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Factors that affect women's uptake of cardiac rehabilitation schemes

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June Davison, BSc (Hons), RN.

Cardiac Rehabilitation Specialist, St Mary’s NHS Trust, Paddington, London

Coronary heart disease (CHD) is the most common cause of death in the UK and, although death rates are falling, it continues to cause disability, suffering and place a financial burden on the state (British Heart Foundation, 2000). Cardiac rehabilitation can improve the prognosis and quality of life for patients with CHD (Jolliffe et al, 2000; O’Connor et al, 1989; Oldridge et al, 1988), but its uptake is poor, despite established benefits, and there are inequalities in access to services (Thompson et al, 1997).

 

Coronary heart disease (CHD) is the most common cause of death in the UK and, although death rates are falling, it continues to cause disability, suffering and place a financial burden on the state (British Heart Foundation, 2000). Cardiac rehabilitation can improve the prognosis and quality of life for patients with CHD (Jolliffe et al, 2000; O’Connor et al, 1989; Oldridge et al, 1988), but its uptake is poor, despite established benefits, and there are inequalities in access to services (Thompson et al, 1997).

 

 

Women are less likely to use such services than men (Halm et al, 1999; McGee and Horgan, 1992; Thompson et al, 1997) and this paper will focus on this issue.

 

 

It outlines the current situation regarding cardiac rehabilitation and looks specifically at women’s poor attendance, attempting to identify factors that may influence their participation. It will discuss how services can be tailored to encourage women to attend, to increase their chances of an improved long-term outcome.

 

 

Cardiac rehabilitation
In the UK, CHD accounted for 137 153 deaths in 1998 (British Heart Foundation, 2000). Until recently, however, the incidence and severity of CHD in women has been under-recognised (Jensen and King, 1997). Figures from the British Heart Foundation (2001) show that one million women have, or have had, angina compared with 1.1 million men. CHD also accounts for one in five deaths in women compared with one in four in men (British Heart Foundation, 2000).

 

 

The government has continued to tackle CHD through policy initiatives such as Our Healthier Nation (Department of Health, 1998) and the National Service Framework for Coronary Heart Disease (DoH, 2000). The latter has set evidence-based standards on the prevention and treatment of CHD, specifically targeting cardiac rehabilitation (Box 1).

 

 

People who have experienced a cardiac event may require specialist intervention to help them understand their condition and treatment, and to come to terms emotionally with their illness. They may also need assistance in making lifestyle changes and regaining confidence to enable them to return to as full and normal a life as possible. A comprehensive cardiac rehabilitation service should enable people to achieve this: the overall aim is to promote recovery, enable people to achieve and maintain better health, and reduce the risk of death in people with CHD (NHS Centre for Reviews and Dissemination, 1998).

 

 

Cardiac rehabilitation should start as soon as the patient is admitted to hospital and is generally divided into four phases, each representing a different component of the patient’s journey (Box 2). Phase three is usually the formal outpatient programme, and this paper will concentrate on patients’ attendance of such rehabilitation programmes.

 

 

According to the NHS Centre for Reviews and Dissemination (1998), people with the following manifestations of CHD can benefit from cardiac rehabilitation:

 

 

- Those with acute myocardial infarction (MI)

 

 

- Those with an angioplasty pre- and post-procedure

 

 

- Patients with coronary artery bypass graft pre- and post-procedure

 

 

- Those with stable angina

 

 

- Those with heart failure

 

 

- Patients who have had a heart transplant.

 

 

Over the past decade there has been an increase in the provision of phase three programmes in the UK. In 1989, there were 91 centres offering cardiac rehabilitation (Horgan et al, 1992) and, by 1997, the number had risen to 300 (Bethell et al, 2000). However, the reality is that many patients who could benefit from it do not receive rehabilitation. Service provision varies dramatically across the country, the programmes are often poorly resourced and there are inequalities in access (Thompson et al, 1997).

 

 

There remains, therefore, considerable scope for improving the quality and quantity of cardiac rehabilitation services.

 

 

The benefits of cardiac rehabilitation
The greatest evidence for the benefits of cardiac rehabilitation comes from meta-analyses of randomised trials. Cardiac rehabilitation programmes have been shown to decrease morbidity rates and reduces mortality by around 25% (Jolliffe et al, 2000; O’Connor et al, 1989; Oldridge et al, 1988). Regular exercise improves physical performance, reduces symptoms of angina and can help control risk factors (Lavie and Milani, 1995; Thompson et al, 1996).

 

 

Cardiac rehabilitation may also improve psychological health, restore self-confidence, relieve anxiety, promote a return to social roles and increase independence in activities of daily living (Coates et al, 1995). Although the majority of research on cardiac rehabilitation has looked at the outcomes for middle-aged men (Thompson, 1999), women are likely to benefit just as much, if not more, from cardiac rehabilitation (Cannistra et al, 1992; Lavie and Milani, 1995).

