Kathryn King-Shier

Factors influencing participation in cardiac rehabilitation programmes after referral and initial attendance: qualitative systematic review and meta-synthesis

Background: Greater participation in cardiac rehabilitation improves morbidity and mortality in people with coronary heart disease, but little is understood of patients’ decisions to participate. Methods: To develop interventions aimed at increasing completion of programmes, we conducted a qualitative systematic review and meta-synthesis to explore the complex factors and processes influencing participation in cardiac rehabilitation programmes after referral and initial access. To be included in the review, studies had to contain a qualitative research component, population specific data on programme participation in adults >18 years, and be published ≥1995 as full articles or theses. Ten databases were searched (31 October 2011) using 100+ search terms. Results: Of 2264 citations identified, 62 studies were included involving: 1646 patients (57% female; mean age 64.2), 143 caregivers, and 79 professionals. Patients’ participation was most strongly influenced by perceptions of the nature, suitability and scheduling of programmes, social comparisons made possible by programmes, and the degree to which programmes, providers, and programme users met expectations. Women’s experiences of these factors rendered them less likely to complete. Comparatively, perceptions of programme benefits had little influence on participation. Conclusions: Factors reducing participation in programmes are varied but amenable to intervention. Participation should be viewed as a ‘consumer behaviour’ and interventions should mobilize family support, promote ‘patient friendly’ scheduling, and actively harness the social, identity-related, and experiential aspects of participation.

Factors influencing referral to cardiac rehabilitation and secondary prevention programs: a systematic review.

Background: Referral to cardiac rehabilitation and secondary prevention programs remains very low, despite evidence suggesting strong clinical efficacy. To develop evidence-based interventions to promote referral, the complex factors and processes influencing referral need to be better understood. Design: We performed a systematic review using qualitative meta-synthesis. Methods: A comprehensive search of 11 databases was conducted. To be included, studies had to contain a qualitative research component wholly or in a mixed method design. Population specific data or themes had to be extractable for referral to programs. Studies had to contain extractable data from adults >18 years and published as full papers or theses during or after 1995. Results: A total of 2620 articles were retrieved: out of 1687 studies examined, 87 studies contained data pertaining to decisions to participate in programs, 34 of which included data on referral. Healthcare professional, system and patient factors influenced referrals. The main professional barriers were low knowledge or scepticism about benefits, an over-reliance on physicians as gatekeepers and judgments that patients were not likely to participate. Systems factors related to territory, remuneration and insufficient time and workload capacity. Patients had limited knowledge of programs and saw physicians as key elements of referral but found the process of attaining a referral confusing and challenging. Conclusions: The greatest increases in patient referral to programs could be achieved by allowing referral from non-physicians or alternatively, automatic referral to a choice of hospital or home-based programs. All referring health professionals should receive educational outreach visits or workshops around the ethical and clinical aspects of programs.

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.

Determinants of Early Readmission After Hospitalization for Heart Failure

BACKGROUND Determination of factors increasing the likelihood of early readmission after hospitalization for heart failure (HF) is fundamental for identifying potential targets for intervention. Thus, we studied the characteristics of patients readmitted within 7 and 30 days after hospitalization for HF in Alberta, Canada. METHODS Using hospital discharge abstract data, we followed patients with incident HF discharged from April 2004-March 2012 and determined their readmission status within 7 and 30 days after an index hospitalization. Logistic regression was used to determine variables associated with readmission. RESULTS Of 18,590 patients with HF (49.8% women; mean age 76.4 years), 5.6% were readmitted within 7 days and 18% were readmitted within 30 days. Readmission rates within 7 and 30 days increased significantly with age. Seven-day all-cause readmissions were associated with history of kidney disease (adjusted odds ratio [aOR], 1.28; 95% confidence interval [CI], 1.08-1.53), and 30-day all-cause readmissions were associated with cancer, pulmonary, liver, and kidney disease. Discharge with home care services at the time of discharge was a risk factor for readmission within 7 days (aOR, 1.26; 95% CI, 1.07-1.49) and 30 days (aOR, 1.23; 95% CI, 1.11-1.35). Discharge from a hospital with HF services was associated with lower readmission at both 7 days (aOR, 0.65; 95% CI, 0.57-0.74) and 30 days (aOR, 0.71; 95% CI, 0.65-0.77). CONCLUSIONS Several factors were associated with increased risk of readmission, whereas patients discharged from hospitals with HF services had a lower risk of readmission within 7 and 30 days of discharge. The interaction of provision of home care and higher early readmission deserves further study.

