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Are the processes recommended by the NHMRC for improving Cardiac Rehabilitation (CR) for Aboriginal and Torres Strait Islander people being implemented?: an assessment of CR Services across Western Australia

Are the processes recommended by the NHMRC for improving Cardiac Rehabilitation (CR) for... Background: Cardiovascular disease is the major cause of premature death of Indigenous Australians, and despite evidence that cardiac rehabilitation (CR) and secondary prevention can reduce recurrent disease and deaths, CR uptake is suboptimal. The National Health and Medical Research Council (NHMRC) guidelines Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander peoples, published in 2005, provide checklists for services to assist them to reduce the service gap for Indigenous people. This study describes health professionals' awareness, implementation, and perspectives of barriers to implementation of these guidelines based on semi-structured interviews conducted between November 2007 and June 2008 with health professionals involved in CR within mainstream health services in Western Australia (WA). Twenty-four health professionals from 17 services (10 rural, 7 metropolitan) listed in the WA Directory of CR services were interviewed. Results: The majority of respondents reported that they were unfamiliar with the NHMRC guidelines and as a consequence implementation of the recommendations was minimal and inconsistently applied. Respondents reported that they provided few in-patient CR-related services to Indigenous patients, services upon discharge were erratic, and they had few Indigenous-specific resources for patients. Issues relating to workforce, cultural competence, and service linkages emerged as having most impact on design and delivery of CR services for Indigenous people in WA. Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:29 http://www.anzhealthpolicy.com/content/6/1/29 Conclusions: This study has demonstrated limited awareness and poor implementation in WA of the recommendations of the NHMRC Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander Peoples: A Guide for Health Professionals. The disproportionate burden of CVD morbidity and mortality among Indigenous Australians mandates urgent attention to this problem and alternative approaches to CR delivery. Dedicated resources and alternative approaches to CR delivery for Indigenous Australians are needed. ingly recognised in achieving access and equity to service Background Cardiac rehabilitation (CR) programs are widely recom- provision [9]. mended for individuals with coronary heart disease (CHD) and widely endorsed in public health policy [1,2]. Guideline development is an important step in driving Despite the survival benefits of CR and improvements in practice change and promoting cultural awareness. Yet it quality of life, participation rates are low even among is well-recognised that guidelines alone do not result in non-Indigenous Australians [3]. Aboriginal and Torres either practice or workplace culture and values changes. Strait Islander Australians are even less likely to participate This study investigated practitioners' awareness and in CR programs than non-Indigenous Australians, despite implementation of Strengthening Cardiac Rehabilitation being more than twice as likely to die from cardiovascular and Secondary Prevention for Aboriginal and Torres Strait disease (where the term 'Indigenous' occurs in this docu- Islander Peoples: A Guide for Health Professionals [10] in CR ment it encompasses both Aboriginal and Torres Strait services in WA. The Guidelines (key features are shown in Islander people) [4]. Approximately 16% of all Indige- Appendix 1) were developed using available evidence and nous Australians live in Western Australia (WA), and they a consultation process with key stakeholders. Through comprise 3.8% of the total WA population. The Indige- providing definitive information on services for Indige- nous population is increasing at a higher than average rate nous patients, this study aimed to help better plan CVD of 2.5% per annum. Indigenous people are the least services for Indigenous Australians in WA. Although some healthy of all Western Australians. The prevalence of Aboriginal Community Controlled Health services pro- chronic conditions is high and gaps persist between the vide CR services, for the most part formalised programs health status of Indigenous and non-Indigenous people are associated with post-hospital discharge programs. [5]. Indigenous people living in rural WA generally have Therefore, this report focuses on mainstream health serv- higher rates of mortality and hospitalisation than those ice CR programs. living in metropolitan regions. Key to increasing participation of Indigenous people in While the incidence of coronary heart disease (CHD) has these programs is the understanding of barriers and facil- been declining over the last three decades in the general itators from their perspectives. population, this trend has not occurred in Indigenous Australians, in spite of an enabling policy context. Cardi- Methods ovascular disease (CVD) also occurs at a younger age, with The sampling frame for this study included public hospi- rates in the 35-54 year age group four times that in Indig- tals and community-based public CR services listed in the enous compared to non-Indigenous populations [6]. A Directory of Western Australian Secondary Prevention previous audit by CR staff at the major tertiary hospital Services [11]. Health professionals were recruited by a CR that receives referrals of Indigenous people from across nurse who contacted rural and metropolitan health serv- WA, found few Indigenous patients ever attended outpa- ice organisations, initially by phone or e-mail, to explain tient CR and a tiny proportion returned for follow-up the study. Semi-structured interviews were conducted (personal communication, Narelle Wilson). Yet despite between November 2007 and March 2008 by a CR nurse the burden of cardiovascular disease and the well- in conjunction with an Indigenous nurse whenever possi- described problems in Indigenous Australians, few effec- ble. The inclusion of an Indigenous nurse in the visits was tive interventions are described. Community involve- to assist with assessment of the CR service in terms of its ment, engagement of Aboriginal Health