 

 

But despite the strong evidence of the benefits, uptake and adherence to such programmes among both men and women remains low. A national survey of cardiac rehabilitation services found that 42% of people did not commence a cardiac rehabilitation programme (Thompson et al, 1997). A more recent UK survey (Bethell et al, 2001) found that only 14-23% of myocardial infarction (MI) patients, 33-56% of cardiac surgery patients and 6-10% of percutaneous transluminal angioplasty patients were enrolled onto a programme. It appears that many centres still do not keep statistics on their activities. There is, therefore, a need for further surveys on the provision and uptake of cardiac rehabilitation.

 

 

Factors influencing attendance are outlined in Box 3.

 

 

Women’s attendance patterns
Although more than one-third of CHD patients in the UK are women, it is estimated that they make up only 15% of people using cardiac rehabilitation services (Thompson et al, 1997). Other researchers suggest that women are also less likely to complete a programme (Halm et al, 1999, McGee and Horgan, 1992).

 

 

An interesting finding from some research is that women are less likely than men to be referred to a cardiac rehabilitation programme by their physician (Ades et al, 1992; Halm et al, 1999). Of those eligible, only 48% of women were referred, compared with 66% of men (Halm et al, 1999). Tackling biases regarding the referral of women is, therefore, of great importance - there is a need for research to explore why women are less likely to be referred, so action can be taken to improve the situation. In the interim, raising the profile of cardiac rehabilitation could encourage physicians to increase their referral rates.

 

 

Continuing cardiac symptoms
Women have been found to report more ongoing cardiac symptoms post-MI and rate their general health as poorer than men (Cannistra et al, 1992; Radley et al, 1998). Furthermore, women who have revascularisation procedures are more x likely to have angina on follow-up (Eaker et al, 1989; Kelsey et al, 1993). Missik (1999) demonstrated that women who had angina were less likely to attend cardiac rehabilitation - thus, the higher incidence of symptoms in women contributes to their lower attendance.

 

 

Women are also more likely to have complications after their cardiac event, such as reinfarction or cerebrovascular accident (Jensen and King, 1997). In addition, because women tend to be older when they develop CHD, they are more likely to have adverse health associated with co-morbidities (Radley et al 1998; Rankin, 1990), both factors that could well contribute to their lower rate of attendance on cardiac rehabilitation programmes.

 

 

The cardiac rehabilitation team is required to educate women on their condition and self-management and should alert them to ongoing symptoms. Educating women and increasing their knowledge regarding their condition will enable them to weigh up the costs and benefits of attending cardiac rehabilitation.

 

 

Women may gain from a more menu-based approach to cardiac rehabilitation, tailoring interventions to suit the individual. For example, if women are unable to exercise, they could still be encouraged to attend the health education component of the programme.

 

 

Social support
People who feel they lack social support are less likely to attend cardiac rehabilitation (Fleury, 1993) and women, in particular, have been identified as having less social support (Boogaard and Briody, 1985).

 

 

However, there is no evidence to suggest that a perceived lack of social support is linked to women’s lower uptake of rehabilitation programmes. Furthermore, not all social support is beneficial and Fleury (1993) identifies that it may cause conflict, stress and lack of control. This, in turn, can lead to reduced motivation to attend cardiac rehabilitation.

 

 

There is more evidence to suggest other aspects of social support have a bearing on whether or not women attend. For example, because on average women who have had a cardiac episode are older than men, they are less likely to have a living partner and may live alone (Brezinka et al, 1998). Schulz and McBurney (2000) found that patients who did not attend cardiac rehabilitation were less likely to be married or living with a partner, and that women constituted the majority of this category.

 

 

Fleury (1993) suggests that the absence of a partner’s encouragement and confidence could reduce the motivation to attend. On the other hand, patients were found more likely to attend by the presence of a partner or friend who was perceived to have a positive view of cardiac rehabilitation.

 

 

The health-care professional needs to take into account people’s social circumstances to identify those susceptible to non-attendance and tailor services specifically to their needs. Relatives and friends should be involved in care, and encouraged to participate in cardiac rehabilitation. Women who do not have a partner may benefit from other sources of support, and staff can help provide this through establishing a good rapport with the patient, being approachable and demonstrating good communication skills.

 

 

Support may also be gained from peers in the cardiac rehabilitation class, through group participation and comradeship. Heart support groups may also be valuable: talking to others who have similar concerns and worries is also a form of support.

 

 

Access
Women are more likely to have difficulties in getting to a rehabilitation centre (Halm et al, 1999), which makes them less likely to attend (Schulz and McBurney 2000). This is because they are less likely to drive or own a car (Ades et al, 1992), possibly because they had previously relied on their late partners to drive. The age factor may also play a role here: women with CHD may be generally more frail, impairing their confidence or their ability to drive.

