Sherry Grace
Can we encourage more women to participate in cardiac rehabilitation? And if so, what are the attributes of the most enticing programs? York University Faculty of Health Professor Sherry Grace posed these vital questions, in collaboration with University Health Network (UHN), and with funding from the Heart and Stroke Foundation of Ontario. To answer these queries, 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 favor 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 counseling, 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,” Grace explains.
Women at particular risk for death
Cardiovascular disease (heart disease and stroke) is the number one cause of death for Canadian women, according to the Heart and Stroke Foundation of Canada. Furthermore, 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, and 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 per cent. 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.
Cardiac rehab holds promise for addressing the risks women face, post stroke or heart attack
However, the majority of women who have had a coronary event are not using rehab programs. A 2014 study, also by Grace’s group, showed that 39 per cent of women were participating in rehab, compared with 45 per cent of men. Why? Group exercising, particularly in a mixed-sex environment, is unattractive to 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.
Research has shown that participation in rehab programs can reduce mortality by 26 percent. But the majority of women who’ve had a heart attack or stroke are not using the programs.
Researchers studied in three different models of rehab for women
This is the context of 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; and
- Home-based rehab.
Grace and her team suspected that both program adherence and hence outcomes would be significantly greater with the women-only program.
Randomized controlled trial ‘gold standard’ for eliminating bias
Participants in the study were encouraged to accumulate at least 150 minutes of exercise per week at their target heart rate, exercising on a stationary bicycle, treadmill or walking
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. Randomized controlled trials are considered the most rigorous way of determining whether a cause-and-effect relationship exists between treatment and outcome.
In this study, recruitment of female patients took place from 2009 to2013, with patient follow-up six months after enrolment in the rehab program. Patients were recruited from six inpatient and outpatient cardiac units in the Greater Toronto area, and then randomized and referred to one of the above-noted three program models.
A total of 169 patients participated. There were three rehab sites involved in the trial, each offering all three models of rehab. 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.
Findings show women only adhered to half of the sessions, regardless of program model
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 behaviors and quality of life from pre- to post-program. “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,” Grace explains.
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.
Although these results don’t clearly favor 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 press for more research on 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.
The first article, “Cardiac Rehabilitation Program Adherence and Functional Capacity Among Women: A Randomized Controlled Trial,” was published in the Mayo Clinic Proceedings (February 2016). The second article, “Women’s health behaviours and psychosocial well-being by cardiac rehabilitation program model: A randomized controlled trial” was published in the Canadian Journal of Cardiology (August, 2016). For more information about Grace’s work, visit her faculty profile.
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By Megan Mueller, manager, research communications, Office of the Vice-President Research & Innovation, muellerm@yorku.ca