Essay: Women’s participation rates in cardiac rehabilitation (CR)

Section one
2.0 Introduction and Rationale:
The Rationale for focusing this dissertation around women’s participation rates in cardiac rehabilitation (CR) comes from both personal and professional interest in cardiac conditions and cardiac rehabilitation. This is used as a driving force to gain knowledge on this topic and understand why participation rates are low, and how CR nurses can enhance participation with their specialist role. By writing this dissertation, I believe that I am benefitting my future practice as I pursue my ambitions of becoming a cardiac specialist nurse, allowing me to transfer this knowledge into practice.
Cardiovascular disease (CVD) is an umbrella term which houses many heart and circulatory diseases. Data presented by Kawamoto, Davis and Duvernoy (2016) identifies that cardiovascular disease remains the leading cause of death in women and the mortality rate is still higher in women compared to men. CVD costs the UK an estimated 19 billion pounds each year and contributes to 25% of all deaths in the UK (British Heart Foundation, 2018). The literature suggests there are many barriers to women’s participation in CR programmes, however, for the purpose of this dissertation, three have been chosen to critically analyse in more depth.
CR is a complex service, facilitating people who suffer from chronic cardiovascular disease, comprising of health promotion, risk reduction, physical activity and medication and stress management (Dalal, 2015). It centres its main focus on reversing the limitations to the pathophysiological consequences of heart disease (Dibben et al, 2018). CR has evolved considerably over the last few decades, during the 1960’s to 1980’s the physiological basis for exercise led to the introduction and development of cardiac rehabilitation programmes, this basis continues into modern day society with its undeniable benefits on mortality (Mampuya, 2012).
CR nurses are fundamental to improving health outcomes in CR, and offer a diverse role to deliver excellent patient care, through the use of education, supervision, support and reinforcement (Southern and Mcleod, 2015). Research conducted by Lin, Netback and Gallagher (2017) express how awareness should be raised on the significance of CR nurses effect on the ever-growing burden of cardiovascular disease. This is associated with the psychological support they deliver when interacting with patients. This aspect of CR has been shown to be of high value to both the patients and the nurses; however resources and funding constrains can raise barriers for the deliverance of care (Turner et al, 2017). CR Nurses coordinate good communication to other members of the multidisciplinary team and are the foundation of implementation for delivering CR, which in essence guides and influences the patients, this aids in positive patient outcomes and improves depressive symptoms (Fridlund, 2002).
Female gender has been identified as a major barrier to CR uptake. Statistics show that 79,746 patients in the UK are engaging in CR (*British Heart Foundation, 2015), however, the *British Heart Foundation (2017) later discovered that 24,000 females were missing out on CR in the UK, which has led to a key recommendation by the government to offer more females CR, and analysis shows that just 38% of female patients who have suffered a Myocardial Infarction (MI), had an angioplasty or bypass participated in CR. Factors which benefit cardiac rehabilitation have been acknowledged for the last few decades such as aerobic fitness capacity, physical fitness, which reduce mortality and reduce the chance of hospital re-admission (Zhao et al, 2018). Although the benefits of participating in CR are clearly outlined, in 2015-2016 39% of people did not attend their CR appointments, making it a real issue and limitation for CR nurses to conduct programmes (British Heart Foundation, 2018). Research by (Hazelton et al, 2014) has identified that CR show a reduced cardiac risk and improve psychological functioning, reduce mortality and reduce the chance of hospital re-admission, particularly in female participants. Which poses the question, CR is known to improve psychological symptoms in women, so why are their participation rates at such a low.
A literature search was carried out using NORA, Science Direct, CINAHL and Elvesier where the three themes picked for discussion were identified within the literature for review. The use of the CASP tool (2018) allowed a comprehensive appraisal of the literature and evidence used for this review. This tool enabled the literature search to gain the most relevant evidence possible in relation to the topic chosen, please refer to appendix one to view key words and databases used in the search.
Section two
3.0 Theme One – Social inequalities and impacts on participation rates
This theme will be exploring the social inequalities in health and how this has impacted women’s participation rates in CR, it will include a background on social inequalities in health and it will review the literature on health literacy and lack of health promotion.