Workers (AHWs) cultural safety and as a strategy for Indigenous research and program delivery within a framework of cultural com- capacity building within the research. All interviews were petence are thought to be important factors in effective conducted face-to-face to enable assessment of the atmos- service provision [7,8]. Cultural competence refers to a set phere and how "Indigenous-friendly" the environment of skills, attitudes and beliefs that enables an individual to was in terms of supporting culturally safe care, as well as work effectively in cross-cultural situations and is increas- ensuring interviewees were fully engaged during the inter- Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:29 http://www.anzhealthpolicy.com/content/6/1/29 view. Visits also enabled opportunities for providing 8.8%) reported having Indigenous community input into information and education to participants as a form of CR design and delivery. reciprocity. The interviews were partially structured using quantifiable close-ended questions regarding awareness Services for Indigenous in-patients and implementation of the NHMRC Guidelines (Appendix Respondents explained that during a hospital stay, they 2), but also allowed for more in-depth discussions not usually did not visit Indigenous patients. Of those who do fully captured in the question list regarding the experi- see Indigenous in-patients, 29% (n = 7) reported discuss- ences and perceptions of CR services for Indigenous peo- ing with them the importance of CR. The majority of ple. All but three interviews were audio-recorded with respondents did not have access to Indigenous-specific permission of participants. Written notes were taken for education resources on common CVD conditions, tests, those who declined recording. Transcripts and notes were interventions, and medications for patients during their analysed using thematic content analysis [12]. Frequen- hospital stay. However, a minority (n = 4; 17%) of pro- cies of categorical responses to closed-ended questions grams reported providing culturally appropriate resources were computed. Analysis involved open coding, in which and had a buddy/mentoring scheme in place for Indige- the data was broken down into distinct units of meaning, nous people hospitalised for a heart condition (n = 2; or codes, according to participants' responses. The axial 8%). coding stage involved continuous comparisons of the codes with one another to discover links between the cat- Post-discharge services for Indigenous patients egories [12]. Related categories were combined and com- Only 8% (n = 2) of services reported being notified by ter- pared to new data. Steps were undertaken to maximise tiary hospitals when local Indigenous patients were dis- reflexivity and rigour through discussion within the charged back to their area following a cardiac event, while research team and verification and clarification of themes a further 46% (n = 11) reported inconsistent notification. emerging from the data [13]. Ethical Approval was When referrals were obtained, 58% (n = 14) reported see- obtained from the WA Aboriginal Health Information ing Indigenous patients following discharge and of these, and Ethics Committee and the Curtin University Human 62.5% (n = 15) reported talking about the importance of Research Ethics Committee. CR during this time and 37% (n = 9) had Indigenous-spe- cific education materials. Only one post-discharge men- toring system was reported. Results Several services listed in the Directory of WA Secondary Prevention Services were not interviewed, including those Perceived barriers and facilitators to service access who had few or no CR patients/referrals (n = 4), serviced Respondents identified the following barriers they were negligible numbers of Indigenous clients (n = 7, six of aware of that could prevent Indigenous people's access to which were private services), or where staff were unavail- services: family commitments and restrictions (n = 15, able during data collection or failed to respond to invita- 62.5%); lack of awareness of available services (n = 14, tions to participate (n = 3). Participating programs were in 58%); lack of transport (n = 14, 58%); other health issues rural settings (n = 10, 59%) and the metropolitan area (n (n = 9, 38%); and financial constraints (n = 7, 29%). Many = 7, 41%). Twenty-four interviews were conducted with of the services offered CR only within very limited hours, participants from 17 tertiary hospitals and community- compounding geographical barriers to access. Issues relat- based public CR services. Of the respondents who ing to workforce, cultural competence, and service link- reported having received the Guidelines (n = 6, 25%), few ages emerged as having most impact on design and could recall any specific elements or recommendations, delivery of CR services to Indigenous people in WA (Table nor did they report attempting to implement the 1). Verbatim quotes are provided in italics to illustrate approaches recommended in the resource. Findings themes. related to Indigenous inpatients and outpatients are sum- marised below. The denominator for data reported below Discussion relates to participants in interviews (n = 24). Despite the ready availability of NHMRC guidelines to all CR services in WA, the majority of respondents reported Indigenous-specific awareness and services that they were unfamiliar with this document and as a A quarter of respondents reported having joint initiatives consequence had not attempted to implement its recom- with an Aboriginal Medical Service (AMS), while nearly mendations. Although there were examples of good prac- one-third reported faxed or telephoned patient referrals tice, we were unable to identify evidence of a systematic to/from an AMS. Fewer than half of respondents reported implementation strategy or outcome assessment strategy that their service has a system in place for identifying across WA. It is well-documented that guideline imple- Indigenous status (n = 10; 41.7%). A minority (n = 2; mentation is a complex and multifaceted process that needs to consider systems, patient and provider issues Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:29 http://www.anzhealthpolicy.com/content/6/1/29 Table 1: Themes and key issues identified by participants as having a major impact on design and delivery of CR to Indigenous people Theme Key issues Workforce • AHWs were described as being pivotal in engaging and maintaining relationships with Indigenous patients and their families. � AHWs are important in mentoring other health professionals by providing cultural insights into care of Indigenous people: "One of the most important things in providing health services to Aboriginal people is to actually work with the people who have the cultural awareness, and that is the health workers, of course, Aboriginal people themselves...The people want services to be provided by their own people." � Only 54% of respondents reported having access to Aboriginal and Torres Strait Islander staff which was a major impediment to engaging Indigenous people within mainstream services. � Existing AHWs faced limited infrastructure and support: "They can't represent their community in that sort of environment, so they leave" � High turnover of non-Indigenous staff impacted on initiative sustainability: "I'm just relieving for J...". "...been here for three months" "...leaving in two weeks" Cultural competence � Failure to appreciate reasons for poor participation: "I don't know why they don't come. " � Features of programs and services are not congruent with Indigenous clients' lifestyles, culture, commitments, and preferences: "Maybe we could run an ATSI-specific class, because they have this huge shame factor when they are with other people and stuff that they don't like doing" Linkages � Few systematic processes for identifying Indigenous people Inadequate communication and referral upon discharge: "We don't know exactly what day they (Aboriginal patients discharged from hospital) are getting back. There are issues around the continuity of care even though we should get a discharge summary". � Disparate health information management systems between organizations � Lack of awareness of available services in different areas: "It's probably our fault as there is not a good relationship between us and the cardiologists in Perth or the surrounding areas, because people might not think the service is available" � Operating in isolation rather than with existing services [14]. To effectively implement guidelines, a number of highlighted several factors inhibiting sustainable funding strategies should be undertaken underpinned by a tar- models for CR in Indigenous people. There is a need for geted marketing and dissemination strategy. No one sin- more integrated strategies in promoting cultural aware- gle strategy is adequate. Strategies such as involving ness and ensuring that these are integrated in service deliv- consumers and professional groups, implementing tech- ery. The lack of Indigenous staff as members of the health nological solutions, as well as providing incentives have team was identified by many respondents as a major been shown to be successful [15-17]. Yet, this study makes impediment to delivering culturally appropriate care. This evident that there are some entrenched challenges to serv- study also identified the tensions between a standard ice delivery that are unlikely to be solved by guideline approach to medical care and secondary prevention and development alone [18]. Workforce shortages and turno- the needs of Indigenous people, underscoring the impor- ver, inferior and inadequate communication across care tance of developing integrated models of care that are suit- sectors and the barriers associated with rural and remote able to Indigenous problems [19]. The lack of awareness Australia remain a challenge. These issues are com- and consequent overlooking of involvement with Aborig- pounded by the socioeconomic and other issues facing inal Community Controlled Health Services among most Indigenous people in rural and remote Australia. This respondents will likely limit the capacity to coordinate underscores the need to focus on structural reform to services; implementation of this needs higher level com- improve health outcomes for Indigenous Australians on a mitment and support. Further, the limited access to psy- whole-of-community level. This involves providing safe chological and social services fails to address the complex communities, engagement of communities, and promo- interplay between physical and mental concerns in Indig- tion of educational strategies [5]. enous health [20]. Limited transportation and family commitments remain key inhibitors to CR attendance as Another important consideration in of the delivery of CR has also been noted in non-Indigenous people [21]. The services is the interface between state and federal govern- potential to link Indigenous family and community edu- ment initiatives [18]. Commonly, CR services are aligned cation and interventions with follow-up and support for with hospital services that are funded by state govern- an index case was beyond the capacity of services, despite ments, whereas many community-based services are its attractiveness as a means of enhancing support to the funded by the Australian Government. The study has patient and strengthening primary and secondary preven- Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:29 http://www.anzhealthpolicy.com/content/6/1/29 tion in the wider Indigenous community. Efforts to study design, data collection, stakeholder engagement strengthen the competencies of health staff to work with and interpretation, KPT assisted with data collection and disadvantaged clients may help providers engage Indige- interpretation, LD assisted with conception, funding and nous people in CR, particularly if there is health manage- stakeholder engagement, MA assisted with study concep- ment support for this as an important component of tion and analysis, MMW assisted with stakeholder engage- policy and practice [22]. ment, TGL assisted with study development and stakeholder engagement, PMD assisted with analysis, When interpreting these study findings, consideration interpretation and writing. All authors approved the final should be given to the method of sampling which may manuscript. have reflected the view of health professionals who had not necessarily been working in that service over a long Appendix 1: Key Features for Successful Cardiac period. Further, although our informants were those most Rehabilitation in Indigenous Australians [10] likely to know the situation within the CR service and at • Ensure cultural competency is integral to the core the patient-CR provider interface, there was