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Women utilise cardiac rehabilitation (CR) significantly less than men. Gender-tailored CR improves adherence and mental health outcomes when compared to traditional programs. This study ascertained the availability of women-only (W-O) CR classes globally.
Methods
In this cross-sectional study, an online survey was administered to CR programs globally, assessing delivery of W-O classes, among other program characteristics. Univariate tests were performed to compare provision of W-O CR by program characteristics.
Results
Data were collected in 93/111 countries with CR (83.8% country response rate); 1,082 surveys (32.1% program response rate) were initiated. Globally, 38 (40.9%; range 1.2–100% of programs/country) countries and 110 (11.8%) programs offered W-O CR. Women-Only CR was offered in 55 (7.4%) programs in high-income countries, versus 55 (16.4%) programs in low- and middle-income countries (p<0.001); it was offered most commonly in the Eastern Mediterranean region (n=5, 55.6%; p=0.22). Programs that offered W-O CR were more often located in an academic or tertiary facility, served more patients/year, offered more components, treated more patients/session, offered alternative forms of exercise, had more staff (including cardiologists, dietitians, and administrative assistants, but not mental health care professionals), and perceived space and human resources to be less of a barrier to delivery than programs not offering W-O CR (all p<0.05).
Conclusion
Women-Only CR was not commonly offered. Only larger, well-resourced programs seem to have the capacity to offer it, so expanding delivery may require exploiting low-cost, less human resource-intensive approaches such as online peer support.
Cardiovascular disease (CVD) is one of the leading burdens of disease and disability in women globally, and it is growing. Women with CVD often have poorer quality of life than men [
]. They are less likely to receive evidence-based management, including revascularisation, preventive medications, and cardiac rehabilitation (CR), such that they often have poorer outcomes [
Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR).
Gender differences in presentation, management and inhospital outcome in patients with ST-segment elevation myocardial infarction: Data from 5000 patients included in the ORBI prospective French regional registry.
Impact of age, gender and indigenous status on access to diagnostic coronary angiography for patients presenting with non-ST segment elevation acute coronary syndromes in Australia.
Reasons for this persistent under-representation of women in CR globally are quite well-understood. Strategies to improve women's CR utilisation have been identified [
]. However, it is not known how commonly W-O CR is offered globally. Therefore, the objectives of this study were to characterise (a) delivery of W-O CR classes by country, and (b) the nature of programs that are more likely to offer W-O CR to understand factors associated with its provision.
Methods
Design and Procedure
This was a cross-sectional study, presenting secondary analysis of the first global survey of CR programs. Detailed methods are reported elsewhere below [
], but are summarised briefly. The study protocol was approved by York University's Office of Research Ethics (Toronto, Canada) and Mayo Clinic's Institutional Review Board (Rochester, United States). Participating CR centres provided informed consent electronically.
First, a list of all countries globally was compiled, by cross-referencing several key sources [
Next, which countries offered any CR was established. Several strategies and sources were used: (a) a previously-published review on global availability of CR [
]; and (b) a search of Google Scholar, among other databases, for articles or abstracts on CR. For countries where no CR was in evidence, the authors searched the internet and queried key informants/experts via the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) to verify.
Finally, CR programs in each country where CR existed were surveyed. The total number of programs and contacts to reach those programs for data collection were sought from cardiac societies, and if not, from CR experts. The survey was then emailed to all identified programs, with repeat mailings to non-responders. Contacts were sent two email reminders. Data collection occurred from February 2016 to July 2017 via online survey administered through REDCap.
Sample
The sample was comprised of all CR programs world-wide offering Phase II (i.e., post-acute care discharge) services. Programs that offered: (1) initial assessment, (2) structured exercise, and (3) at least one other strategy to control CV risk factors, were included. All CR programs were contacted in countries with ≤350 programs; otherwise, a random subsample of 250 were contacted (this was only the case for the United States). The random subsample was generated electronically using the simple random sample module in (SAS institute, Cary, NC, USA).
]. Central to this paper, programs were asked to report their country and whether they offered “women-only classes” in any model (yes/no).
Program characteristics were also assessed, including: location, wait times, source of funding, service delivery cost estimates, annual patient volumes, number of program sessions (dose), whether the program offers alternative forms of exercise (e.g., yoga, dance) or CR in alternative settings (i.e. home-based, community-based), type and number of professionals on CR team, and barriers to delivery (e.g., space, equipment, financial and human resources; rated on a 5-point Likert scale). A composite measure of 11 internationally-agreed core components by CR societies (e.g., initial assessment, exercise training, patient education, management of CV risk factors, stress management, tobacco cessation intervention/counselling) was also computed [
Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery.
AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services.