The association of income with health behavior change and disease monitoring among patients with chronic disease.

Background Management of chronic diseases requires patients to adhere to recommended health behavior change and complete tests for monitoring. While studies have shown an association between low income and lack of adherence, the reasons why people with low income may be less likely to adhere are unclear. We sought to determine the association between household income and receipt of health behavior change advice, adherence to advice, receipt of recommended monitoring tests, and self-reported reasons for non-adherence/non-receipt. Methods We conducted a population-weighted survey, with 1849 respondents with cardiovascular-related chronic diseases (heart disease, hypertension, diabetes, stroke) from Western Canada (n = 1849). We used log-binomial regression to examine the association between household income and the outcome variables of interest: receipt of advice for and adherence to health behavior change (sodium reduction, dietary improvement, increased physical activity, smoking cessation, weight loss), reasons for non-adherence, receipt of recommended monitoring tests (cholesterol, blood glucose, blood pressure), and reasons for non-receipt of tests. Results Behavior change advice was received equally by both low and high income respondents. Low income respondents were more likely than those with high income to not adhere to recommendations regarding smoking cessation (adjusted prevalence rate ratio (PRR): 1.55, 95%CI: 1.09–2.20), and more likely to not receive measurements of blood cholesterol (PRR: 1.72, 95%CI 1.24–2.40) or glucose (PRR: 1.80, 95%CI: 1.26–2.58). Those with low income were less likely to state that non-adherence/non-receipt was due to personal choice, and more likely to state that it was due to an extrinsic factor, such as cost or lack of accessibility. Conclusions There are important income-related differences in the patterns of health behavior change and disease monitoring, as well as reasons for non-adherence or non-receipt. Among those with low income, adherence to health behavior change and monitoring may be improved by addressing modifiable barriers such as cost and access.

Gender, socioeconomic and ethnic/racial disparities in cardiovascular disease: A time for change

Cardiovascular disease (CVD) mortality rates have declined steadily over the past few decades but gender, socioeconomic and ethnic/racial disparities have not. These disparities impede cardiovascular health care reaching all those in need. The origins of disparities in CVD are numerous and wide-ranging, having largely evolved from inequalities in society. Similarly, disparities in CVD, interventions and outcomes will also vary depending on the minority or disadvantaged group. For this reason, strategies aimed at reducing such disparities must be stratified according to the target group, while keeping in mind that these groups are not mutually exclusive. There is a pressing need to move beyond what can be inferred from traditional cardiovascular risk factor profiling toward implementation of interventions designed to address the needs of these populations that will eventuate in a reduction of disparities in morbidity and mortality from CVD. This will require targeted and sustainable actions. Only by ensuring timely and equitable access to care for all through increased awareness and active participation can we start to close the gap and deliver appropriate, acceptable and just care to all, regardless of gender, socioeconomic status or ethnicity/race.

Prescribing patterns and adherence to medication among South-Asian, Chinese and white people with Type 2 diabetes mellitus: a population-based cohort study

To determine the prescribing of and adherence to oral hypoglycaemic agents, insulin, angiotensin‐converting enzyme inhibitors, angiotensin receptor blockers and statin therapy among South‐Asian, Chinese and white people with newly diagnosed diabetes.

South Asians’ cardiac medication adherence

Aim: This paper is a report of a narrative review examining the current state of knowledge regarding adherence with cardiac medication among South Asian cardiac patients. Background: South Asians experience higher rates of cardiovascular disease than any other ethnic group. South Asians may be less adherent with a cardiac medication regimen than Caucasians. The factors contributing to adherence are important to discover to assist South Asians to optimize their cardiac health. Data sources: CINAHL, Medline (Ovid), PsychINFO, EMB Reviews-(Cochrane), and EMBASE were accessed using the key words: ‘South Asian’, ‘Asia’, ‘East India’, ‘India’, ‘Pakistan’, ‘Bangladesh’, ‘Sri Lanka’, ‘medication compliance’, ‘medication noncompliance’ and ‘medication adherence’. English language papers published from January 1980 to January 2013 were eligible for inclusion. Review methods: Abstracts were reviewed for redundancy and eligibility by the primary author. Manuscripts were then retrieved and reviewed for eligibility and validity by the first and last authors. Content analysis strategies were used for the synthesis. Results: Thirteen papers were in the final data set; most were conducted in India and Pakistan. Medication side-effects, cost, forgetfulness and higher frequency of dosing contributed to non-adherence. South Asian immigrants also faced language barriers, which contributed to non-adherence. Knowledge regarding the medications prescribed was a factor that increased adherence. Conclusion: South Asians’ non-adherence to cardiac medications is multifaceted. How South Asians who newly immigrate to Western countries make decisions regarding their cardiac medication adherence ought to be explored in greater detail.