no source business of an organization and supported at all levels data verification from health service management regard- within the organization. ing the opinions expressed. In spite of these limitations, this study elucidated barriers and facilitators to guideline � Involve Aboriginal Health Workers and family mem- implementation and strategies to improve Indigenous bers in the care of Indigenous Australians and develop Health in WA. In addition, it underscores the importance flexible approaches to highlighting the merit of CR. of following up guideline release with targeted implemen- tation and evaluation strategies. Further, it emphasises the � Draw on existing CR and secondary prevention serv- importance of policy diffusion from a state and federal ices as appropriate and engage with local community level to a local service delivery context. Importantly, the networks. views reported are the views of clinicians responsible for CR service implementation and guideline adherence in � Ensure community involvement at every level in the real world. It is important to understand these views planning and implementing CR, including the devel- in improving services. This information provides a way opment of culturally appropriate resources. forward for service planning and underscores an urgent need to invest in enabling health providers to provide cul- � Develop and sustain partnerships between stake- turally appropriate service models. holder agencies. � Tailor CR approach according to the specific needs of Conclusions Although evidence-based guidelines are integral for clini- Indigenous Australians and develop supportive poli- cians and supporting service reform, this study demon- cies and procedures. strated sub-optimal awareness in WA of Strengthening Cardiac Rehabilitation and Secondary Prevention for Aborigi- � Develop specialist education resources for continu- nal and Torres Strait Islander Peoples: A Guide for Health Pro- ing professional development and support of all fessionals among the professionals at whom they were health professionals working in heart care, including targeted. Potentially limited endorsement and recogni- Aboriginal Health Workers. tion at a local policy level have influenced this. Unsurpris- ingly, limited uptake of the recommendations was also Appendix 2: Topics guiding semi-structured identified. The disproportionate burden of CVD morbid- interviews with cardiac rehabilitation providers ity and mortality among Indigenous Australians, particu- � Awareness of NHMRC guidelines [10] larly following an acute cardiac event, requires urgent attention to ensure culturally appropriate and competent � Degree of incorporation of recommendations into secondary prevention services. Alternative approaches to routine practice how CR services could be delivered are needed. � Barriers to implementation Competing interests The authors declare that they have no competing interests. � Aboriginal Health Worker involvement in care of Indigenous patients Authors' contributions SCT contributed to study design, securing funding, ethics � Collaboration and integration with existing service approval, interpretation and writing, MLD assisted with providers analysis, interpretation and writing; JSS assisted with Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:29 http://www.anzhealthpolicy.com/content/6/1/29 17. National Health & Medical Research Council: A guide to the devel- � Cultural competency training opment, implementation and evaluation of clinical practice guidelines. Canberra 1999. � Opportunities for continuing professional develop- 18. Fernandez R, Davidson P, Griffiths R: Cardiac rehabilitation coor- dinators' perceptions of patient-related barriers to imple- ment menting cardiac evidence-based guidelines. J Cardiovasc Nursing 2008, 23(5):449-57. 19. Anderson I, Crengle S, Kamaka ML, Chen TH, Palafox N, Jackson-Pul- � Type, structure, content, organisation, coordination, ver L: Indigenous health in Australia, New Zealand, and the staffing and funding of the service with specific rele- Pacific. Lancet 2006, 367(9524):1775-85. vance to Indigenous people 20. DiGiacomo M, Davidson P, Davison J, Moore L, Abbott P: Stressful life events, resources and access: key considerations in quit- ting smoking at an Aboriginal Medical Service. Aust NZ J Public Acknowledgements Health 2007, 31(2):174-6. We thank participants and health services for their time and gratefully 21. Daly J, Sindone A, Hancock K, Chang E, Davidson P: Barriers to par- ticipation in and adherence to cardiac rehabilitation pro- acknowledge colleagues Ms Francine Eades, Dr Tom Briffa, Ms Narelle Wil- grams: a critical literature review. Progress Cardiovasc Nursing son and Mr Trevor Shilton for their assistance with this project. We also 2002, 17(1):8-17. acknowledge the assistance of Royal Perth Hospital and the National Heart 22. Harris E, Harris M, Madden L, Wise M, Sainsbury P, MacDonald J, Gill Foundation WA. This research was supported by the WA Department of B: Working in disadvantaged communities: what additional Health through a State Health Research Advisory Council grant and competencies do we need? Aust NZ Health Policy 2009 in press. NHMRC Project grant ID 479222. Dr DiGiacomo is a post doctoral fellow supported by Curtin University and receives some salary support from NHMRC Capacity Building Grant ID 533547. References 1. Ades PA, Green NM, Coello CE: Effects of exercise and cardiac rehabilitation on cardiovascular outcomes. Cardiology Clinics 2003, 21(3):435-48. 2. Briffa TG, Eckermann SD, Griffiths AD, Harris PJ, Heath MR, Freed- man SB, Donaldson LT, Briffa NK, Keech AC: Cost-effectiveness of rehabilitation after an acute coronary event: a randomised controlled trial. Med J Aust 2005, 183(9):450-5. 3. Sundararajan V, Bunker S, Begg S, Marshall R, McBurney H: Attend- ance rates and outcomes of cardiac rehabilitation in Victo- ria, 1998. Med J Aust 2004, 180(6):268-71. 4. Pincock S: Australia lags behind in attempts to improve health of indigenous people. BMJ 2007, 334(7597):765. 5. Western Australian Aboriginal Health Strategy. Department of Health, Perth; 2000. 6. Zhao Y, Guthridge S, Mangus A, Vos T: Burden of disease and injury in Aboriginal and non-Aboriginal populations in the Northern Territory. Med J Aust 2004, 180(10):498-502. 7. Hayman NE, Wenitong M, Zangger JA, Hall EM: Strengthening car- diac rehabilitation and secondary prevention for Aboriginal and Torres Strait Islander peoples. Med J Aust 2006, 184(10):485-6. 