Accessible and culturally appropriate services are needed
The National Heart Foundation of Australia and the World Health Organization recommend that all patients with cardiovascular disease are routinely referred to an appropriate cardiac rehabilitation program.1,2 Their recommendations are based on firm evidence that three-phase rehabilitation programs — inpatient, outpatient and maintenance — provide a range of short-term and long-term benefits to health and wellbeing.
Key points for success
Ensure that cultural competency is integral to the core business of an organisation and supported at all levels within the organisation (eg, employ Indigenous staff across the organisation, support cultural awareness training for non-Indigenous staff, ensure availability of and support for interpreters and cultural mentors).
Involve Aboriginal health workers and family members in the care of Aboriginal and Torres Strait Islander patients and develop flexible approaches to raising awareness of the importance of cardiac rehabilitation.
Ensure community involvement in planning, implementing and evaluating health promotion, including the development of culturally appropriate materials.
Incorporate elements of cardiac rehabilitation and secondary prevention into existing activities or set up activities that draw on existing networks within the community.
Develop and sustain partnerships between organisations (eg, a hospital providing outreach cardiac rehabilitation services through the local Aboriginal Community Controlled Health Service).
Take the specific needs of Aboriginal and Torres Strait Islander patients into consideration in planning and delivering mainstream cardiac services and develop policies and procedures to address these needs (eg, identifying Aboriginal or Torres Strait Islander status, providing culturally appropriate information on hospital discharge).
Develop a specialist education base for continuing training and support of all health professionals working in cardiac care, including Aboriginal health workers.
Although the benefits of cardiac rehabilitation are clear, only a small proportion of the people in the general population who have experienced cardiac events attend programs.3 Aboriginal and Torres Strait Islander people are even less likely to participate in cardiac rehabilitation programs than non-Indigenous Australians,3-5 despite being twice as likely to die from cardiovascular disease.6
As there is little published literature specific to cardiac rehabilitation among Aboriginal and Torres Strait Islander peoples, the National Health and Medical Research Council convened a committee to investigate barriers to effective practice and develop guidance for health professionals working in the area. In November and December 2004, the committee conducted workshops, hosted by Aboriginal Community Controlled Health Services in Darwin, Townsville and Mt Druitt (Sydney). Indigenous health professionals and consumers were asked to share their stories and make suggestions about how cardiac rehabilitation services could be made more accessible. This information contributed to the development of a practical guide for health professionals — Strengthening cardiac rehabilitation and secondary prevention for Aboriginal and Torres Strait Islander peoples: a guide for health professionals.7 The guide was tested for suitability by potential users of the manual at a workshop held in Adelaide in June 2005 and was published in September 2005.
“Not enough black faces”: Aboriginal and Torres Strait Islander people are not sufficiently involved in planning, delivering and evaluating relevant health care services. Contributing to this is a lack of training, education and support for Aboriginal health workers.
Communication and understanding: Cultural factors that are often not understood and therefore not taken into account in mainstream services include the diversity of Aboriginal and Torres Strait Islander peoples and culture; the complexity of Aboriginal law; the importance of family and community involvement; and a holistic view of health that includes the body, the land and spirituality.
Continuity of care: The process of cardiac care usually involves many different settings and people. Lack of continuity and linkages between services, in particular between mainstream and Aboriginal and Torres Strait Islander services, mean that people can miss out on important aspects of care. This is made worse when people live in remote communities and have to travel long distances to access services.
Taking the message back home: It can be difficult to maintain a healthy lifestyle back in the community, where adopting healthy behaviours may be less of a priority than meeting basic needs such as food and housing, expectations of health may be low, and there may be strong counteracting social pressures.
Self-determination and control: Health intervention programs may be implemented without appropriate consultation and community involvement from the outset. Programs are unlikely to succeed unless they build on the leadership provided by the community and on real partnership with the local community.
