Pamela LeBlanc

Chinese immigrants' management of their cardiovascular disease risk.

The authors have undertaken a series of grounded theory studies to describe and explain how ethnocultural affiliation and gender influence the process that cardiac patients undergo when faced with making behavior changes associated with reducing their cardiovascular disease (CVD) risk. Data were collected through audiorecorded semistructured interviews (using an interpreter as necessary), and the authors analyzed the data using constant comparative methods. The core variable that emerged through the series of studies was “meeting the challenge.” Here, the authors describe the findings from a sample of Chinese immigrants (10 men, 5 women) to Canada. The process of managing CVD risk for the Chinese immigrants was characterized by their extraordinary diligence in seeking multiple sources of information to enable them to manage their health.

Adhesive-Enhanced Sternal Closure to Improve Postoperative Functional Recovery: A Pilot, Randomized Controlled Trial

BACKGROUND We previously established a proof-of-concept in a human cadaveric model where conventional wire cerclage was augmented with a novel biocompatible bone adhesive that increased mechanical strength and early bone stability. We report the results of a single-center, pilot, randomized clinical trial of the effects of adhesive-enhanced closure of the sternum on functional postoperative recovery. METHODS In 55 patients undergoing primary sternotomy, 26 patients underwent conventional wire closure and were compared with 29 patients who underwent adhesive-enhanced closure, which consisted of Kryptonite biocompatible adhesive (Doctors Research Group Inc, Southbury, CT) applied to each sternal edge in addition to conventional 7-wire cerclage. Patients were monitored postoperatively at 72 hours, weekly for 12 weeks, and then after 12 months for incisional pain, analgesic use, and maximal inspiratory capacity measured by spirometry. Standardized assessment tools measured postoperative physical disability and health-related quality of life. RESULTS No adverse events or sternal complications from the adhesive were observed early or after 12 months. Incisional pain and narcotic analgesic use were reduced in adhesive-enhanced closure patients. Inspiratory capacity was significantly improved, postoperative health-related quality of life scores normalized more rapidly, and physical disability scores were reduced. Computed tomography imaging was suggestive of sternal healing. CONCLUSIONS Adhesive-enhanced closure is a safe and simple addition to conventional wire closure, with demonstrated benefits on functional recovery, respiratory capacity, incisional pain, and analgesic requirements. A large, multicenter, randomized controlled trial to examine the potential of the adhesive to prevent major sternal complications in higher risk patients is warranted.

First Nations People's Challenge in Managing Coronary Artery Disease Risk

First Nations peoples bring a particular history and cultural perspective to healing and well-being that significantly influences their health behaviors. The authors used grounded theory methods to describe and explain how ethnocultural affiliation and gender influence the process that 22 First Nations people underwent when making lifestyle changes related to their coronary artery disease (CAD) risk. The transcribed interviews revealed a core variable, meeting the challenge. Meeting the challenge of CAD risk management was influenced by intrapersonal, interpersonal (relationships with others), extrapersonal (i.e., the community and government), sociodemographic, and gendered factors. Salient elements for the participants included their beliefs about origins of illness, the role of family, challenges to accessing information, financial and resource management, and the gendered element of body image. Health care providers need to understand the historical, social, and culturally embedded factors that influence First Nations peoples appraisal of their CAD.

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.

Finding resiliency in the face of financial barriers: Development of a conceptual framework for people with cardiovascular-related chronic disease.