8. Cheng MH: Aboriginal workers key to indigenous health in Australia. Lancet 2007, 370(9598):1533-6. 9. Davidson P, Gholizadeh L, Rotem A, DiGiacomo M, Eisenbruch M, Salamonson Y: A cultural competence view of cardiacrehabili- tation. J Clin Nursing in press. 10. National Health and Medical Research Council: Strengthening car- diac rehabilitation and secondary prevention for Aboriginal and Torres Strait Islander Peoples: a guide for health profes- sionals. Canberra: Australian Government; 2005. 11. National Heart Foundation of Australia (WA Division): Directory of Western Australian Secondary Prevention Services. Perth, Heart Foundation of WA; 2007. Publish with Bio Med Central and every 12. Grbich C: Qualitative research in health: an introduction. Syd- ney: Allen & Unwin; 1999. scientist can read your work free of charge 13. Kitto S, Chesters J, Grbich C: Quality in qualitative research. "BioMed Central will be the most significant development for Med J Aust 2008, 188(4):243-6. disseminating the results of biomedical researc h in our lifetime." 14. Smith KB, Humphreys JS, Wilson MG: Addressing the health dis- advantage of rural populations: how does epidemiological Sir Paul Nurse, Cancer Research UK evidence inform rural health policies and research? Aust J Your research papers will be: Rural Health 2008, 16(2):56-66. 15. Davis DA, Thomson MA, Oxman AD, Haynes RB: Changing physi- available free of charge to the entire biomedical community cian performance: a systematic review of the effect of con- peer reviewed and published immediately upon acceptance tinuing medical education strategies. JAMA 1995, 274:700-6. 16. Grimshaw J, Russell I: Achieving health gain through clinical cited in PubMed and archived on PubMed Central guidelines II: ensuring guidelines change medical practice. yours — you keep the copyright Qual Health Care 1994, 3:45-52. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

Are the processes recommended by the NHMRC for improving Cardiac Rehabilitation (CR) for Aboriginal and Torres Strait Islander people being implemented?: an assessment of CR Services across Western Australia

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Springer Journals
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Copyright © 2009 by Thompson et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Social Policy
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1743-8462
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10.1186/1743-8462-6-29
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20042097
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Abstract

Background: Cardiovascular disease is the major cause of premature death of Indigenous Australians, and despite evidence that cardiac rehabilitation (CR) and secondary prevention can reduce recurrent disease and deaths, CR uptake is suboptimal. The National Health and Medical Research Council (NHMRC) guidelines Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander peoples, published in 2005, provide checklists for services to assist them to reduce the service gap for Indigenous people. This study describes health professionals' awareness, implementation, and perspectives of barriers to implementation of these guidelines based on semi-structured interviews conducted between November 2007 and June 2008 with health professionals involved in CR within mainstream health services in Western Australia (WA). Twenty-four health professionals from 17 services (10 rural, 7 metropolitan) listed in the WA Directory of CR services were interviewed. Results: The majority of respondents reported that they were unfamiliar with the NHMRC guidelines and as a consequence implementation of the recommendations was minimal and inconsistently applied. Respondents reported that they provided few in-patient CR-related services to Indigenous patients, services upon discharge were erratic, and they had few Indigenous-specific resources for patients. Issues relating to workforce, cultural competence, and service linkages emerged as having most impact on design and delivery of CR services for Indigenous people in WA. Page 1 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:29 http://www.anzhealthpolicy.com/content/6/1/29 Conclusions: This study has demonstrated limited awareness and poor implementation in WA of the recommendations of the NHMRC Strengthening Cardiac Rehabilitation and Secondary Prevention for Aboriginal and Torres Strait Islander Peoples: A Guide for Health Professionals. The disproportionate burden of CVD morbidity and mortality among Indigenous Australians mandates urgent attention to this problem and alternative approaches to CR delivery. Dedicated resources and alternative approaches to CR delivery for Indigenous Australians are needed. ingly recognised in achieving access and equity to service Background Cardiac rehabilitation (CR) programs are widely recom- provision [9]. mended for individuals with coronary heart disease (CHD) and widely endorsed in public health policy [1,2]. Guideline development is an important step in driving Despite the survival benefits of CR and improvements in practice change and promoting cultural awareness. Yet it quality of life, participation rates are low even among is well-recognised that guidelines alone do not result in non-Indigenous Australians [3]. Aboriginal and Torres either practice or workplace culture and values changes. Strait Islander Australians are even less likely to participate This study investigated practitioners' awareness and in CR programs than non-Indigenous Australians, despite implementation of Strengthening Cardiac Rehabilitation being more than twice as likely to die from cardiovascular and Secondary Prevention for Aboriginal and Torres Strait disease (where the term 'Indigenous' occurs in this docu- Islander Peoples: A Guide for Health Professionals [10] in CR ment it encompasses both Aboriginal and Torres Strait services in WA. The Guidelines (key features are shown in Islander people) [4]. Approximately 16% of all Indige- Appendix 1) were developed using available evidence and nous Australians live in Western Australia (WA), and they a consultation process with key stakeholders. Through comprise 3.8% of the total WA population. The Indige- providing definitive information on services for Indige- nous population