in many countries among others, Poland suffers from the underutilization of cardiac rehabilitation services. Cardiovascular diseases are the worldwide number one cause of mortality, morbidity, and disability and are responsible for the substantial increase in health care costs. Thus, the aim of the research was the analysis of geographical accessibility to cardiac rehabilitation services in Poland. Perkal’s method was employed in this research. The conducted research allowed to recognize the regional variation, but also made it possible to classify Polish voivodeships in terms of the level of availability achieved. This enables the identification of voivodeships that provide a good, or even very good, access to cardiology rehabilitation services and those characterized by low, or very low access. It was found that there was a slight regional variability in the access to cardiological rehabilitation services. However, the sufficient development of a rehabilitation infrastructure has been also recognized.

The Impact of Socio-environmental Barriers on the Process of Engagement in Cardiac Rehabilitation Programs

Cardiac rehabilitation (CR) is a multi-disciplinary intervention designed to stabilise, slow, or reverse CVD, restore health following a cardiac event and facilitate the prevention of further events. The Model of Therapeutic Engagement (MTE) is a comprehensive conceptual model for explaining the process of engagement in rehabilitation. Of concern is that the role of socio-environmental factors is absent from explaining individual engagement in the MTE. There is also a lack of prospective studies investigating the impact of socio-environmental barriers on engagement in CR programs over time. This study aimed to expand the MTE, by illuminating the role of socio-environmental barriers in a three-stage process of engagement in CR programs. A prospective study was conducted, with 217 individuals recruited from the Cardiology Ward in the Gold Coast University Hospital (GCUH) and the Robina Cardiac Rehabilitation Centre. The collected data were examined using a structural equation model that added socio-environmental factors into the MTE, using multi-group analyses. In this study, we found that socio-environmental factors were not associated with intention to engage in the CR program, but were related to actual attendance and maintenance of participation in CR programs. Knowing how these socio-environmental barriers affect the process of engagement at different stages may help to tailor more accessible CR programs for the population.

Culturally Tailored Resources for South Asian Immigrant Women With Gestational Diabetes: Do They Work and What's Missing? A Qualitative Study

OBJECTIVES

Gestational diabetes mellitus (GDM) increases the risk of pregnancy complications. South Asian immigrant women have among the highest rates of GDM in Canada and they also have the highest lifelong risk of developing type 2 diabetes after a GDM pregnancy. Diabetes Canada has been developing diabetes education material that accounts for the cultural preferences of South Asians. However, there is uncertainty to whether South Asian immigrants are aware of these resources or trust them, or if other factors influence their uptake of advice.

METHODS

In this study, we conducted qualitative interviews to explore, among South Asian immigrant women with GDM: 1) their awareness of diabetes education resources, 2) their attitudes toward information from different resources and varying health-care providers and 3) their barriers and facilitators for GDM management recommendations. Gender theory is embedded in this study, as culturally specific gender roles regarding motherhood have been shown to be important to South Asian immigrant women and their perceptions of health.

RESULTS

There was an emergence of 3 main themes. First, awareness of culturally tailored educational resources is low. Second, there is an overabundance of GDM management information, which leads to variability among participants of how they rank accuracy of informational sources. Finally, there is a gender role reversal present, where women are being taken care of by their families instead of being the providers of care.

CONCLUSIONS

These results indicate that better dissemination strategies for GDM educational material are needed for health-care providers and patients, and may require additional consideration of family involvement during GDM education sessions.

Effect of Cardiac Rehabilitation on Quality of Life, Depression and Anxiety in Asian Patients

This study explored the effect of cardiac rehabilitation on quality of life, depression, and anxiety in Asian patients in Singapore. Out of the 194 patients who were recruited into the study, 139 patients (71.6%) completed both the pre- and post-cardiac rehabilitation questionnaires. Their ages ranged from 28 to 80 (M = 56.66, SD = 8.88), and 103 patients (74.1%) were males and 21 patients (15.1%) were females. As hypothesized, there was a statistically significant difference between the pre- and post-cardiac rehabilitation scores on the combined dependent variables, F (4, 135) = 34.84, p < 0.001; Wilks' Lambda = 0.49; partial eta squared = 0.51. An inspection of the mean scores indicated that patients reported higher levels of physical and mental quality of life and lower levels of depression post-cardiac rehabilitation. The findings were discussed in regards to implications in cardiac rehabilitation in Singapore.