Australian Cardiovascular Health and Rehabilitation Association (ACRA) core components of cardiovascular disease secondary prevention and cardiac rehabilitation 2014.
]. Descriptive statistics were used to characterise which countries offered W-O classes, and the proportion of programs in each country offering it. Availability was compared by WHO region and country income classification using generalised linear mixed models to account for clustering of programs. Finally, program characteristics (independent variables) associated with provision of W-O classes (dependent variable) were tested using chi-square or independent samples t-tests as applicable.
], there were 111/203 (54.7%) countries in the world with CR, of which data were collected in 93 (83.8% country response rate). The number of responding programs/country (mean=9.7±17.3 surveys initiated), and program response rate by country (32.1% globally) are also reported elsewhere [
As shown in Figure 1, 38 (40.9%) countries with CR offered W-O CR globally (18.7% of all countries globally). Of those offering W-O CR, in six countries (10.5%; Afghanistan, Bahrain, Belarus, Bosnia and Herzegovina, Chile, Qatar) all CR programs offered it (but there was only one program in four of these countries), and in another three countries W-O CR was offered in ≥50% of programs (Iran, Pakistan, Greece). In countries that delivered it, on average 32.1±33.8 % (median=1; Q25–Q75=1–3) of programs offered it; with a range from 1.2% of programs offering W-O CR in Australia to 100% in the countries listed above (Table 1).
Figure 1Countries offering women-only cardiac rehabilitation classes, and proportion of programs offering it.
Random sub-sample of only 250 programs surveyed. Therefore, proportion of programs offering women-only classes should not be over-interpreted.
HIC
65/2,632 (2.5%)
4 (6.2%)
Uruguay
HIC
5/12 (41.7%)
1 (20.0%)
Regional total (mean %)
19 (9.4%)
Eastern Mediterranean
Afghanistan
LIC
1/1 (100.0%)
1 (100.0%)
Bahrain
HIC
1/1 (100.0%)
1 (100.0%)
Iran
UMI
14/34 (41.2%)
7 (50.0%)
Pakistan
LMI
2/4 (50.0%)
1 (50.0%)
Qatar
HIC
1/1 (100.0%)
1 (100.0%)
Regional total (mean %)
11 (80.0%)
Europe
Austria
HIC
5/26 (19.2%)
1 (20.0%)
Belarus
UMI
1/5 (20.0%)
1 (100.0%)
Bosnia And Herzegovina
UMI
1/1 (100.0%)
1 (100.0%)
Czech Republic
HIC
6/15 (40.0%)
1 (16.7%)
Finland
HIC
11/25 (44.0%)
1 (9.1%)
France
HIC
16/130 (12.3%)
1 (6.3%)
Georgia
UMI
13/17 (76.5%)
1 (7.7%)
Germany
HIC
34/120 (28.3%)
5 (14.7%)
Greece
HIC
4/4 (100.0%)
3 (75.0%)
Hungary
HIC
20/33 (60.6%)
2 (10.0%)
Israel
HIC
6/22 (27.3%)
1 (16.7%)
Italy
HIC
70/221 (31.7%)
12 (17.1%)
Lithuania
HIC
9/25 (36.0%)
2 (22.2%)
Poland
HIC
21/56 (37.5%)
1 (4.8%)
Portugal
HIC
21/23 (91.3%)
1 (4.8%)
Serbia
UMI
2/2 (100.0%)
1 (50.0%)
Spain
HIC
47/87 (54.0%)
3 (6.4%)
Turkey
UMI
9/10 (90.0%)
4 (44.4%)
United Kingdom
HIC
83/296 (28.0%)
3 (3.6%)
Regional total (mean %)
45 (32.6%)
South-East Asia
India
LMI
18/23 (78.3%)
2 (11.1%)
Indonesia
LMI
10/13 (76.9%)
1 (10.0%)
Regional total (mean %)
3 (10.6%)
Western Pacific
Australia
HIC
85/314 (27.1%)
1 (1.2%)
China
UMI
83/216 (38.4%)
25 (30.1%)
Malaysia
UMI
4/6 (66.7%)
1 (25.0%)
New Zealand
HIC
27/43 (62.8%)
2 (7.4%)
Regional total (mean %)
29 (15.9%)
Global total (mean %)
848/4749 (17.9%)
110 (13.0%)
Abbreviations: HIC, high-income country; UMI, upper-middle income country; LMI, lower-middle income country; LIC, Low-income country, WHO, World Health Organization.
a Random sub-sample of only 250 programs surveyed. Therefore, proportion of programs offering women-only classes should not be over-interpreted.