is increasing at a higher than average rate nous patients, this study aimed to help better plan CVD of 2.5% per annum. Indigenous people are the least services for Indigenous Australians in WA. Although some healthy of all Western Australians. The prevalence of Aboriginal Community Controlled Health services pro- chronic conditions is high and gaps persist between the vide CR services, for the most part formalised programs health status of Indigenous and non-Indigenous people are associated with post-hospital discharge programs. [5]. Indigenous people living in rural WA generally have Therefore, this report focuses on mainstream health serv- higher rates of mortality and hospitalisation than those ice CR programs. living in metropolitan regions. Key to increasing participation of Indigenous people in While the incidence of coronary heart disease (CHD) has these programs is the understanding of barriers and facil- been declining over the last three decades in the general itators from their perspectives. population, this trend has not occurred in Indigenous Australians, in spite of an enabling policy context. Cardi- Methods ovascular disease (CVD) also occurs at a younger age, with The sampling frame for this study included public hospi- rates in the 35-54 year age group four times that in Indig- tals and community-based public CR services listed in the enous compared to non-Indigenous populations [6]. A Directory of Western Australian Secondary Prevention previous audit by CR staff at the major tertiary hospital Services [11]. Health professionals were recruited by a CR that receives referrals of Indigenous people from across nurse who contacted rural and metropolitan health serv- WA, found few Indigenous patients ever attended outpa- ice organisations, initially by phone or e-mail, to explain tient CR and a tiny proportion returned for follow-up the study. Semi-structured interviews were conducted (personal communication, Narelle Wilson). Yet despite between November 2007 and March 2008 by a CR nurse the burden of cardiovascular disease and the well- in conjunction with an Indigenous nurse whenever possi- described problems in Indigenous Australians, few effec- ble. The inclusion of an Indigenous nurse in the visits was tive interventions are described. Community involve- to assist with assessment of the CR service in terms of its ment, engagement of Aboriginal Health Workers (AHWs) cultural safety and as a strategy for Indigenous research and program delivery within a framework of cultural com- capacity building within the research. All interviews were petence are thought to be important factors in effective conducted face-to-face to enable assessment of the atmos- service provision [7,8]. Cultural competence refers to a set phere and how "Indigenous-friendly" the environment of skills, attitudes and beliefs that enables an individual to was in terms of supporting culturally safe care, as well as work effectively in cross-cultural situations and is increas- ensuring interviewees were fully engaged during the inter- Page 2 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:29 http://www.anzhealthpolicy.com/content/6/1/29 view. Visits also enabled opportunities for providing 8.8%) reported having Indigenous community input into information and education to participants as a form of CR design and delivery. reciprocity. The interviews were partially structured using quantifiable close-ended questions regarding awareness Services for Indigenous in-patients and implementation of the NHMRC Guidelines (Appendix Respondents explained that during a hospital stay, they 2), but also allowed for more in-depth discussions not usually did not visit Indigenous patients. Of those who do fully captured in the question list regarding the experi- see Indigenous in-patients, 29% (n = 7) reported discuss- ences and perceptions of CR services for Indigenous peo- ing with them the importance of CR. The majority of ple. All but three interviews were audio-recorded with respondents did not have access to Indigenous-specific permission of participants. Written notes were taken for education resources on common CVD conditions, tests, those who declined recording. Transcripts and notes were interventions, and medications for patients during their analysed using thematic content analysis [12]. Frequen- hospital stay. However, a minority (n = 4; 17%) of pro- cies of categorical responses to closed-ended questions grams reported providing culturally appropriate resources were computed. Analysis involved open coding, in which and had a buddy/mentoring scheme in place for Indige- the data was broken down into distinct units of meaning, nous people hospitalised for a heart condition (n = 2; or codes, according to participants' responses. The axial 8%). coding stage involved continuous comparisons of the codes with one another to discover links between the cat- Post-discharge services for Indigenous patients egories [12]. Related categories were combined and com- Only 8% (n = 2) of services reported being notified by ter- pared to new data. Steps were undertaken to maximise tiary hospitals when local Indigenous patients were dis- reflexivity and rigour through discussion within the charged back to their area following a cardiac event, while research team and verification and clarification of themes a further 46% (n = 11) reported inconsistent notification. emerging from the data [13]. Ethical Approval was When referrals were obtained, 58% (n = 14) reported see- obtained from the WA Aboriginal Health Information ing Indigenous patients following discharge and of these, and Ethics Committee and the Curtin University Human 62.5% (n = 15) reported talking about the importance of Research Ethics Committee. CR during this time and 37% (n = 9) had Indigenous-spe- cific education materials. Only one post-discharge men- toring system was reported. Results Several services listed in the Directory of WA Secondary Prevention Services were not interviewed, including those Perceived barriers and facilitators to service access who had few or no CR patients/referrals (n = 4), serviced Respondents identified the following barriers they were negligible numbers of Indigenous clients (n = 7, six of aware of that could prevent Indigenous people's access to which were private services), or where staff were unavail- services: family commitments and restrictions (n = 15, able during