By Theresa M. Beckie, PhD, MN, RN, FAHA, FAAN
Consider Thomas, a 64-year-old male who was diagnosed with a heart attack and subsequently underwent coronary bypass surgery. Melanie is a 59-year-old woman, who also had a heart attack followed by coronary bypass surgery. Thomas was referred to, and completed, 36 sessions of cardiac rehabilitation (CR). However, Melanie, who was referred as well, never attended a single session. This scenario is all too common in the CR community. Why are women less likely to enroll in or complete CR, despite having just as many – or more – health benefits to gain from it as men? We know there are several barriers for women – transportation challenges, financial constraints, family responsibilities, depression/anxiety and others – some of which are modifiable. Armed with this information, what gaps in care delivery can we identify to reduce some of the sex-based disparities? What ways can we tailor CR for women that incorporate sex and gender-specific components to improve their participation?
CR Specifically for Women
Conduct a gender-specific assessment of risks to begin the process of individualizing CR for women. The prevalence of traditional (obesity, dyslipidemia, hypertension) and non-traditional female-specific factors (polycystic ovary syndrome, history of gestational diabetes, history of pregnancy related complications, autoimmune diseases) have unfortunately increased over the last decade. These worsening risk factors have triggered an alarming increase in hospitalizations for heart attack among women younger than 45 years, particularly within racial and ethnic minority groups.
Thoughtfully tailoring our assessments of women also includes evaluation for anxiety, depression and social isolation because these psychosocial risk factors interfere with motivation for behavior change and adherence to lifestyle interventions. Beyond musculoskeletal issues that can interfere with the exercise prescription, women should be queried about their preferred leisure time activity and mode of exercise to foster maintenance of physical activity after CR. Women who are overweight or obese tend to know they struggle with weight management. Perhaps we could individualize our care of these women by being sensitive to their struggles and either have them step on the scale in private or perhaps only at every other CR session rather than at each session.
Pay careful attention to health literacy and numeracy. Our education materials can make use of a variety of modes of delivery including videos, printed materials written at a 6th grade level, large font and generous use of illustrations. Communication should acknowledge and incorporate cultural beliefs; and visual images should include familiar people, settings and symbols. When providing patient education, it’s helpful to integrate an emotional story with scientific evidence to move people along the stages of behavior change. A diverse CR workforce is also beneficial for meeting the needs of diverse women in CR.
Educate all health team members, from the medical director to volunteers serving women in CR, with adequate sex- and gender-based education. That includes education on the risk factors predominantly in women, cardiovascular disease presentation in women and the unique challenges that women face with behavior change. A critical element for tailoring CR for women is understanding the theories about what influences health behaviors as well as gaining skill in implementing behavior change techniques that will guide women to more healthy lifestyles. Understanding that not all women who begin CR are ready and willing to change their behavior to become healthier will become clearer by learning about the stages of behavior change. Frequently assess for readiness to change behavior, raising self-efficacy and confidence and letting women articulate their own reasons for wanting to change. Educating women that most cardiovascular disease is preventable and manageable through positive lifestyle behaviors such as physical activity, healthy eating, not smoking, limiting alcohol intake, sleeping seven hours of sleep each night and routinely practicing stress reduction may give them a greater sense of control over their own health.
Consider the social determinants of health. Disparities in cardiovascular disease between Black and White women arise from complex differences in clinical and social determinants, including health behaviors, psychosocial stressors and socioeconomic position. Because social determinants of health profoundly influence women’s ability to optimize their cardiovascular health, we can tailor CR by providing low-cost facilities, resources or activities when they are not in CR sessions that improve their health behaviors. It’s important, for example, to inquire if women can afford their prescription medications. We can also tailor CR for women by understanding dress customs, norms about sweating and eating patterns. Additionally, we can personalize our modes of exercise and nutrition counseling to incorporate diverse women’s values, preferences and goals.
Employ an empathetic counseling style. This approach seems to facilitate change, and its absence may deter change and instead lead to high dropout rates and poor outcomes. Motivational interviewing can help women discover their own reasons for change.
Examining women’s ambivalence about changing their behavior can ultimately lead to better self-management, which is essential for preparing them for independence after completing a Phase II program. While a milestone, graduation from Phase II should not be perceived as the end but rather the beginning of their new identity as someone with heart disease who is thriving with a healthy lifestyle.
Remember to attend to psychosocial issues. Depression is roughly twice as prevalent in women than men and carries an increased risk of adverse cardiovascular outcomes. Identifying and addressing psychological and psychosocial issues among women is helpful because they comprise barriers for adherence to CR and lifestyle change. Psychosocial issues (anxiety, depression, loneliness, poor relationships) also contribute to risks for future cardiac events. Fortunately, physical activity has been shown to reduce psychosocial distress as well as benefit the heart and brain. Group discussions with women experiencing similar psychosocial issues can be beneficial for reducing their fears, uncertainties and anxiety.
Tailor nutrition counseling to be culturally appropriate and easy to understand. Women want to eat healthier, but are confused by mixed messages in the media, on the internet and from their peers. While they desire clear advice, it needs to be simple and specific.
Related to nutrition, women who were sedentary prior to beginning exercise training in CR often believe that now that they have started exercising, they can eat more food. Women may need to be reminded that the exercise conducted in CR will not lead to substantial weight loss without changing dietary habits as well.
Offer a variety of options. Tailoring exercise modalities for women may be difficult in a facility-based CR program where exercise equipment is typically comprised of treadmills, bicycles, recumbent bicycles, elliptical trainers and rowing machines – equipment many women will not have in their homes. This makes the transition of physical activity in CR to the home or community environment after program completion especially difficult and presents the risk that exercise will not continue. If possible, it would be helpful to ask women if they would like to participate in some classes in the facility that include dance, yoga, Zumba or some other physical activity they would enjoy more than treadmill walking. Providing other physical activity choices that account for musculoskeletal issues may also be beneficial for some women.
Offer women-exclusive classes, if financially feasible. Providing community options for women to gain physical activity between session days and after CR completion, such as water aerobics and pickle ball, will foster transition to life-long physical activity more easily. Additionally, some women enroll in CR with a very physically active lifestyle. It’s important to quickly get them safely back to their previous level to avoid having them drop out because they felt held back. We need to tailor exercise training to the varied abilities and needs of women. If needed, before they drop out, transition them to appropriate community-based facilities.
Provide women with reputable resources for their health information. Doing so is critical to dispel myths and predatory advertisements they may encounter. Here are a few useful options:
- WomenHeart.org: The National Coalition for Women with Heart disease
- Heart.org: The American Heart Association
- Cardiosmart.org: The American College of Cardiology.
Dr. Beckie is a professor in the College of Nursing and College of Medicine at the University of South Florida.