A review of the cultural competence view of cardiac rehabilitation

Predictors of Discharge Against Medical Advice in a Tertiary Paediatric Hospital

Background: Patients who discharge against medical advice (DAMA) from hospital carry a significant risk of readmission and have increased rates of morbidity and mortality. We sought to identify the demographic and clinical characteristics of DAMA patients from a tertiary paediatric hospital. Methods: Data were extracted retrospectively from electronic medical records for all inpatient admissions over a 5-year period. Demographic characteristics (age, sex, Aboriginality, socioeconomic status and remoteness of residence) and clinical characteristics (admitting hospital site, level of urgency on admission, diagnosis and previous DAMA) were extracted and logistic regression models were used to identify predictors of DAMA with 95% confidence intervals. Results: There were 246,359 admissions for 124,757 patients, of which 1871 (0.8%) admissions and 1730 patients (1.4%) DAMA. Predictors of DAMA in a given admission were hospital site (OR 4.8, CI 4.2–5.7, p < 0.01), a mental health/behavioural diagnosis (OR 3.3, CI 2.2–4.8, p < 0.01), Aboriginality (OR 1.6, CI 1.3–2.1, p < 0.01), emergency rather than elective admissions (OR 0.7ha, CI 0.6–0.8, p < 0.01), a gastrointestinal diagnosis (OR 1.5, CI 1.1–2.0, p = 0.04) and a history of previous DAMA (OR 2.0, CI 1.2–3.2, p = 0.05). Conclusions: There are clear predictors of DAMA in this tertiary hospital admission cohort and identification of these provides opportunities for intervention at a practice and policy level in order to prevent adverse outcomes.

Using person-centred approaches to improve access to comprehensive cardiac rehabilitation

Cardiac rehabilitation has significant benefits for patients with cardiovascular disease in terms of physical health and psychosocial well-being. Comprehensive cardiac rehabilitation programmes comprise graduated exercise, health education, psychological support, advice on preventive medicines, and stress management. However, service provision in the UK is inconsistent. Not all eligible patients are referred to cardiac rehabilitation programmes, and there are inequities in patient access linked to socio-economic status, gender, ethnic background, mental health issues, age and frailty. A person-centred approach would improve equity of access to cardiac rehabilitation programmes and ensure that all patients receive a programme of cardiac rehabilitation that is tailored to their needs and preferences. This article outlines the core components of a cardiac rehabilitation programme, discusses inequities in patient access, and suggests person-centred approaches that nurses can use in cardiac rehabilitation and other healthcare settings.

A phenomenological construct of caring among spouses following acute coronary syndrome

The aim of this study was interpret the existential construct of family caring following Acute Coronary Syndrome. Family support is known to have a positive impact on recovery and adjustment after cardiac events. Few studies provide philosophically-based, interpretative explorations of carer experience following a spouse's ischaemic event. As carer experiences, behaviours and meaning-making may impact on the quality of the support they provide to patients, further understanding could improve both patient outcomes and family experience. Fourteen spouses of people experiencing Acute Coronary Syndrome in Sydney, Australia were engaged in a single, semi-structured interview. Interviews were audio-recorded and transcribed verbatim. Data were analysed using hermeneutic interpretation within a Heideggerian phenomenological framework. Acute Coronary Syndrome disrupts lived temporality, and the projected potential for carers' being-alongside. Carers experienced an existential uncertainty that arose from difficulty in diagnosis, and situated fear as an attuned, being-towards-death. They constructed protective strategies to insulate their partner and themselves from further stress and risk, however, unclear boundaries for protection heightened carer anxiety. The existential structure of care included one of two possible Heideggerian modes: leaping-in care was a dominating mode that required a high level of carer vigilance; leaping-ahead care was a metaphorical walking alongside, as carers gave back control, freeing opportunities for the person to 'own' care. Supporting carers through the intensive phase of leaping-in care, and equipping them for informed leaping-ahead care should be a focus in both the acute and post-discharge care phases.