 

 

The NSF for coronary heart disease (DoH, 2000) recommends that patients be provided with transport to attend rehabilitation programmes, if difficulties in accessing the centre are identified. Alternative modes of transport, such as a hopper bus or a buddy lift system, could be explored.

 

 

There is a need to seek alternative approaches to cardiac rehabilitation programmes to make them more inclusive. Community schemes widen choice and access and allow people to be assessed in the context of their social environment. Home-based cardiac rehabilitation may benefit people who have difficulties travelling or those who prefer exercising alone.

 

 

One such programme, the Heart Manual, was found to improve psychological recovery, reduce hospital admissions and GP contact (Lewin et al, 1992). Another option is to develop an individual home-based exercise and lifestyle programme together with the patient.

 

 

The current situation
The priority now is to assess the situation in each local area and undertake up-to-date surveys on attendance rates and patterns. More localised research investigating why women are less likely to attend cardiac rehabilitation is also required, as this will enable gaps in service provision to be identified and allow implementation of evidence-based practice.

 

 

Continual audit should be undertaken to evaluate whether the changes have been effective. Both evidence-based practice and audit are an essential component of clinical governance in ensuring high-quality care.

 

 

Single-sex programmes
The provision of single-sex cardiac rehabilitation classes would enable programmes to be tailored to meet the specific needs/concerns of each sex, which may help motivate them to attend.

 

 

However, it could be argued that segregating patients could diminish the support and camaraderie of classes. Without evidence of effectiveness, providing separate classes for women and men cannot be justified.

 

 

The best option appears to be provision of mixed-sex classes, while addressing the specific needs of individual patients needs through one-to-one consultation.

 

 

Implications on resources
Initiatives to tackle the issue of women’s lower attendance on cardiac rehabilitation programmes compared to men have great implications for resources. Encouraging women to attend and achieving this goal will put greater pressures on staffing and services.

 

 

It is vital all programmes identify gaps in service provision and it is hoped that the government will provide funds to meet any shortfalls.

 

 

Conclusion
This paper has discussed cardiac rehabilitation, considered the benefits and examined uptake rates. It appears that women are less likely to attend and complete a cardiac rehabilitation programme than men, partly because of their lower referral rate.

 

 

It is also apparent that women have a higher incidence of continuing cardiac symptoms and co-morbidities, which is likely to affect their ability or motivation to attend cardiac rehabilitation. In addition, women have more difficulties in accessing cardiac rehabilitation centres and are less likely to have a partner, both of which account for their lower attendance rates.

 

 

There is an urgent need for up-to-date surveys on attendance rates and research into reasons for non-attendance. There needs to be a concentration of effort on raising awareness of cardiac rehabilitation, and encouraging the referral of women for rehabilitation.

 

 

Women with CHD have unique needs, so a menu-based approach to cardiac rehabilitation is called for. They need an individualised assessment that takes into account their symptoms, co-morbidities and social circumstances, to enable services to be tailored specifically to their needs. There needs to be continuing research into cardiac rehabilitation, which should be implemented. The service should be continually audited to evaluate whether the changes have had any effect.

 

 

In the short term, the health-care system may benefit financially from women’s lower attendance rates; however, in the long term, these inequalities in access could have a detrimental effect on women’s health and subsequently on health-care costs generally. While encouraging women to take up services, it is vital to ensure that there is adequate investment to cope with the extra demand.

 

 

Enabling more women to receive cardiac rehabilitation should bring health benefits by reducing morbidity and mortality, and improving the quality of life for women with CHD.

 

 

Further reading
Coates, A., McGee, H., Stokes, H., Thompson D. (1995)
BACR: Guidelines for cardiac rehabilitation. Oxford: Blackwell Science.

 

 

Department of Health. (2000)National Service Framework for Coronary Heart Disease. London: DoH.

 

 

Scottish Intercollegiate Guidelines Network. (2002)Cardiac Rehabilitation. A National Clinical Guideline. Edinburgh: Scottish Intercollegiate Guidelines Network.

 

 

 

 

Ades, P.A., Waldman, M.L., Polk, D.M., Coflesky. J.T. (1992)Referral patterns and exercise response in the rehabilitation of female coronary patients aged greater than or equal to 62 years. American Journal of Cardiology 69: 1422-1425.

 

 

Bethell, H., Turner, S., Flint, E.J., Rose, L. (2000)The BACR database of cardiac rehabilitation units in the UK. Coronary Health Care 4: 92-95.

 

 

Bethell, H., Turner, S., Evans, J., Rose, L. (2001)Cardiac Rehabilitation in the UK: How complete is the provision? Journal of Cardiopulmonary Rehabilitation 21: 2, 111-115.