3.1 Background on social inequalities of health
The Black Report established social class, education and the environment, and pinpointed as the inequalities of health. Marmot (2005) conducted research which furthered The Black Report’s findings by polishing and refining the underpinning ideologies in regards to the economic inequalities in health. Strong research conducted by Wilson and Pickett (2009) argues that this is relative rather than absolute poverty that can have the most severe impact on health inequalities, this literature is outdated, however is still very relevant in modern day practice. Pedersen et al (2018) believe the mechanisms which explain social inequality in CR are not fully understood and further research is needed. Hald et al (2018) conducted a prospective cohort study which concluded that no long term effects were recorded from patients who were from socially vulnerable areas who took part in CR. It becomes necessary to understand and learn about the social and cultural determinants of patients to improve medical practices and reduce some social inequalities in health (Racadon, Masson and Peze, 2018). The five year forward plan (Public Health England, 2014) was devised in order to close the gap on social inequalities and upgrade the public health sector. However, The Lancet Report (2017) concluded that the government cut the public health funding by 200 million in 2015-2016 and believes this will be furthered to 331 million by 2020.
3.2 Health literacy
Health literacy is common among low income areas within the UK; it requires understanding of health information and active interaction with health care professionals. It is essential for patients to understand and engage in the management of their health conditions and this may also reduce anxiety and improve wellbeing (Ishikawa and Yano, 2008). Cardiovascular disease requires a high level of knowledge for self-management of the condition (Lee, Lee, Kim and Kang, 2012). Low levels of health literacy have been linked to low education levels, low income, ethnic minority and living alone (Aaby et al, 2017). This associated with poor health management for patients with long term conditions has been identified as a key social determinant of health (Edwards, Wood, Davies and Edwards, 2012). It is documented by Wolf, Parker and Ratzan (2008) that the more socially and economically deprived an area is, the more likely the residence will be exposed to health literacy, not having the ability to process and understand basic health information given and services available to them.
There is a strong correlation between low health literacy levels and low levels of adherence to lifestyle preventative programmes (Peters, 2017). If patients do not understand the importance and content of preventative health measures, then they will not attend the relevant health appointments or programmes (Arena et al, 2015). However, if patients do not understand the importance of CR and attendance, then it poses the question, are the materials and information given to patients too complex and not easily comprehensible (McCray, 2005). Also, low literacy stigma can significantly impair people’s verbal and nonverbal interactions with healthcare professionals and their potential benefits from health services (Easton, Entwistle and Williams, 2013). Dalal (2015) explores how people suffering from social inequalities in health correlates to a direct exclusion from local commissioning agreements, this literature isn’t as strong, due to more reformed government strategies to combat public health issues such as the Five Year Forward View (2014).
Women who are aged 75 and over would have lived through the era where most women were housewives, and did not have an occupation. Most of these females left education at an early age to conform to the housewife duties and roles. Many elderly women also cannot drive, as this was the norm in the 1950’s – 1970’s, this leads to transporting issues (Beaumont, 2016). Transportation has been noted as a barrier to women trying to access CR, especially if they live in a more rural area as the closest CR programme may be a distance that is un accessible (Shanmugasegaram et al, 2013). If female patients live in rural areas, they have to factor in travel time to and from CR, essentially affecting their motivation to participate and complete the programme (Leung et al, 2010). This additional travel time and associated cost can fuel financial stresses on families, creating negative connotations on the programme, so women are less likely to participate (Supervia, 2017). A lot of these women were excluded from social and productive life, and did not have access to health education (Forrest, 2016). Even in modern day society, there is a correlation between low income areas and low education levels (Jerrim and Macmillan, 2015). Although it is noted that women have a higher life expectancy than men, they have a poorer health status in regards to mental health, chronic illness, disability and self-reported general health (Malmusi, Vives, Benach and Borrell, 2014). Women who take part in CR who suffer from social inequalities are less likely to engage in any physical activity in between programme sessions, making them more likely to drop out of the programme (Racodon, Masson and Peze, 2018).
3.3 Lack of health promotion
Public Health England (2016) set out a strategic plan for better outcomes working towards 2020. One of their main focuses is improving the health gap between the most affluent and the most vulnerable. Corbin (2017) defines Health Promotion as an essential factor in modern day communities and believes it works to enhance the issues of health literacy and creates supportive networks between health professionals and patients. Its aim is to address health inequalities and influence the factors affecting the public’s health, while empowering patients to take more control of their own health (Public Health England, 2018). Turner-Wilson, Mills and Rees (2017) express how nurses are the backbone to public health and are driven by the ideology of health promotion components and challenges in government strategies.