Heart Disease and Depression

Purpose: This article seeks to review and discuss the evidence linking depression, coronary heart disease (CHD), and culture. Method: PsychInfo, CINAHL, PubMed, and Google were searched for pertinent evidence linking depression, culture, and CHD, and retrieved articles were analyzed using thematic content analysis. Findings: Identified themes were the followings: depression is a factor in development and prognosis of CHD and affects the capacity to self-manage and adhere to treatment recommendations; culture mediates mental health/illness representations and treatment-seeking behaviors; screening and assessment of depression can be affected by cultural factors; and there is a need for culturally appropriate screening and therapeutic strategies. Discussion and Conclusions: As depression is a predictor and moderating variable in the genesis and progression of CHD, understanding how factors such as culture affect screening and management of the disease is important to inform the development of culturally and linguistically competent strategies that ensure accurate screening, detection, and treatment of depression in cardiac patients in clinical practice.

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.

The effect of a preoperative spiritual/religious intervention on anxiety in Shia Muslim patients undergoing coronary artery bypass graft surgery: a randomized controlled trial

BACKGROUND

Coronary artery bypass grafting (CABG) is associated with anxiety. Preoperative anxiety is considered a predictor for a range of suboptimal postsurgical outcomes.

OBJECTIVE

To evaluate the effect of a spiritual/religious training intervention on anxiety in Shia Muslim individuals scheduled for CABG.

METHODS

A randomized controlled trial of a preoperative spiritual/religious training intervention, congruent with Islamic supplication (Zikr), was administered in five sessions of 45 minutes duration to test the impact on anxiety in comparison with standard care. Seventy participants were selected based on inclusion criteria and randomly allocated to treatment and control groups. Baseline levels of anxiety and the impact of the intervention were assessed using the Persian version of the Hamilton Anxiety Scale.

RESULTS

Baseline characteristics were comparable between the intervention and control groups. Following the intervention, there was a statistically significant difference in anxiety mean scores between intervention (19.48 ± 2.03) and control groups (43.27 ± 5.49), p < .001.

CONCLUSIONS

This study demonstrates that preoperative spiritual/religious training can reduce anxiety in Muslim patients undergoing CABG. Further evaluation of this intervention in other population groups is warranted and the study underscores the importance of culturally appropriate and interventions.

Factors influencing health care utilisation among Aboriginal cardiac patients in central Australia: a qualitative study

BACKGROUND

Aboriginal Australians suffer from poorer overall health compared to the general Australian population, particularly in terms of cardiovascular disease and prognosis following a cardiac event. Despite such disparities, Aboriginal Australians utilise health care services at much lower rates than the general population. Improving health care utilisation (HCU) among Aboriginal cardiac patients requires a better understanding of the factors that constrain or facilitate use. The study aimed to identify ecological factors influencing health care utilisation (HCU) for Aboriginal cardiac patients, from the time of their cardiac event to 6-12 months post-event, in central Australia.

METHODS

This qualitative descriptive study was guided by an ecological framework. A culturally-sensitive illness narrative focusing on Aboriginal cardiac patients' "typical" journey guided focus groups and semi-structured interviews with Aboriginal cardiac patients, non-cardiac community members, health care providers and community researchers. Analysis utilised a thematic conceptual matrix and mixed coding method. Themes were categorised into Predisposing, Enabling, Need and Reinforcing factors and identified at Individual, Interpersonal, Primary Care and Hospital System levels.

RESULTS

Compelling barriers to HCU identified at the Primary Care and Hospital System levels included communication, organisation and racism. Individual level factors related to HCU included language, knowledge of illness, perceived need and past experiences. Given these individual and health system barriers patients were reliant on utilising alternate family-level supports at the Interpersonal level to enable their journey.

CONCLUSION

Aboriginal cardiac patients face significant barriers to HCU, resulting in sub-optimal quality of care, placing them at risk for subsequent cardiovascular events and negative health outcomes. To facilitate HCU amongst Aboriginal people, strategies must be implemented to improve communication on all levels and reduce systemic barriers operating within the health system.