Feasibility of community-based screening for cardiovascular disease risk in an ethnic community: the South Asian Cardiovascular Health Assessment and Management Program (SA-CHAMP).

BackgroundSouth Asian Canadians experience disproportionately high rates of cardiovascular disease (CVD). The goal of this qualitative study was to determine the feasibility of implementing a sustainable, culturally adapted, community-based CVD risk factor screening program for this population.MethodsSouth Asians (≥ 45 years) in Calgary, Alberta underwent opportunistic cardiovascular risk factor screening by lay trained volunteers at local religious facilities. Those with elevated blood pressure (BP) or ≥ 1 risk factor underwent point of care cholesterol testing, 10-year CVD risk calculation, counseling, and referral to family physicians and local culturally tailored chronic disease management (CDM) programs. Participants were invited for re-screening and were surveyed about health system follow-up, satisfaction with the program and suggestions for improvement. Changes in risk factors from baseline were estimated using McNemar’s test (proportions) and paired t-tests (continuous measures).ResultsBaseline assessment was completed for 238 participants (median age 64 years, 51% female). Mean TC, HDL and TC/HDL were 5.41 mmol/L, 1.12 mmol/L and 4.7, respectively. Mean systolic and diastolic blood pressures (mmHg) were 129 and 75 respectively. Blood pressure and TC/HDL ratios exceeded recommended targets in 36% and 58%, respectively, and 76% were at high risk for CVD. Ninety-nine participants (47% female) attended re-screening. 82% had accessed health care providers, 22% reported medication changes and 3.5% had attended the CDM programs. While BP remained unchanged, TC and TC/HDL decreased and HDL increased significantly (mean differences: -0.52 mmol/L, -1.04 and +0.07 mmol/L, respectively). Participants were very satisfied (80%) or satisfied (20%) with the project. Participants suggested screening sessions and CDM programs be more accessible by: delivering evening or weekends programs at more sites, providing transportation, offering multilingual programs/translation assistance, reducing screening wait times and increasing numbers of project staff.ConclusionsSA-CHAMP demonstrated the feasibility and value of implementing a lay volunteer–led, culturally adapted, sustainable community-based CVD risk factor screening program in South Asian places of worship in Calgary, Alberta, Canada. Subsequent screening and CDM programs were refined based on the learnings from this study. Further research is needed to determine physician and patient factors associated with uptake of and adherence to risk reduction strategies.

The influence of ethnicity and gender on navigating an acute coronary syndrome event

Background: Ethnicity and gender may influence acute coronary syndrome patients recognizing symptoms and making the decision to seek care. Objective: To examine these potential differences in European (Caucasian), Chinese and South Asian acute coronary syndrome patients. Methods: In-depth interviews were conducted with 20 European (Caucasian: 10 men/10 women), 18 Chinese (10 men/eight women) and 19 South Asian (10 men/nine women) participants who were purposively sampled from those participating in a large cohort study focused on acute coronary syndrome. Analysis of transcribed interviews was undertaken using constant comparative methods. Results: Participants followed the process of: having symptoms; waiting/denying; justifying; disclosing/ discovering; acquiescing; taking action. The core category was ‘navigating the experience’. Certain elements of this process were in the forefront, depending on participants’ ethnicity and/or gender. For example, concerns regarding language barriers and being a burden to others varied by ethnicity. Women’s tendency to feel responsibility to their home and family negatively impacted the timeliness in their decisions to seek care. Men tended to disclose their symptoms to receive help, whereas women often waited for their symptoms to be discovered by others. Finally, the thinking that symptoms were ‘not-urgent’ or something over which they had no control and concern regarding potential costs to others were more prominent for Chinese and South Asian participants. Conclusion: Ethnic- and gender-based differences suggest that education and support, regarding navigation of acute coronary syndrome and access to care, be specifically targeted to ethnic communities.