data collection or failed to respond to invita- 62.5%); lack of awareness of available services (n = 14, tions to participate (n = 3). Participating programs were in 58%); lack of transport (n = 14, 58%); other health issues rural settings (n = 10, 59%) and the metropolitan area (n (n = 9, 38%); and financial constraints (n = 7, 29%). Many = 7, 41%). Twenty-four interviews were conducted with of the services offered CR only within very limited hours, participants from 17 tertiary hospitals and community- compounding geographical barriers to access. Issues relat- based public CR services. Of the respondents who ing to workforce, cultural competence, and service link- reported having received the Guidelines (n = 6, 25%), few ages emerged as having most impact on design and could recall any specific elements or recommendations, delivery of CR services to Indigenous people in WA (Table nor did they report attempting to implement the 1). Verbatim quotes are provided in italics to illustrate approaches recommended in the resource. Findings themes. related to Indigenous inpatients and outpatients are sum- marised below. The denominator for data reported below Discussion relates to participants in interviews (n = 24). Despite the ready availability of NHMRC guidelines to all CR services in WA, the majority of respondents reported Indigenous-specific awareness and services that they were unfamiliar with this document and as a A quarter of respondents reported having joint initiatives consequence had not attempted to implement its recom- with an Aboriginal Medical Service (AMS), while nearly mendations. Although there were examples of good prac- one-third reported faxed or telephoned patient referrals tice, we were unable to identify evidence of a systematic to/from an AMS. Fewer than half of respondents reported implementation strategy or outcome assessment strategy that their service has a system in place for identifying across WA. It is well-documented that guideline imple- Indigenous status (n = 10; 41.7%). A minority (n = 2; mentation is a complex and multifaceted process that needs to consider systems, patient and provider issues Page 3 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:29 http://www.anzhealthpolicy.com/content/6/1/29 Table 1: Themes and key issues identified by participants as having a major impact on design and delivery of CR to Indigenous people Theme Key issues Workforce • AHWs were described as being pivotal in engaging and maintaining relationships with Indigenous patients and their families. � AHWs are important in mentoring other health professionals by providing cultural insights into care of Indigenous people: "One of the most important things in providing health services to Aboriginal people is to actually work with the people who have the cultural awareness, and that is the health workers, of course, Aboriginal people themselves...The people want services to be provided by their own people." � Only 54% of respondents reported having access to Aboriginal and Torres Strait Islander staff which was a major impediment to engaging Indigenous people within mainstream services. � Existing AHWs faced limited infrastructure and support: "They can't represent their community in that sort of environment, so they leave" � High turnover of non-Indigenous staff impacted on initiative sustainability: "I'm just relieving for J...". "...been here for three months" "...leaving in two weeks" Cultural competence � Failure to appreciate reasons for poor participation: "I don't know why they don't come. " � Features of programs and services are not congruent with Indigenous clients' lifestyles, culture, commitments, and preferences: "Maybe we could run an ATSI-specific class, because they have this huge shame factor when they are with other people and stuff that they don't like doing" Linkages � Few systematic processes for identifying Indigenous people Inadequate communication and referral upon discharge: "We don't know exactly what day they (Aboriginal patients discharged from hospital) are getting back. There are issues around the continuity of care even though we should get a discharge summary". � Disparate health information management systems between organizations � Lack of awareness of available services in different areas: "It's probably our fault as there is not a good relationship between us and the cardiologists in Perth or the surrounding areas, because people might not think the service is available" � Operating in isolation rather than with existing services [14]. To effectively implement guidelines, a number of highlighted several factors inhibiting sustainable funding strategies should be undertaken underpinned by a tar- models for CR in Indigenous people. There is a need for geted marketing and dissemination strategy. No one sin- more integrated strategies in promoting cultural aware- gle strategy is adequate. Strategies such as involving ness and ensuring that these are integrated in service deliv- consumers and professional groups, implementing tech- ery. The lack of Indigenous staff as members of the health nological solutions, as well as providing incentives have team was identified by many respondents as a major been shown to be successful [15-17]. Yet, this study makes impediment to delivering culturally appropriate care. This evident that there are some entrenched challenges to serv- study also identified the tensions between a standard ice delivery that are unlikely to be solved by guideline approach to medical care and secondary prevention and development alone [18]. Workforce shortages and turno- the needs of Indigenous people, underscoring the impor- ver, inferior and inadequate communication across care tance of developing integrated models of care that are suit- sectors and the barriers associated with rural and remote able to Indigenous problems [19]. The lack of awareness Australia remain a challenge. These issues are com- and consequent overlooking of involvement with Aborig- pounded by the socioeconomic and other issues facing inal Community Controlled Health Services among most Indigenous people in rural and remote Australia. This respondents will likely limit the capacity to coordinate underscores the need to focus on structural reform to services; implementation of this needs higher level com- improve health outcomes for Indigenous Australians on a mitment and support. Further, the limited