Time to bring down the twin towers in poor Aboriginal hospital care: addressing institutional racism and misunderstandings in communication

Improvements in Aboriginal health have been slow. Research demonstrates ongoing discrimination towards Aboriginal Australians based on race, including in health services, leads to poor health outcomes. Using an eclectic methodology based on observations and discussions with health practitioners experienced in working with Aboriginal patients, this paper identifies how cross-cultural misunderstandings undermine the quality of care to Aboriginal patients in hospital and offers suggestions for improving practice. It also explores the concept of institutional racism and challenges doctors to reflect on their role in perpetuating power imbalances. We argue that physicians and healthcare providers need to do more than just deliver evidence-based interventions, by critically reflecting on their own attitudes to and practices with Aboriginal Australians and work collectively to effect systemic change which creates a more inclusive and safe environment for all people accessing healthcare.

Negotiating norms, navigating care: findings from a qualitative study to assist in decreasing health inequity in cardiac rehabilitation

Purpose. People from culturally and linguistically diverse backgrounds (CaLDBs) have lower rates of participation in cardiac rehabilitation (CR). Systematically evaluating barriers and facilitators to service delivery may decrease health inequalities. This study investigated approaches for promoting cultural competence in CR. Methods. A qualitative study of 25 health practitioners was undertaken across three CR programs using a purposive sampling strategy. Interviews and participant observation were undertaken to identify factors to promote culturally competent care. Results. Three key foci were identified for implementing cultural competence approaches: (1) point of contact; (2) point of assessment; and (3) point of service. Based upon study findings and existing literature, a conceptual model of cultural competency in CR was developed. Conclusion. Culturally competent strategies for identifying and tailoring activities in the CR setting may be a useful approach to minimise health inequities. The findings from this study identified that, in parallel with mainstream health services, CR service delivery in Australia faces challenges related to cultural and ethnic diversity. Encouragingly, study findings revealed implementation and integration of culturally competent practices in rehabilitation settings, in spite of significant odds. What is known about the topic? Cultural competence can improve the ability of health systems and health providers to deliver appropriate services to diverse populations in order to reduce disparities and improve health outcomes. What does this paper add? Description of cardiac rehabilitation practitioners’ interaction and views on interacting with patients from culturally and linguistically diverse backgrounds. An empirically derived model of cultural competence identifying key points of intervention. What are the implications for practitioners? This model improves practitioner’s ability to address diverse needs of individuals from culturally and linguistically diverse backgrounds and improve equity in health care delivery in Australia.

Are the processes recommended by the NHMRC for improving Cardiac Rehabilitation (CR) for Aboriginal and Torres Strait Islander people being implemented?: an assessment of CR Services across Western Australia

BACKGROUND

Cardiovascular disease is the major cause of premature death of Indigenous Australians, and despite evidence that cardiac rehabilitation (CR) and secondary prevention can reduce recurrent disease and deaths, CR uptake is suboptimal. The National Health and Medical Research Council (NHMRC) guidelines Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander peoples, published in 2005, provide checklists for services to assist them to reduce the service gap for Indigenous people. This study describes health professionals' awareness, implementation, and perspectives of barriers to implementation of these guidelines based on semi-structured interviews conducted between November 2007 and June 2008 with health professionals involved in CR within mainstream health services in Western Australia (WA). Twenty-four health professionals from 17 services (10 rural, 7 metropolitan) listed in the WA Directory of CR services were interviewed.

RESULTS

The majority of respondents reported that they were unfamiliar with the NHMRC guidelines and as a consequence implementation of the recommendations was minimal and inconsistently applied. Respondents reported that they provided few in-patient CR-related services to Indigenous patients, services upon discharge were erratic, and they had few Indigenous-specific resources for patients. Issues relating to workforce, cultural competence, and service linkages emerged as having most impact on design and delivery of CR services for Indigenous people in WA.

CONCLUSIONS

This study has demonstrated limited awareness and poor implementation in WA of the recommendations of the NHMRC Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander Peoples: A Guide for Health Professionals. The disproportionate burden of CVD morbidity and mortality among Indigenous Australians mandates urgent attention to this problem and alternative approaches to CR delivery. Dedicated resources and alternative approaches to CR delivery for Indigenous Australians are needed.