Cardiac Rehabilitation Outcomes by Ethnocultural Background: RESULTS FROM THE CANADIAN CARDIAC REHAB REGISTRY

BACKGROUND

Patients of diverse ethnocultural backgrounds are underrepresented among participants and, hence, little is known about their outcomes. The objectives of this study were to compare cardiac rehabilitation (CR) utilization, cardiovascular risk factor reduction (blood pressure, lipids, anthropometrics), and functional capacity between white and ethnocultural minority patients participating in CR across Canada.

METHODS

The study was a retrospective, observational cohort study using the Canadian Cardiac Rehab Registry (CCRR). Participants from an ethnocultural minority (n ≥ 25) were propensity-matched to white participants based on sociodemographic and clinical characteristics. CR outcomes were compared.

RESULTS

In the CCRR, 3848 (53.8%) participants had an ethnocultural background reported. Of those, whites (n = 3630) and South Asians (n = 26), Southeast Asians (n = 45), and Arab/West Asians (n = 37) minorities had sufficient representation in the registry to be analyzed. In the matched sample, 364 (97.1%) participants completed a discharge assessment. Southeast Asian participants adhered to (96.5%, P = .02) and completed (88.2%, P = .02) CR more often than white participants (90.2% and 55.6%, respectively). Southeast Asian participants had significantly lower diastolic blood pressure (P = .002) at CR discharge than matched white participants. No other differences in outcomes or functional capacity were observed.

CONCLUSIONS

Ethnocultural minorities make up a small proportion of CR participants in Canada. However, when they do participate, they achieve similar CR outcomes compared with white participants. CR programs should seek to ensure ethnoculturally diverse patients are referred to their programs and ensure their programs are culturally sensitive to the needs of the preponderant ethnocultural groups in their catchment areas.

Reported Health Behaviour Changes after a Diagnosis of Gestational Diabetes Mellitus among Ethnic Minority Women Living in Canada

The aim of this cross-sectional study was to examine differences in health behaviours among ethnic minority and Caucasian women after a diagnosis of gestational diabetes mellitus (GDM). Data were derived from medical charts and a questionnaire among a multi-ethnic cohort of 898 Canadian pregnant women diagnosed with GDM attending prenatal diabetes clinics in Ontario, Canada. Health behaviours were compared between ethnic minority and Caucasian women, adjusting for relevant covariates. The mean age was 33.9 ± 6.1 years; 60.0 % self-reported to be part of an ethnic minority group. After adjustment for socio-demographic, behavioural and clinical characteristics, ethnic minority women were more likely to report reducing their meal portion sizes (odds ratio [OR] 1.98; 95.0 % confidence interval [CI] 1.20-3.26) and increasing their physical activity (OR 1.71; 95.0 % CI 1.12-2.62) in response to a GDM diagnosis compared to Caucasian women. Ethnic minority women were more likely to report changes in health behaviours after a GDM diagnosis. Further research is needed to determine the impact of these findings on maternal health and perinatal outcomes, during and after delivery.

Impact of South Asian Ethnicity on Long-Term Outcomes After Coronary Artery Bypass Grafting Surgery: A Large Population-Based Propensity Matched Study

Background

Ethnicity is an important predictor of coronary artery bypass graft surgery (CABG) outcomes. South Asians (SA), one of the largest ethnic groups with a high burden of cardiovascular disease, are hypothesized to have inferior outcomes after CABG compared to other ethnic groups. Given the paucity and controversy of literature in this area, the objective of this study was to examine the impact of SA versus the general population (GP) on long‐term outcomes following CABG.