Addressing these barriers presents considerable challenges. No single solution can be applied, due to the diversity within the population, as well as the need to find approaches that are suitable to remote, rural and urban areas and that take into account cultural issues and staff availability. Multidisciplinary methods are therefore required2 that can be adapted to make use of the skills available in each setting while taking a standardised approach to supporting system change.
The Indigenous health sector and Indigenous health professionals are best placed to provide cardiac rehabilitation to Aboriginal and Torres Strait Islander people and should be supported to do this. However, cardiac rehabilitation is more likely to comprise a combination of both Indigenous and mainstream services (ideally a team including an Aboriginal health worker and general practitioner, with other health professionals as required). Establishing and maintaining links between individuals and organisations involved in cardiac rehabilitation is therefore fundamental to improving outcomes. Such linkages support continuity and quality of care, broaden the capacity of the health organisation, increase access to resources and help to integrate mainstream and Indigenous health services, so that it is easier for patients to move between the two systems.
At the centre of care are the patients themselves. Showing cultural respect, as well as learning from patients and their families, carers and the community, will increase understanding of how culturally competent health care can best be provided.8 For example, addressing chronic diseases together in an holistic way is more consistent with Aboriginal and Torres Strait Islander concepts of health and illness than considering single diseases or body parts. This approach can also better take into account the importance of spirituality to health and wellbeing, depression and other psychosocial factors increasing the risk of cardiovascular disease,9 and the cultural, environmental and historical risk conditions that place Aboriginal and Torres Strait Islander people at greater risk of the onset and complications of chronic diseases.
There is considerable activity under way across Australia to improve the cardiovascular health of Aboriginal and Torres Strait Islander peoples. Systems are in place to assist health services to improve preventive and coordinated care for these patients10 and there is a growing knowledge base to support improved practice. However, continuing efforts are needed across all health care settings, at both individual and organisational levels, to implement sustainable changes that will ensure that appropriate cardiac rehabilitation services are available for Aboriginal and Torres Strait Islander Australians.
- 1. World Health Organization. Report of expert committee on rehabilitation after cardiovascular disease. Geneva: WHO, 1993.(WHO Technical Report Series No. 831.)
- 2. National Heart Foundation of Australia, Australian Cardiac Rehabilitation Association. Recommended framework for cardiac rehabilitation ‘04. National Heart Foundation of Australia, 2004. Available at: http://www.heartfoundation.com.au/downloads/CR_04_Rec_Final.pdf. (accessed Apr 2006).
- 3. Scott IA, Lindsay KA, Harden HE. Utilisation of outpatient cardiac rehabilitation in Queensland. Med J Aust 2003; 179: 341-345. <MJA full text>
- 4. Cunningham J. Diagnostic and therapeutic procedures among Australian hospital patients identified as indigenous. Med J Aust 2002; 176: 58-62. <MJA full text>
- 5. Shepherd F, Battye K, Chalmers E. Improving access to cardiac rehabilitation for remote Indigenous clients. Aust N Z J Public Health 2003; 27: 632-636.
- 6. Australian Bureau of Statistics, Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples. Canberra: ABS, AIHW, 2003. (ABS Catalogue No. 4704.0; AIHW Catalogue No. IHW11.)
- 7. National Health and Medical Research Council. Strengthening cardiac rehabilitation and secondary prevention for Aboriginal and Torres Strait Islander peoples: a guide for health professionals. Canberra: NHMRC, 2005. Available at: http://www.nhmrc.gov.au/publications/synopses/ind1syn.htm (accessed Mar 2006).
- 8. Australian Health Ministers’ Advisory Council. Cultural respect framework for Aboriginal and Torres Strait Islander Health 2004–2009. Adelaide: Department of Health, 2004.
- 9. Bunker SJ, Colquhoun DM, Esler MD. “Stress” and coronary heart disease: psychosocial risk factors. National Heart Foundation of Australia position statement update. Med J Aust 2003; 178: 272–276. <MJA full text>
- 10. Mayers N, Couzos S. Towards health equity through an adult health check for Aboriginal and Torres Strait Islander people. Med J Aust 2004; 181: 531–532. <MJA full text>
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