Health promotion and risk factor reduction are essential to patient participation and patient management of CR. Integrated health education and campaigns have been proven to reduce the risk of cardiovascular events and improve overall quality of life (Bitsch et al, 2018). Without nursing education for post cardiac event patients, the patients will not have any knowledge and awareness on the importance of attending CR programmes (Shockley, 2012). Women tend to be faced with more conflicting financial priorities, and are therefore unable to allocate CR associated costs such as transport in the older population (Arthur et al, 2012). Graverson et al (2017) suggest that patients lack the knowledge about barriers to CR and what impact that has on their overall health status. Also lack of government funding for health promotion in more deprived areas dramatically affect CR participation rates (Southerm and Mcleod, 2015).
 
4.0 Theme two – psychological factors affecting participation
This theme will be exploring the psychological factors which impact women’s participation rates in CR; it will look at negative body image, lack of motivation and beliefs, and depression in women with cardiovascular disease in relation to CR.
4.1 Body image
Studies conducted by Grace et al (2016) demonstrated that women’s low participation rates were contributed to feeling self-conscious regarding their body image. This brings on feelings of fear and embarrassment. Positive attitudes correlate to positive self-perceptions of body image; women who suffer from depressive symptoms are more likely to have a negative self-perception of body image, making them less likely to attend CR (Prichard and Tiggermann, 2008). Research by Jackson et al (2014) demonstrated that negative body image directly relates to depressive symptoms in women. Furthering this research, Dressler (2013) suggests that socially embarrassing factors play a massive role in lack of participation; the research discovered that women fear incontinence during sessions, and fear of pain. Research found that 58% of people reported that the amount of exercise they participated in was influenced by how they perceived their body image, feeling of being overweight and feeling unattractive (Homan and Tylka, 2014). This research is not contemporary and can be linked in to modern practice.
4.2 Lack of motivational belief
Motivation plays a key role in adherence to participation. Lack of beliefs in CR patients can also negatively affect their journey to recovery and overall health status. The physical, psychological and social environments impact patient’s attitude and beliefs about the possibility of overcoming the healthy needs by getting involved in CR and engaging in self-care (Shahsavari, Shahriari and Alimohammadi (2012). The majority of women who don’t usually participate in group activities and exercise suffer from embarrassment from body image and body functions such as incontinence (Mind UK, 2018). Women also believe that they need to live up to unrealistic expectations of physical and aerobic capacity; the first group session is seen as a major hurdle for the women’s confidence (NICE, 2013). Not only do these women feel embarrassed, they suffer from fear of other participants finding out about their lack of exercise ability and their incontinence, these have become a major barrier in participation in group exercise (Sinclair and Ramsay, 2011).
4.3 Depression in women with cardiovascular disease
Depression and anxiety are extremely common in women living with cardiovascular disease and are associated with worse health outcomes. Research conducted by Wright, Simpson and Van Lieshout (2014) suggest that decreases in levels of regulatory T cells and a chronic increase in pro-inflammatory cytokine secretion is a major contributing factor to depression in women with cardiovascular disease, this literature demonstrates a strong understanding of the pathophysiological background of depression in women. Depression may not always be seen as a priority by healthcare professionals, as its symptoms may be mistaken for adaptions to new lifestyle factors and medications (Dhar and Barton, 2016). Because psychological distress like depression and anxiety make participation in CR difficult, patients need to be assessed as early as possible for best patient outcomes (McGrady et al, 2009). Another barrier which contributes to depression, is a lack of social support from friends and family, resulting in social isolation (Supervia et al, 2017). Research conducted by Albert (2015) suggests that women are more genetically pre-disposed to mental health disorders than men. Depressive symptoms in women and older women have been linked to women’s poorer recovery from cardiac events, suffering from vegetative symptoms such as; slow speech, movement and extreme fatigue. These symptoms, if not assessed and dealt with early enough will extinguish any motivation and self-care the patients may have towards CR (Grace et al, 2001).