Method and Results

Using administrative databases and a surname algorithm, 83 850 patients (SA: 2653, GP: 81 197) who underwent isolated CABG in Ontario, Canada from 1996 to 2007 were identified; mean follow‐up was 9.1±3.9 years. SA were younger (SA: 61.7±9.4, GP: 64.1±10.0 years, standardized difference=0.25) with more cardiac risk factors, including diabetes (SA: 54.1%, GP: 34.9%, standardized difference =0.40). Propensity‐score matching resulted in 2473 matched pairs between SA and GP with all baseline covariates being balanced (standardized difference <0.1). Being a SA compared to the GP was protective against freedom from major adverse cardiac and cerebrovascular events, defined by all‐cause death, myocardial infarction, stroke, or coronary reintervention: Adjusted Cox‐proportional hazard ratio 0.91, 95% CI (0.83–0.99), adjusted‐P=0.04; this was also true for freedom from all‐cause mortality: hazard ratio 0.81, 95% CI (0.72–0.91), adjusted P=0.0004. The adjusted proportion of major adverse cardiac and cerebrovascular events was lower in the SA (SA: 34.7%, GP: 37.8%, McNemar P=0.03), driven largely by all‐cause mortality (SA: 20.4%, GA: 24.3%, McNemar P=0.001).

Conclusions

Contrary to existing notions, our study finds that being a SA is protective with respect to freedom from long‐term major adverse cardiac and cerebrovascular events and mortality after CABG. More studies are required to corroborate and explore causal factors of these findings.

Effect of Cardiac Rehabilitation on South Asian Individuals With Cardiovascular Disease: Results From the APPROACH Registry

BACKGROUND

Unequivocally, cardiac rehabilitation (CR) in patients with established cardiovascular disease improves survival. However, its effect on higher-risk ethnic groups has not been explored. Accordingly, we evaluated the effect of CR on South Asian (SA) compared with European Canadians with coronary artery disease (CAD).

METHODS

Using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry, 26,167 patients from Edmonton, Alberta who received coronary angiography with documented CAD were reviewed (January 2002 to March 2012). After excluding Chinese patients, 1027 SA patients were compared with 11,992 European Canadian patients using validated surname algorithms. Adjustment was performed using a Cox proportional hazard model.

RESULTS

Of the SA cohort, 50.6% attended CR, compared with 43.0% of the European Canadian cohort (P < 0.001). After adjustment, CR was associated with long-term survival irrespective of ethnic group (total study population: hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.52-0.63; P < 0.001; SA population: HR, 0.63; 95% CI, 0.40-0.99; P = 0.045; European population: HR, 0.57; 95% CI, 0.52-0.63; P < 0.001). When comparing SA vs European Canadians attending CR, improved survival was observed in SA patients (HR, 0.58; 95% CI, 0.40-0.85; P < 0.001). This benefit appeared limited to SA patients who completed CR (complete CR: HR, 0.37; 95% CI, 0.17-0.85; P = 0.02; incomplete CR: HR, 0.78; 95% CI, 0.45-1.35; P = 0.38).

CONCLUSIONS

Overall, referral rates to CR remains low but attendance appears higher in SA patients. Among those who attended CR, there is a strong association with improved survival irrespective of ethnic status. In SA patients with CAD, attendance and completion of CR should be strongly endorsed because of its incremental benefit.

Facilitating or getting in the way? The effect of clinicians' knowledge, values and beliefs on referral and participation

BACKGROUND

Despite the compelling evidence of the benefits of cardiac rehabilitation (CR) on risk factor modification, quality of life and mortality reduction, a significant proportion of eligible patients are not referred or do not participate. Factors influencing CR referral and participation are complex and are likely patient, referral system and clinician-related. Little is known about clinician-related factors, which include attitudes, values and beliefs towards CR, or how these factors affect patient referral and attendance. This review examines the current evidence in the literature in relation to clinicians' attitudes, values and beliefs about CR.

