Can we encourage more women to participate in cardiac rehabilitation? And if so, what are the attributes of the most enticing programs?
Heart & Stroke researcher Dr. Sherry Grace, of York University in Toronto, posed these vital questions, in collaboration with University Health Network (UHN). To find the answers, she studied women’s adherence to traditional co-ed cardiac rehab versus women-only programs.
The results, published in Mayo Clinic Proceedings and the Canadian Journal of Cardiology last year, don’t clearly favour any single model of rehab; women only go to about half of prescribed sessions of any type of program.
This suggests that other proven strategies, such as self-monitoring, action planning and tailored counselling, should be used to ensure that women attend more of their life-saving rehab sessions.
“There have been calls to deliver women-only cardiac rehab programs to engage more patients to participate, but we are among the first to test if offering these programs will truly address women’s barriers to attending,” explains Dr. Grace, a professor in York's faculty of health.
Women at risk
Heart disease and stroke is the number one killer of women worldwide.
Women who have had an acute coronary event, such as a heart attack, often have a more complicated recovery than men due to lower physical function, having many additional health problems including mental illness. They may be more likely to die in the first year of recovery.
Cardiac rehab – meaning, exercise, education, etc. – is proven to address this risk. Research has already shown that participation in rehab reduces death by 26%. Participation also reduces the need for re-hospitalization and repeat heart procedures, which saves healthcare dollars, when compared to care that lacks a rehab component.
However, the majority of women who have had a coronary event are not using rehab programs. A 2014 study, also by Dr. Grace’s group, showed that 39% of women were participating in rehab, compared with 45% of men.
Why? Group exercising, particularly in a mixed-sex environment, is unattractive to some women due to fear and embarrassment, a lack of experience, low levels of functional ability and self-consciousness regarding body image.
Given women’s low uptake of rehab programs and the reasons why this is happening, many have suggested that alternatives, such as home-based models to overcome distance/transportation barriers and time constraints, and women-only models might work better for women.
Three models tested
This is the context of Dr. Grace’s research. What’s unique about her work is that it’s the first time that rehab program adherence and outcomes were compared in all three of the available models:
- co-ed rehab
- women-only rehab
- home-based rehab.
Dr. Grace and her team suspected that both program adherence and outcomes would be significantly greater with the women-only program.
The researchers undertook a randomized controlled trial, a type of scientific experiment that aims to reduce bias when testing a new treatment. Participants in the trial are randomly selected – in this way, it’s similar to tossing a coin.
In this study, recruitment of women patients took place from 2009 to 2013, with followup six months after enrolment in the rehab program. Patients were referred to one of the three program models.
A total of 169 patients participated. Participants attending on-site rehab programs exercised in the facility one to two times a week for up to one hour. Participants in the home program were phoned weekly or biweekly, and given standard education materials that were reviewed on the phone with program staff. They also discussed their progress with the exercise routine.
We are among the first to test if offering these programs will truly address women’s barriers.
No significant differences
Ninety-six of the 169 patients completed their rehab program. There were no significant differences in the percentage of rehab sessions attended whether patients were in the women-only or home-based group. In other words, no one group was adhering to the rehab program more than any other group.
In terms of outcomes, participants achieved a significant improvement in functional capacity, heart-health behaviours and quality of life. “This is a good outcome, but there were no differences between the groups of patients. Simply put, the women-only or home-based programs were not leading to better outcomes in patients,” Dr. Grace explains.
Although these results don’t clearly favour any single model of rehab, there was some suggestion that the women-only program was better for women’s mental health. Many women with heart disease suffer from depression and anxiety, and this can lead to poorer outcomes for them.
Looking ahead, the researchers want to see more investigation of alternative program models. They also suggest that proven strategies such as self-monitoring, action planning and tailored counseling, should be applied more widely to ensure that patients can get the most of their rehab.
This article first appeared in Brainstorm, a special issue of YFile, York University’s journal of record.
- Learn more about women and heart disease in the Heart & Stroke 2018 Heart Report.