Abstract Patients with chronic diseases often face financial barriers to optimize their health. These financial barriers may be related to direct healthcare costs such as medications or self-monitoring supplies, or indirect costs such as transportation to medical appointments. No known framework exists to understand how financial barriers impact patients’ lives or their health outcomes. We undertook a grounded theory study to develop such a framework. We used semistructured interviews with a purposive sample of participants with cardiovascular-related chronic disease (hypertension, diabetes, heart disease, or stroke) from Alberta, Canada. Interview transcripts were analyzed in triplicate, and interviews continued until saturation was reached. We interviewed 34 participants. We found that the confluence of 2 events contributed to the perception of having a financial barrier—onset of chronic disease and lack of income or health benefits. The impact of having a perceived financial barrier varied considerably. Protective, predisposing, or modifying of factors determined how impactful a financial barrier would be. An individuals particular set of factors is then shaped by their worldview. This combination of factors and lens determines ones degree of resiliency, which ultimately impacts how well they cope with their disease. The role of financial barriers is complex. How well an individual copes with their financial barriers is intimately tied to resiliency, which is related to the composite of a personal circumstances and their worldview. Our framework for understanding the experience of financial barriers can be used by both researchers and clinicians to better understand patient behavior.

The influence of coronary artery bypass graft harvest site on women's pain, functional status, and health services utilization throughout the first post-operative year: A longitudinal study

BACKGROUND Coronary artery bypass graft surgery is a commonly performed procedure aimed at managing coronary symptoms and prolonging life. Researchers have typically examined morbidity and mortality outcomes of predominantly male populations. Less is known about the influence of graft harvest site on recovery outcomes such as surgery-related pain, functional status, and health services utilization, especially in women. OBJECTIVES We aimed to examine the relationships between coronary artery bypass graft harvest site (saphenous vein, internal mammary arteries or both) and surgery-related pain, functional status, health services use at 6 weeks, 12 weeks and 12 months post-operatively. DESIGN Longitudinal extension survey following participation in a clinical trial. SETTING Ten Canadian centres. PARTICIPANTS Women (222) who participated in the Womens Recovery from Sternotomy Trial, underwent coronary artery bypass graft surgery with or without heart valve surgery, and completed the 12-month follow-up interview. METHODS Harvest site data were collected by health record audit at the time of hospital discharge. Surgery-related pain, functional status, pain medication use and health services use data were collected by standardized interview over the telephone at 6 weeks, 12 weeks and 12 months post-operatively. Surgery-related pain and functional status were measured using the short Health Assessment Questionnaire. Health services use was measured by questionnaire and recorded as reported by the participants. RESULTS Surgery-related pain, functional disability and health services use decreased over the first post-operative year. Participants who had left internal mammary artery grafts were more likely to have surgery-related pain (Adjusted Odds Ratio (AOR)=2.79; 95% Confidence Interval (CI) 1.40-5.70) and use pain medication (AOR=4.32; 95% CI 1.44-12.91) than those who had saphenous vein grafts. Conversely, participants who had saphenous vein grafts reported significantly more functional disability (AOR=2.63; 95% CI 1.16-6.25) over 12 months post-surgery than those with left internal mammary artery grafts. Participants who had pain over the course of follow-up were more likely to visit their family physician or nurse practitioner (p=0.017), visit another type of provider (i.e., naturopath or chiropractor, p=0.004), or use any health care service (p<0.0001). CONCLUSIONS Following coronary artery bypass graft surgery, women who had left internal mammary artery grafts reported more pain and health services use while those who had saphenous vein grafts were more functionally disabled. Women who reported surgery-related pain also used more health services.

Weight and Patients’ Decision to Undergo Cardiac Surgery

Obese patients are less likely to have cardiac surgery than normal weight patients. This could be due to physician or patient decision-making. We undertook a qualitative descriptive study to explore the influence of obesity on patients’ decision-making to have cardiac surgery. Forty-seven people referred for coronary artery bypass graft (CABG) surgery were theoretically sampled. Twelve people had declined cardiac surgery. Participants underwent in-depth interviews aimed at exploring their decision-making process. Data were analyzed using conventional content analysis. Though patients’ weight did not play a role in their decision, their relationship with their cardiologist/surgeon, the rapidity and orchestration of the diagnosis and treatment, appraisal of risks and benefits, previous experience with other illness or others who had cardiac surgery, and openness to other alternatives had an impact. It is possible that there is a lack of comfort or acknowledgment by all parties in discussing the influence of weight on CABG surgery risks.