METHODS

A review of the literature was conducted on studies in relation to clinicians' attitudes, values and beliefs toward CR. An expert consensus methodology was used to develop the concepts presented in this paper.

RESULTS

Besides guidelines, a range of other factors influence clinicians' view about CR. This review suggests that clinicians lacking cardiac qualifications may have limited knowledge and awareness of CR and its benefits. Low agreement among clinicians on who is more likely to benefit from CR was also identified. Clinicians' personal lifestyle and health belief, the availability and quality of local the CR programme, and the lack of a standard administrative process of referral can also hinder the referral of patients to CR.

CONCLUSIONS

Clinician-related factors are important to consider in relation to CR referral and participation. Education for clinicians, discussion of local services and the support of an efficacious system at programme and organisation levels are essential.

Barriers and Facilitators for Type-2 Diabetes Management in South Asians: A Systematic Review

Objective

Although South Asian populations have among the highest burden of type 2 diabetes in the world, their diabetes management remains poor. We systematically reviewed studies on South Asian patient’s perspectives on the barriers and facilitators to diabetes management.

Methods

We conducted a literature search using OVID, CINHAL and EMBASE (January, 1990 –February, 2014) evaluating the core components of diabetes management: interactions with health care providers, diet, exercise, and medication adherence. South Asian patients were self-reported as Indian, Pakistani, Malaysian-Indian or Bangladeshi origin. From 208 abstracts reviewed, 20 studies were included (19 qualitative including mixed methods studies, 1 questionnaire). Barriers and facilitators were extracted and combined using qualitative synthesis.

Results

All studies included barriers and few facilitators were identified. Language and communication discordance with the healthcare provider was a significant barrier to receiving and understanding diabetes education. There was inconsistent willingness to partake in self-management with preference for following their physician’s guidance. Barriers to adopting a diabetic diet were lack of specific details on South Asian tailored diabetic diet; social responsibilities to continue with a traditional diet, and misconceptions on the components of the diabetic diet. For exercise, South Asian patients were concerned with lack of gender specific exercise facilities and fear of injury or worsening health with exercise. Patients reported a lack of understanding about diabetes medication management, preference for folk and phytotherapy, and concerns about the long-term safety of diabetes medications. Facilitators included trust in care providers, use of culturally appropriate exercise and dietary advice and increasing family involvement. Overall themes for the barriers included lack of knowledge and misperceptions as well as lack of cultural adaptation to diabetes management.

Conclusion

Diabetes programs that focus on improving communication, addressing prevailing misconceptions, and culture specific strategies may be useful for improving diabetes management for South Asians.

The Uptake of Screening for Type 2 Diabetes and Prediabetes by Means of Glycated Hemoglobin versus the Oral Glucose Tolerance Test among 18 to 60-Year-Old People of South Asian Origin: A Comparative Study

Background

Direct comparisons of the effect of a glycated haemoglobin measurement or an oral glucose tolerance test on the uptake and yield of screening in people of South Asian origin have not been made. We evaluated this in 18 to 60-year-old South Asian Surinamese.

Materials and Methods

We invited 3173 South Asian Surinamese for an oral glucose tolerance test between June 18^th 2009- December 31^st 2009 and 2012 for a glycated hemoglobin measurement between April 19^th 2010-November 11^th, 2010. Participants were selected from 48 general practices in The Hague, The Netherlands. We used mixed models regression to analyse differences in response and participation between the groups. We described differences in characteristics of participants and calculated the yield as the percentage of all cases identified, if all invitees had been offered screening with the specified method.

Results

The response and participation in the glycated hemoglobin group was higher than in the group offered an oral glucose tolerance test (participation 23.9 vs. 19.3; OR: 1.30, 95%-confidence interval1.01–1.69). After adjustment for age and sex, characteristics of participants were similar for both groups. Overall, glycated hemoglobin identified a similar percentage of type 2 diabetes cases but a higher percentage of prediabetes cases, in the population than the oral glucose tolerance test.

