By Denise Williams | News & Views

• How can I support a Muslim participant whose fasting period for Ramadan conflicts with cardiac rehabilitation (CR) business hours?
• How can I overcome the language barrier to alleviate a Spanish speaker’s misunderstanding and fear of treatment?
• How can I convince my Asian-American patient that a “Mediterranean” diet is best for them?

If you’ve ever asked yourself any of these questions, you’re already on the right track to facilitating the change needed for a more inclusive CR environment. But what more can be done to reshape the practice landscape to not only bring more patients from different ethnic backgrounds to cardiac rehabilitation (CR), but to improve their outcomes via culturally competent care?

The literature bears out the need for both, according to Paul Oh, MD, MSC, FRCPC, FACP, FAACVPR, who partnered with three colleagues at University Health Network — part of the Toronto Rehabilitation Institute — to host an AACVPR live webinar on the topic this past summer. It’s fitting that the presentation took place against the backdrop of a Canadian city that, with 200 ethnic groups speaking more than 140 different languages, represents the depth of North America’s increasingly diverse makeup.

During the session, which was recorded and is now available for viewing in the AACVPR Learning Center, Dr. Oh references research findings reported in publications including the Journal of Cardiopulmonary Rehabilitation and Prevention and the Journal of the American Heart Association. The evidence synthesizes the struggles that cultural minorities face in health care settings and conclusively shows that these patient populations participate in CR at a markedly lower rate than non-minorities. And although lower socioeconomic status is also associated with poor enrollment of CR, the pattern persists across all income levels.

Even when enrollment is achieved, the science suggests, the challenges do not end there. Language barriers and communication glitches surface, exacerbated by unfamiliarity with the U.S. health care system and/or fear of certain interventions. The detrimental impact of these factors, the research cited by Dr. Oh conveys, is reflected in subpar access to care, reduced treatment compliance, and less-than-optimal outcomes.

Traditional Medicines, Exercise, and Diets

When working to reverse this trajectory in affected patient populations, Dr. Oh’s personal experience suggests that CR professionals should focus less on the perceived “deficits” of a people and more on the strengths — including rich cultural traditions. Rather than dismissing them, he believes in recognizing and respecting the role of family and deep-seated connections to the land and ancestral heritage, as well as time-honored practices such as yoga, meditation, mindfulness, and traditional medicine disciplines such as Chinese acupuncture and the Indian practice of Ayurveda.

Dr. Oh is joined for the presentation by registered dietitian Fatim Ajwani, RD, who turns the focus to traditional food choices in multicultural communities. She delves into the role of regimens such as the African Heritage Food Pyramid and the Mediterranean Diet with respect to CR participants — explaining, for example, how white rice, a culinary staple for many cultures, can still be enjoyed as part of heart-healthy eating. Ajwani also discusses the benefits of inviting family members of CR participants to take part in educational programming; and she directs CR professionals to resources they can use, including PEN (Practice Evidence-based Nutrition) and Oldways guides, along with various online resources.

Approach to Education

Also adding to the broader conversation is physiotherapist and researcher Gabriela L. Melo Ghisi, BSC, PT, MSC, PhD, who lists the main principles of multicultural CR delivery, as supported by the literature. Those key learnings include, but are not limited to, personalized and purpose-driven rehab, anchored using culturally relevant examples; practical but culturally relevant activities; and clear communication and transparency. Dr. Ghisi also speaks to the importance of delivering patient education within CR in the context that culturally and linguistically diverse populations prefer. For example, she cites research indicating that the preferred learning format for participants from India is animated video, whereas patients from China would rather receive information via phone technology and those from Latin America tend to gravitate toward thick booklets that they can pore over at home. Personalizing education based on language preference, socioeconomic status, demographics, and more is essential, explains Dr. Ghisi, who champions the use of questionnaires as one way to understand patients’ needs.

Additional perspective comes from Crystal Aultman, MSC, BED, RKIN, a kinesiologist, researcher, and educator who warns against the pitfalls of trying to generalize messaging to multicultural audiences. It’s important to take a patient-centered approach, she notes, adapting resources so that they are relatable to the target patient. This commitment cascades from translating educational materials into different languages, Aultman shares, all the way down to the kind of images that are selected to appear in those materials. It’s even having an awareness, when determining how to convey messages, that not everyone has the same level of access and technical savvy.

All said, the four co-presenters are unified in their call for CR professionals to be aware of cross-cultural issues, be open to adapting as needed to reach different types of patients, and be attentive to their needs in order to better tear down racial and ethnic disparities in health and health care.

For more in-depth insight into this topic — and the opportunity to earn AACVPR and ANCC credit — visit the Learning Center for access to the recorded webinar “Multi-Cultural and Multi-lingual Delivery of Cardiovascular and Pulmonary Rehabilitation.” The on-demand webinar is available at no charge for AACVPR members.