 

 

Boogaard, M.A.K., Briody, M.E. (1985)Comparison of rehabilitation of men and women post-myocardial infarction. Journal of Cardiopulmonary Rehabilitation 5: 379-384.

 

 

Brezinka, V., Dusseldorp, E., Maes, S. (1998)Gender differences in psychosocial profile at entry into cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation 18: 445-449.

 

 

British Heart Foundation. (2000)Coronary Heart Disease Statistics. London: British Heart Foundation.

 

 

British Heart Foundation. (2001)Coronary Heart Disease Statistics. Morbidity supplement. London: British Heart Foundation.

 

 

Cannistra, L.B., Balady, G.J., O’Malley, C.J. et al. (1992)Comparison of the clinical profile of women and men in cardiac rehabilitation. American Journal of Cardiology 69: 1274-1279.

 

 

Coates, A., McGee, H., Stokes, H, Thompson. D. (1995)BACR Guidelines for Cardiac Rehabilitation. Oxford: Blackwell Science.

 

 

Department of Health. (1998)Saving Lives: Our healthier nation. London: Department of Health.

 

 

Department of Health. (2000)National Service Framework for Coronary Heart Disease. London: Department of Health.

 

 

Eaker, E.D., Kronmal, R., Kennedy, J.W., Davis, K. (1989)Comparison of the long term, post-surgical survival of women and men in the coronary artery surgery study. American Heart Journal 117: 71-81.

 

 

Fleury, J. (1993)An exploration of the role of social networks in cardiovascular risk reduction. Heart and Lung 22: 134-144.

 

 

Halm, M., Penque, S., Doll, N., Beahrs, M. (1999)Women and cardiac rehabilitation: referral and compliance patterns. Journal of Cardiovascular Nursing 13: 3, 83-92.

 

 

Horgan, J., Bethell, H., Carson, P. et al. (1992)Working party report on cardiac rehabilitation. British Heart Journal 67: 412-418.

 

 

Jensen, L., King, K.M. (1997)Women and heart disease: the issues. Critical Care Nurse 17: 2, 45-53.

 

 

Jolliffe, J.A., Rees, K., Taylor, R. S. et al. (2000)Exercise-based rehabilitation for coronary heart disease. The Cochrane Library, Issue 4. Oxford: Update Software.

 

 

Kelsey, S.F., James, M., Holubkov, A.L. et al. (1993)Results of percutaneous transluminal coronary angioplasty in women. Circulation 87: 720-727.

 

 

Lavie, C.J., Milani, R.V. (1995)Effects of cardiac rehabilitation and exercise training on exercise capacity, coronary risk factors, behavioural characteristics and quality of life in women. American Journal of Cardiology 75: 340-343.

 

 

Lewin, B., Robertson, I.H., Cay, E.L. et al. (1992)A self-help post MI rehabilitation package - The Heart Manual: effects on psychological adjustment, hospitalisation and GP consultation. Lancet 339: 1036-1040.

 

 

McGee, H.M., Horgan, J.H. (1992)Cardiac rehabilitation programmes: are women less likely to attend? British Medical Journal 305: 283-284.

 

 

Missik, E. (1999)Personal perceptions and women’s participation in cardiac rehabilitation. Rehabilitation Nursing 24: 4, 158-165.

 

 

NHS Centre for Reviews and Dissemination, University of York. (1998)Cardiac rehabilitation. Effective Health Care 4: 4.

 

 

O’Connor, G.T., Buring, J.E., Yusef, S. et al. (1989)An overview of randomised trials of rehabilitation and exercise after myocardial infarction. Circulation 80: 234-244.

 

 

Oldridge, N.B., Guyatt. G.H, Fischer, M.E., Rimm, A.A. (1988)Cardiac rehabilitation after myocardial infarction: combined experience of randomised clinical trials. Journal of the American Medical Association 260: 945-950.

 

 

Radley, A., Grove, A., Wright, S., Thurston, H. (1998)Problems of women compared with those of men following myocardial infarction. Coronary Health Care 2: 202-209.

 

 

Rankin, S.H. (1990)Differences in recovering from cardiac surgery; a profile of male and female patients. Heart and Lung 19: 482-485.

 

 

Schulz, D.L., McBurney, H. (2000)Factors which influence attendance at a rural Australian cardiac rehabilitation programme. Coronary Health Care 4: 135-141.

 

 

Thompson, D.R., Bowman, G.S., Kitson, A.L. et al. (1996)Cardiac rehabilitation in the United Kingdom: guidelines and audit standards. Heart 75: 1, 89-93.

 

 

Thompson, D.R., Bowman, G.S., Kitson, A.L. et al. (1997)Cardiac rehabilitation services in England and Wales: a national survey. International Journal of Cardiology 59: 299-304.

 

 

Thompson, D.R. (1999)How valuable is cardiac rehabilitation and who should get it? Heart 82: 545-546.

 

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