Conclusion

We found that glycated hemoglobin and the oral glucose tolerance test may be equally efficient for identification of type 2 diabetes in populations of South Asian origin. However, for programs aimed at identifying people at high risk of type 2 diabetes (i.e. with prediabetes), the oral glucose tolerance test may be a less efficient choice than glycated hemoglobin.

Cardiovascular risk among South Asians living in Canada: a systematic review and meta-analysis

BACKGROUND

South Asians represent about 3% of the Canadian population and have a higher burden of certain cardiovascular risk factors and cardiovascular disease (CVD) compared with white people. The objective of this study was to review the literature to compare cardiovascular risk factors and disease management practices among adult South Asian and white Canadians.

METHODS

We searched MEDLINE, Embase, Cochrane and Cumulative Index to Nursing and Allied Health Literature databases from their inception through Feb. 17, 2014 and the reference lists of the selected articles. English-language studies of interventions and observational studies of biological mechanisms underlying CVD risk in South Asians conducted in Canada were eligible for inclusion. Where appropriate, we used random-effects meta-analyses to integrate results comparing the CVD risk profiles of South Asian and white Canadians.

RESULTS

We included 50 articles (n = 5 805 313 individuals) in this review. Compared with white Canadians, South Asian Canadians had a higher prevalence and incidence of CVD, an increased prevalence of diabetes (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.81 to 2.80, p < 0.001) and hypertension (OR 1.11, 95% CI 1.02 to 1.22, p = 0.02), lower high-density lipoprotein cholesterol levels (mean difference -0.19 mmol/L, 95% CI -0.25 to -0.13 mmol/L, p < 0.001) and a higher percentage of body fat (men: absolute mean difference 3.23%, 95% CI 0.83% to 5.62%, p = 0.008; women: absolute mean difference 4.09%, 95% CI 3.46% to 4.72%, p < 0.001). South Asian people are also more sedentary, consume higher levels of carbohydrates and are less likely to smoke tobacco (OR 0.38, 95% CI 0.24 to 0.60, p < 0.001]) than white Canadians. No differences in access to diagnostic tests, outcomes following cardiovascular surgery or use of cardiac rehabilitation programs were apparent.

INTERPRETATION

Compared with white people, South Asian people living in Canada have a higher prevalence and incidence of CVD and possess a unique cardiovascular risk profile.

Exploring the experience of facilitating self-management with minority ethnic stroke survivors: a qualitative study of therapists' perceptions

PURPOSE

The utility of self-management with people from minority ethnic backgrounds has been questioned, resulting in the development of culturally specific tools. Yet, the use of stroke specific self-management programmes is underexplored in these high risk groups. This article presents the experience of stroke therapists in using a stroke specific self-management programme with stroke survivors from minority ethnic backgrounds.

METHODS

26 stroke therapists with experience of using the self-management programme with stroke survivors from minority ethnic backgrounds participated in semi-structured interviews. These were audio recorded, transcribed verbatim and analysed thematically.

RESULTS

Three themes were identified. One questioned perceived differences in stroke survivors interaction with self-management based on ethnicity. The other themes contrasted with this view demonstrating two areas in which ethnic and cultural attributes were deemed to influence the self-management process both positively and negatively. Aspects of knowledge of health, illness and recovery, religion, family and the professionals themselves are highlighted.

CONCLUSIONS

This study indicates that ethnicity should not be considered a limitation to the use of an individualized stroke specific self-management programme. However, it highlights potential facilitators and barriers, many of which relate to the capacity of the professional to effectively navigate cultural and ethnic differences.

The Impact of Ramadan on lifestyle behaviours and implications for cardiac rehabilitation: A review

Introduction:

The Muslim population worldwide have a higher incidence of cardiovascular disease than that of the non-Muslim population, and this may become exaggerated during the religious observances of Ramadan. This review assessed the evidence regarding the impact of Ramadan on lifestyle behaviours in Muslims with cardiovascular disease.