By WHO region (Figure 2), provision of W-O CR was highest in Eastern Mediterranean countries (EMR; n=5, 55.6%) as well as Europe (n=19, 46.3%), and lowest in Africa (n=1, 20.0%; p=0.22). Women-Only CR was offered in 22 (46.8%) high-income countries (HICs), versus 16 (34.0%) low- and middle-income countries (LMICs; p<0.001; in 12 [40.0%] upper-middle income, 3 [20.0%] lower-middle income, and 1 [50.0%] low-income country).
Figure 2Percentage of countries offering women-only classes by WHO region.
Women-Only CR was offered in 110 (11.8%) programs globally (Table 1). As reported elsewhere, provision of W-O CR was highest among programs in the EMR (p<0.01). In HICs, W-O CR was offered in 55/747 (7.4%) programs, versus 55/335 (16.4%) programs in LMICs (p=0.07; 50/279 [17.9%] in upper-middle income, 4/54 [7.4%] programs in lower-middle income, and 1/2 [50.0%] programs in low-income countries).
Factors Associated with Program Delivery of W-O CR
Characteristics of CR programs offering W-O CR are shown in Table 2. Factors associated with W-O CR provision are also shown. Univariate analysis showed that offering W-O CR was significantly greater with each of the following: being situated in an academic/tertiary facility, serving a greater number of patients per year, treating more patients per exercise session, offering more core components, having telemetry, offering alternative forms of exercise (e.g, dance, yoga, tai chi), having more staff (including cardiologists, dietitians, non-physiotherapist exercise professionals, and administrative assistants), and perceiving safety and human resources as less of a barrier to delivery, when compared to programs that do not offer W-O CR.
Table 2Characteristics of programs with women-only classes, and association with offering such classes.
Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery.
AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services.
Australian Cardiovascular Health and Rehabilitation Association (ACRA) core components of cardiovascular disease secondary prevention and cardiac rehabilitation 2014.
] were considered: initial assessment, risk assessment/stratification, exercise training, patient education, management of CV risk factors, nutrition counselling, stress management, smoking cessation, vocational counselling/return-to-work, end-of-program re-assessment and communication with primary care.
c Alternative forms of exercise, such as yoga, dance or tai-chi
d Combination of kinesiologists, exercise specialists, exercise physiologists and/or biokinetists
e Combination of psychologist, psychiatrist and/or social worker
f i.e., cardiologist, physiatrist, sports medicine physician, nurse/practitioner, physiotherapist, exercise specialist/kinesiologist, psychiatrist/psychologist/social worker, dietitian, pharmacist, community health worker, administrative assistant/secretary, other; part-time staff were counted as 0.5.
g Scores range from 1 (this is definitely not an issue) to 5 (this is a major issue).
]. Nevertheless, only approximately one of five of countries globally offer W-O CR, with just over 100 programs offering at least some W-O classes. There was significant regional variation in the proportion of programs delivering it, with it being most commonly-offered in the EMR (although this should be interpreted with caution as the sample size was small in the EMR); this is likely attributable to religious and cultural values in the region [
]. W-O classes were not commonly offered in HICs despite greater availability of resources. For example, in Australia only 1% of programs offered W-O classes.
Programs offering W-O classes appeared to have the capacity to do so because they were larger, more well-resourced programs. For instance, they were more often in academic centres, treated more patients, were more comprehensive, and had less space and human resource constraints. It was found that the programs offering W-O CR more often offered alternative forms of exercise, which is in accordance with women's preferences for dance and yoga, for example [
]. While programs offering W-O classes had more staff, it was discouraging that they did not have more mental health professionals on staff, considering the high and hazardous burden of depression in women with CVD [
]. First, some programs may not have been identified; therefore, availability of W-O CR could be under-estimated. Indeed, we were unable to collect data in 18 countries presumed to have CR, and assumed that they did not offer W-O CR. On the other hand, although a high response rate at the country-level of 85% was achieved, the response rate among programs within countries was only 1/3, and hence there may be bias, with more established/larger programs (which may be more likely to offer W-O CR as identified here, and also have more staff and hence capacity to complete the survey) represented in the sample. Therefore, there is likely some error associated with estimates of W-O CR availability.
Other limitations relate to design and analyses. Causal conclusions cannot be drawn. This was the first examination of factors related to delivery of W-O CR, and therefore further research is needed to verify the findings, including direction of effect. Due to the exploratory nature of the analyses to ascertain characteristics of programs that are more likely to offer W-O CR, multiple comparisons were performed, which would have increased error.