Ethno-Cultural Considerations in Cardiac Patients' Medication Adherence.

We aimed to develop an in-depth understanding about factors that influence cardiac medication adherence among South Asian, Chinese, and European White cardiac patients. Sixty-four patients were purposively sampled from an ongoing study cohort. Interviews were audio-recorded and transcribed for analyses. Physicians’ culturally sensitive communication and patients’ motivation to live a symptom-free and longer life enhanced adherence. European Whites were motivated to enhance personal well-being and enjoy family life. South Asians’ medication adherence was influenced by the desire to fulfill the will of God and family responsibilities. The Chinese were motivated to avoid pain, illness, and death, and to obey a health care provider. The South Asians and Chinese wanted to ultimately reduce medication use. Previous positive experiences, family support, and establishing a routine also influenced medication adherence. Deterrents to adherence were essentially the reverse of the motivators/facilitators. This analysis represents an essential first step forward in developing ethno-culturally tailored interventions to optimize adherence.

Ethnocultural influences in how people prefer to obtain and receive health information

AIMS AND OBJECTIVES To develop an understanding of south Asian and Chinese peoples preferences about where to find health information and how best to receive health information, relative to their white counterparts. BACKGROUND South Asian and Chinese ethnic groups represent the largest proportion of Canadas growing visible minorities. There may be challenges to ensuring that south Asian and Chinese people have access to health information in the same way that others do. DESIGN Qualitative descriptive. METHODS Fifty-two participants (12 white, 16 south Asian and 24 Chinese) engaged in six focus groups (two for each ethnocultural group). Focus groups were conducted in English, Punjabi and Cantonese, with the assistance of Punjabi and Cantonese interpreters. Questions were focused on how participants have preferred or would prefer to receive health information (e.g., when, where, what format, from whom), as well as the facilitators and barriers to understanding the health information. RESULTS Participants agreed that although physicians were their primary source for health information, they also used written materials, media and the Internet to glean information. Participants identified concerns regarding the use of technical jargon by healthcare providers. South Asians and Chinese referred to their English language fluency and the lack of ethnoculturally specific information as additional challenges to understanding information they were offered. Whether and how family members were included in the communication process, also varied by ethnocultural group. CONCLUSIONS As Canada welcomes immigrants from other countries, and its population becomes more diverse, healthcare providers need to have an understanding of the potential diversity in how to approach offering health information. RELEVANCE TO CLINICAL PRACTICE Healthcare providers need to consider what people of different ethnocultural backgrounds need when developing effective health communication strategies.

51 Coronary Artery Bypass Graft Harvest Site and Post-Op Recovery in Women

Methods: Data were collected on CHD risk factors from 80 patient-partner pairs as part of a multi-factorial exploratory prospective study. This study was unusual in collecting data on both patients and partners early in the treatment trajectory just after it had been confirmed that the patient would go on the waiting list for CABG surgery. Results: The patients had significantly reduced their modifiable CHD risk factors by 4 months post-operatively, whilst the partners significantly increased their CHD risk factors. At 4 months follow-up the patients still had an average 1.78 modifiable CHD risk factors and the partners an average of 1.54 risk factors. There were significant differences between the patients and partners for the total number of modifiable CHD risk factors preand post-operatively. The pattern that emerged post-CABG indicated a move towards concordance in risk factors between the patients and partners. The patients’ greater post-operative total number of CHD risk factors was significantly predicted by their greater total number of pre-operative CHD risk factors and by being female. Similarly, the partners’ greater total number of pre-operative modifiable CHD risk factors significantly predicted their higher total number of post-operative CHD risk factors. Conclusions: This study highlights the potential that pre-operative rehabilitation and the use of interventions preand post-operatively that target the patient and their partner have for the primary and secondary prevention of CHD.