Method:

This article reviews the literature concerning the impact of Ramadan on lifestyle behaviours and its effects on cardiac rehabilitation between 2000 and 2012. Studies were identified, using Academic Search Complete, Google Scholar, PsycInfo, PsycARTICLES, Medline and CINAHL Plus. The search terms used were: ‘cardiac rehabilitation’; ‘cardiovascular disease’; ‘Ramadan’; ‘fasting’; ‘physical activity’; ‘exercise’; ‘diet’; ‘smoking’; ‘sleep’; ‘behaviour change’; ‘medication’; and ‘treatment’.

Findings:

Evidence suggests that fasting during Ramadan can have a beneficial effect on factors such as cholesterol levels, body weight and blood pressure; however, benefits are rarely sustained in the long term. Other behavioural changes such as non-adherence to medication, and diet and exercise regimes have more negative consequences for sufferers of cardiac disease.

Conclusions:

Lifestyle behaviours adopted during Ramadan can have a negative impact on cardiovascular disease. Health professionals are urged to find innovative ways to engage this population in healthy lifestyle choices throughout this period.

A qualitative systematic review of influences on attendance at cardiac rehabilitation programs after referral

BACKGROUND

Cardiac rehabilitation and secondary prevention programs can prevent heart disease in high-risk populations. However, up to half of all patients referred to these programs do not subsequently participate. Although age, sex, and social factors are common predictors of attendance, to increase attendance rates after referral, the complex range of factors and processes influencing attendance needs to be better understood.

METHODS

A systematic review using qualitative meta-synthesis was conducted. Ten databases were systematically searched using 100+ search terms until October 31, 2011. To be included, studies had to contain a qualitative research component and population-specific primary data pertaining to program attendance after referral for adults older than 18 years and be published as full articles in or after 1995.

RESULTS

Ninety studies were included (2010 patients, 120 caregivers, 312 professionals). Personal and contextual barriers and facilitators were intricately linked and consistently influenced patients' decisions to attend. The main personal factors affecting attendance after referral included patients' knowledge of services, patient identity, perceptions of heart disease, and financial or occupational constraints. These were consistently derived from social as opposed to clinical sources. Contextual factors also influenced patient attendance, including family and, less commonly, health professionals. Regardless of the perceived severity of heart disease, patients could view risk as inherently uncontrollable and any attempts to manage risk as futile.

CONCLUSIONS

Decisions to attend programs are influenced more by social factors than by health professional advice or clinical information. Interventions to increase patient attendance should involve patients and their families and harness social mechanisms.

Participating in cardiac rehabilitation: a systematic review and meta-synthesis of qualitative data

BACKGROUND

Participation in cardiac rehabilitation (CR) benefits patients with coronary heart disease (CHD), yet worldwide only some 15–30% of those eligible attend. To improve understanding of the reasons for poor participation we undertook a systematic review and meta-synthesis of the qualitative literature.

METHODS

Qualitative studies identifying patient barriers and enablers to attendance at CR were identified by searching multiple electronic databases, reference lists, relevant conference lists, grey literature, and keyword searching of the Internet (1990–2010). Studies were selected if they included patients with CHD and reviewed experience or understanding about CR. Meta-synthesis was used to review the papers and to synthesize the data.

RESULTS

From 1165 papers, 34 unique studies were included after screening. These included 1213 patients from eight countries. Study methodology included interviews (n = 25), focus groups (n = 5), and mixed-methods (n = 4). Key reasons for not attending CR were physical barriers, such as lack of transport, or financial cost, and personal barriers, such as embarrassment about participation, or misunderstanding the reasons for onset of CHD or the purpose of CR.

CONCLUSIONS

There is a vast amount of qualitative research which investigates patients’ reasons for non-attendance at CR. Key issues include system-level and patient-level barriers, which are potentially modifiable. Future research would best be directed at investigating strategies to overcome these barriers.

Punjabi Sikh patients' perceived barriers to engaging in physical exercise following myocardial infarction

OBJECTIVE

The aim of this research was to describe Punjabi Sikh patients' perceived barriers to engaging in physical exercise following myocardial infarction (MI).

