To the Editor: Engaging patients in cardiac rehabilitation (CR), a program of secondary prevention measures, is crucial to improving outcomes after myocardial infarct.1 Rates of participation in CR by Aboriginal and Torres Strait Islander (hereafter Aboriginal) people are extremely low.2,3
We conducted a qualitative study on barriers to CR use from November 2007 to March 2008 with 15 Aboriginal cardiac patients (seven women and eight men, aged 31–74 years) living in Perth, Western Australia. Six had participated in some outpatient CR sessions; nine had not. Participants were interviewed face-to-face using a semistructured interview guide, with questions exploring their views and experiences of CR, barriers to use and suggestions for improvement.
Recurring themes included challenges associated with extended family responsibilities and sociocultural inappropriateness of the program. These themes, along with less commonly discussed issues of poor knowledge of CR and the connection between colonialism and health services, reflect findings from previous studies.2,4,5 However, two new themes — media heart health messages and the younger age of the affected Aboriginal population — highlight further factors influencing participation (Box 1).
We found that some patients feel constantly reminded of, and therefore come to expect, poor health outcomes, due to dire statistics repeated in the media. While the dominant theme in the Australian media of Aboriginal fatality and futility has been discussed,6 heart health messages are often disempowering, negatively affecting motivation to engage with health programs. This is likely reinforced by regular attendance at funerals for Aboriginal people, who die very prematurely from cardiovascular disease (CVD). This highlights the need for a shift in media and public health campaigns from “shock” headlines and statistics to a focus on strengths and successes, inspiring the groups involved and supporting them to make changes.
Younger Aboriginal participants also spoke about feeling isolated in CR sessions among non-Aboriginal people who were 20–30 years older than them. The age demographic of CR program attendees generally reflects CVD epidemiology in the wider community, but the burden of CVD occurs at much younger ages in the Aboriginal population.7 This widening differential7 demands rethinking of how CR should work for this very different demographic group (Box 2). CR programs addressing the needs of younger people may improve receptivity and opportunities for primary prevention in the family and broader community.
Although these two themes were reported by a small number of patients, further research into issues for Aboriginal patients with CVD is warranted. Importantly, it will contribute to understanding of how younger Aboriginal people think about their health, and feel motivated and supported by wider society to do something about it.
1 Quotes from Aboriginal cardiac patients reflecting barriers to participating in cardiac rehabilitation (CR) programs
... even with the newspaper, every second page has something to do with the heart ... Turn the radio on, “oh, there’s this new survey about heart conditions”. And I don’t want to know about it! Don’t tell me! ... I don’t want to be told the negatives ... it’s all you used to hear of all the stories regarding the heart. (Aboriginal patient 10)
I didn’t like it [the CR program] because everybody else was at least twice my age. I was like the youngest one there and it was just a turn-off for me ... I’d feel more comfortable if people my own age were there for a start, you know? (Aboriginal patient 11)
Aboriginal people don’t use [CR and health services] ... as a matter of course because the discrimination that took place in Australia against Aboriginal people ... instead it remained in the psyche of the Aboriginal people that mainstream services are only there for other people. They’re not there for you. (Aboriginal patient 9)
2 Recommendations from Aboriginal patients for improving cardiac rehabilitation (CR) programs
Offer CR programs out of working hours
Have opportunistic drop-in sessions rather than allocated times
Make CR programs more appealing to younger clients
Hold CR programs in Aboriginal community health centres
Build trust and relationships with patients (the importance of yarning)
Develop programs for use at home by the whole family
Tailor lifestyle and diet advice to modern Aboriginal family situations
Have both male and female Aboriginal health staff delivering CR if possible
Target youth with heart health education messages
Refocus public health messages away from being negative and fear-based to being positive and strength-based
Encourage Aboriginal patients to attend CR sessions together (buddy system)