There are also measurement issues. The survey was by self-report, and respondents may have responded in a socially desirable manner, thus inflating reported rates of W-O CR delivery. Second, the survey queried offering W-O “classes”; we did not ask about full W-O “programs” (nor did we ask whether the W-O content was tailored to women's needs and preferences [
], or comprised solely single-sex services of the same content as the traditional programs). The rates of W-O CR delivery would likely be lower if delivery of W-O programs were assessed. This is an important area for future research. In addition, there is a need to know more about what, exactly, programs are delivering in their W-O classes (and programs), but it does seem that alternative exercise modalities and settings are being exploited. Are programs tailoring education session content or offering a few “women-tailored” sessions per program (e.g., discussion of comorbid conditions and CV risk factors more common in women, such as depression) [
], offering W-O education and/or exercise sessions only, offering exercise modalities that are preferred by women (e.g., dance, aerobics; i.e., cause less pain and fatigue such as yoga and aquabics) [
], or other program modifications to meet women's needs and preferences (e.g., early contacts to increase enrolment, peer support, more emotional support/psychosocial services)?
There are other important areas for further study. It is unknown how many W-O sessions are offered to patients at these programs, and if there is sufficient choice in terms of time offered for women to take advantage of the sessions while fulfilling their multiple roles [
]. It would also be important to understand whether there is sufficient space for separate change rooms in these programs (particularly considering space was a barrier to W-O CR delivery and women report valuing privacy at CR) [
]. Finally, considering the programs offering it were able to do so as they had less space and fewer human resource constraints, clearly the resource implications of offering W-O programs and classes needs to be considered [
], likely broader availability should be achieved. However, given the findings here, there is likely a wide variation in W-O CR delivery in the ‘real world’ which would impact patient outcomes. Accordingly, some standards should be agreed (e.g., a model based on principles of women’s health, in a safe and non-competitive environment [
] to ensure consistent, high-quality delivery where implemented.
Space and human resource constraints will need to be considered so that W-O CR can be feasibly be more widely implemented. Potentially, online peer support could be exploited, given women prefer more support from CR, this could benefit their psychosocial well-being as well as promote self-management, and it requires few resources [
]. Other eCR resources could be used, such as meditation apps and behavioural trackers. Implementation could be facilitated by working with the ∼100 programs offering it in the 38 countries where it is available, and expanding from there.
Conclusion
Despite evidence that W-O CR may improve utilisation for such an under-served group in need, it was not commonly offered. It appears that only larger, well-resourced and staffed programs have the capacity to offer W-O CR, and so expanding delivery may require exploiting less human resource-intensive approaches requiring little space such as online peer support. If it were feasible to offer at least some W-O CR sessions, potentially more women would participate, and achieve the 20% mortality and morbidity reductions associated with participation.
Funding
This project was supported by a research grant from York University’s Faculty of Health.
Declaration of Interest
The authors declare that there is no conflict of interest.
Acknowledgements
On behalf of the International Council of Cardiovascular Prevention and Rehabilitation through which this study was undertaken, the Global CR Program Survey Investigators are grateful to the many national champions who collaborated to identify and reach programs in their country or region, including: Dr. Marco Ambrosetti, Dr. Karl Andersen, Dr. Graciela Gonzalez, Dr. Jong Seng Khiong, Dr. Elad Asher, Dr. Carolyn Baer, Dr. Birna Bjarnason-Wehrens, Dr. Raquel Britto, Dr. Juan Castillo Martin, Dr. Ssu-Yuan Chen, Dr. Lucky Cuenza, Dr. Jacqueline Cliff, Dr. Wayne Derman and Dr. Gerard Burdiat, Dr. Susan Dawkes, Dr. Zbigniew Eysymontt, Dr. Stefan Farsky, Dr. Rosalia Fernandez, Dr. Dan Gaita, Dr. Abraham Babu, Dr. Tee Joo Yeo, Dr. Claudia Anchique-Santos, Dr. Evangelia Kouidi, Dr. Eduardo Rivas Estany, Dr. Chul Kim, Dr. Basuni Radi, Dr. Attila Simon, Dr. Lela Maskhulia. We also thank Ms. Ella Pesah for assisting with cleaning and coding of data. We gratefully acknowledge the World Heart Federation who formally endorsed the study protocol, as well as the International Society of Physical and Rehabilitation Medicine for their collaboration in national champion and program identification.
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A survey of attitudes and experiences of women with heart disease.
Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR).
Gender differences in presentation, management and inhospital outcome in patients with ST-segment elevation myocardial infarction: Data from 5000 patients included in the ORBI prospective French regional registry.
Impact of age, gender and indigenous status on access to diagnostic coronary angiography for patients presenting with non-ST segment elevation acute coronary syndromes in Australia.
Secondary prevention in the clinical management of patients with cardiovascular diseases. Core components, standards and outcome measures for referral and delivery.
AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services.
Australian Cardiovascular Health and Rehabilitation Association (ACRA) core components of cardiovascular disease secondary prevention and cardiac rehabilitation 2014.
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