DESIGN AND SAMPLE

A qualitative, interpretive descriptive methodology was used. The sample included 15 Punjabi Sikh patients who were attending a cardiac rehabilitation education program in an urban center of British Columbia, Canada, following MI.

MEASUREMENTS

Data were collected via semi-structured interviews and were audio recorded, translated from Punjabi to English, and transcribed verbatim. Data were analyzed using an interpretive thematic approach that involved a process of coding and constant comparison.

RESULTS

Four key factors emerged that related to participants' perceived barriers to sustained engagement in physical activity: (1) difficulty in determining safe exertion levels independently; (2) fatigue and weakness; (3) preference for 'informal' exercise; and (4) migration-related challenges.

CONCLUSIONS

The findings have implications for the design and delivery of health promotion strategies aimed at Punjabi Sikh patients' post-MI that is contingent on the use of 'formal' exercise settings to promote regular physical activity. The willingness among Punjabi Sikh patients to practise brisk walking offers a positive direction that public health nurses and other healthcare professionals may want to capitalize on in the delivery of exercise-related health promotion.

Canadian Punjabi Sikh men's experiences of lifestyle changes following myocardial infarction: cultural connections

OBJECTIVE

To describe how culture underlies Canadian Punjabi Sikh men's experiences of adopting lifestyle changes following myocardial infarction (MI).

DESIGN

Qualitative, interpretive design. In-depth, individual interviews were conducted with 27 Canadian Punjabi Sikh men post-MI. Data were analysed using constant comparative methods.

RESULTS

Cultural influences were identified in Punjabi Sikh men's descriptions of their experience of adopting lifestyle changes. Actions related to self-care, rehabilitation and lifestyle change post-MI were embedded in collectivist family and community contexts. Three themes, derived from the data, were found to intertwine with these contexts; they related to food consumption, physical exercise and faith and religion.

CONCLUSION AND IMPLICATIONS

These findings highlight how collectivist ideals influence Canadian Punjabi Sikh men's adoption of lifestyle changes post-MI. The content and processes by which healthcare providers deliver heart health and rehabilitation to Canadian Punjabi Sikh men might be guided, at least in part, by the collectivist cultural practices underpinning our findings.

A narrative review of South Asian patients' experiences of cardiac rehabilitation

AIMS AND OBJECTIVES

To review the empirical literature relating to South Asian patients' experiences of cardiac rehabilitation.

BACKGROUND

Individuals of South Asian origin (originating from India, Pakistan, Bangladesh, or Sri Lanka) have increased risk of coronary heart disease-related mortality and morbidity. Low levels of cardiac rehabilitation participation have been reported among South Asian groups in several English-speaking countries.

DESIGN

Narrative review.

METHODS

Primary research evidence published in English between 1999-2010 obtained using pre-defined search criteria in electronic databases MEDLINE, CINAHL, PubMed, EMBASE, Google Scholar and PsycINFO.

RESULTS

Eleven studies met the inclusion criteria for review. Four prominent themes were identified in the literature related to: (1) exercise; (2) culture and religion; (3) programme access and structure; (4) communication and language.

CONCLUSIONS

The emerging themes distilled from the review encompass several factors associated with South Asian patients' experiences of cardiac rehabilitation that are commensurate with low uptake and poor adherence. However, few researchers have disaggregated their data by ethnic origin to describe what might best meet the needs of South Asian patients. Further research is needed to thoughtfully address issues of uptake of and compliance with cardiac rehabilitation by South Asian patients and to support the development of culturally sensitive and safe CR programmes.

RELEVANCE TO CLINICAL PRACTICE

The findings from this review can help nurses to develop guidelines for the design and delivery of culturally competent South Asian cardiac rehabilitation programmes. Important considerations related to physical exercise, language and communication preferences, religious and cultural needs and programme access and structure, need to be addressed in a culturally relevant and culturally sensitive manner to enhance the uptake and efficacy of cardiac rehabilitation for South Asian individuals.