Some researchers suggest that cardiovascular disease is overlooked in women who suffer from anxiety. Women who suffer from anxiety are 75% more likely to have reduced blood flow, mirroring similar symptoms to ischemia, essentially masking the symptoms of cardiovascular disease (Paine et al, 2016). This literature is American however, and perhaps not as relevant in UK health care, however not much research has been carried out on this subject in the UK. If depression and anxiety are left untreated in women with cardiovascular disease, it puts them at high risk of recurrent cardiac events and re admissions to hospital. Lack of motivation often gets missed in primary patient assessment; awareness of individual motivations is needed for effective nursing practice. Psychologists and researchers alike explore how motivational interviewing is an essential and effective source of motivation for behavior change in patients (Pietrabissa et al, 2015).
5.0 Theme three – lack of collaboration in CR
This theme will explore the lack of collaboration in CR and how that impacts on women’s participation rates; it will give a background on the importance of collaboration in relation to CR programmes. It will look at lack of communication and patient trust in healthcare professionals, and staffing and funding in relation to collaboration in CR.
5.1 Background on the importance of collaboration
Multidisciplinary team working (MDT) allows health professionals to utilise knowledge, skills and best practice from other spectrums and disciplines of health. Eigenmann (2015) suggests that this is linked to positive patient safety outcomes and has actually helped to minimise adverse and clinical incidents. It is multifactorial with specialist cardiac rehabilitation nurses on the front line. They usually consist of a consultant cardiologist, CR nurse specialists, a dietician, cardiac physiotherapist and occasionally a clinical psychologist (British Journal of Cardiac Nursing, 2016). NHS England (2013) publicised ‘integrated care and support: our shared commitment’, this was launched for integrated care to be considered the norm, underpinned by collaborative practice. The Five Year Forward Plan (2014) offered many opportunities for MDT involvement in new care models, focusing on patient-centered care. MDT work can be limited and constricted by miscommunication; this is seen to be one of the biggest culprits of unintentional harm to patients. Seneviratine, Stone and King (2009) discuss how there is little research or published practice guidelines for MDT work in CR programmes, and this makes it difficult for health practitioners to engage fully in collaboration in a holistic manner. However this research is outdated and not contemporary, the relevance is in question and there a gap in the literature.
2. Lack of communication and patient trust
Lack of communication is one of the biggest factors for poor collaboration; it poses a huge risk to patient safety and quality of care (Norouzinia et al, 2016). Research conducted by Baker, Egan-lee, Martimianakis and Reeves (2011) suggests that although healthcare professionals are aware of correct communication techniques for collaboration, it is very rarely used in clinical practice. Barriers to communication in collaboration include a misunderstanding of professional identities, roles and responsibilities. Recognition of other areas of expertise and competence are key areas to overcoming these barriers (Steihaug et al, 2016). Nurses have the ability to create a culture that encourages values that favour collaboration in practice. Along with communication, other concepts which research has proven key to effective collaboration are; trust, respect, mutual acquaintanceship, power, patient-centeredness task characteristics and environment (Atwal and Caldwell, 2006).
Trust in nursing is essential and a core component to any practice. Patient’s experiences of trust in health care professionals are dependent on the professional’s knowledge and level of commitment (Rortveit et al, 2015). Patient- nurse relationships have effects on health outcomes and adherence to health programmes. Without adequate emotional support and effective communication, patients can not engage in a trusting relationship (Weeger and Farin, 2015). There is a significant inequality of power between the patients and healthcare professionals in CR, which effectively lead to poor and inappropriate collaboration (Steihaug et al, 2016). Research conducted by Brennan et al (2013) suggests that trust in healthcare professionals by patients is often overlooked and in order to deliver effective, holistic care, it needs to be addressed and assessed.
5.3 Staffing and funding
Over the past few years it has been evident that lack of staffing has become a major issue in collaborative teams in CR. Evidence shows that there is a significant lack of professionals who can offer psychological support to patients, no CR programmes in the UK have a support worker involved, and only a few programmes incorporated psychologists (BHF, 2018). Public health staffing across the UK has been scaled back to save money and professional organisations have warned that public health may be adversely affected if the staffing continues to be dispersed (BMJ, 2014). CR specialist nurses are required to undertake research as part of their specialist role, even though they have demanding tasks in clinical roles, making it hard to meet all patients need (Gallagher et al, 2013). Along with professional support, family support is imperative during the recovery period of a cardiac event and throughout CR period, levels of support vary from family to family, without safe staffing levels, high quality support cannot be given to family members adequately/ (Astin and Atkin, 2008).