access to psy- whole-of-community level. This involves providing safe chological and social services fails to address the complex communities, engagement of communities, and promo- interplay between physical and mental concerns in Indig- tion of educational strategies [5]. enous health [20]. Limited transportation and family commitments remain key inhibitors to CR attendance as Another important consideration in of the delivery of CR has also been noted in non-Indigenous people [21]. The services is the interface between state and federal govern- potential to link Indigenous family and community edu- ment initiatives [18]. Commonly, CR services are aligned cation and interventions with follow-up and support for with hospital services that are funded by state govern- an index case was beyond the capacity of services, despite ments, whereas many community-based services are its attractiveness as a means of enhancing support to the funded by the Australian Government. The study has patient and strengthening primary and secondary preven- Page 4 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:29 http://www.anzhealthpolicy.com/content/6/1/29 tion in the wider Indigenous community. Efforts to study design, data collection, stakeholder engagement strengthen the competencies of health staff to work with and interpretation, KPT assisted with data collection and disadvantaged clients may help providers engage Indige- interpretation, LD assisted with conception, funding and nous people in CR, particularly if there is health manage- stakeholder engagement, MA assisted with study concep- ment support for this as an important component of tion and analysis, MMW assisted with stakeholder engage- policy and practice [22]. ment, TGL assisted with study development and stakeholder engagement, PMD assisted with analysis, When interpreting these study findings, consideration interpretation and writing. All authors approved the final should be given to the method of sampling which may manuscript. have reflected the view of health professionals who had not necessarily been working in that service over a long Appendix 1: Key Features for Successful Cardiac period. Further, although our informants were those most Rehabilitation in Indigenous Australians [10] likely to know the situation within the CR service and at • Ensure cultural competency is integral to the core the patient-CR provider interface, there was no source business of an organization and supported at all levels data verification from health service management regard- within the organization. ing the opinions expressed. In spite of these limitations, this study elucidated barriers and facilitators to guideline � Involve Aboriginal Health Workers and family mem- implementation and strategies to improve Indigenous bers in the care of Indigenous Australians and develop Health in WA. In addition, it underscores the importance flexible approaches to highlighting the merit of CR. of following up guideline release with targeted implemen- tation and evaluation strategies. Further, it emphasises the � Draw on existing CR and secondary prevention serv- importance of policy diffusion from a state and federal ices as appropriate and engage with local community level to a local service delivery context. Importantly, the networks. views reported are the views of clinicians responsible for CR service implementation and guideline adherence in � Ensure community involvement at every level in the real world. It is important to understand these views planning and implementing CR, including the devel- in improving services. This information provides a way opment of culturally appropriate resources. forward for service planning and underscores an urgent need to invest in enabling health providers to provide cul- � Develop and sustain partnerships between stake- turally appropriate service models. holder agencies. � Tailor CR approach according to the specific needs of Conclusions Although evidence-based guidelines are integral for clini- Indigenous Australians and develop supportive poli- cians and supporting service reform, this study demon- cies and procedures. strated sub-optimal awareness in WA of Strengthening Cardiac Rehabilitation and Secondary Prevention for Aborigi- � Develop specialist education resources for continu- nal and Torres Strait Islander Peoples: A Guide for Health Pro- ing professional development and support of all fessionals among the professionals at whom they were health professionals working in heart care, including targeted. Potentially limited endorsement and recogni- Aboriginal Health Workers. tion at a local policy level have influenced this. Unsurpris- ingly, limited uptake of the recommendations was also Appendix 2: Topics guiding semi-structured identified. The disproportionate burden of CVD morbid- interviews with cardiac rehabilitation providers ity and mortality among Indigenous Australians, particu- � Awareness of NHMRC guidelines [10] larly following an acute cardiac event, requires urgent attention to ensure culturally appropriate and competent � Degree of incorporation of recommendations into secondary prevention services. Alternative approaches to routine practice how CR services could be delivered are needed. � Barriers to implementation Competing interests The authors declare that they have no competing interests. � Aboriginal Health Worker involvement in care of Indigenous patients Authors' contributions SCT contributed to study design, securing funding, ethics � Collaboration and integration with existing service approval, interpretation and writing, MLD assisted with providers analysis, interpretation and writing; JSS assisted with Page 5 of 6 (page number not for citation purposes) Australia and New Zealand Health Policy 2009, 6:29 http://www.anzhealthpolicy.com/content/6/1/29 17. National Health & Medical Research Council: A guide to the devel- � Cultural competency training opment, implementation and evaluation of clinical practice guidelines. Canberra 1999. � Opportunities for continuing professional develop- 18. Fernandez R, Davidson P, Griffiths R: Cardiac rehabilitation coor- dinators' perceptions of patient-related barriers to imple- ment menting cardiac evidence-based guidelines. J Cardiovasc Nursing 2008, 23(5):449-57. 19. Anderson I, Crengle S, Kamaka ML, Chen TH, Palafox N, Jackson-Pul- � Type, structure, content, organisation, coordination, ver L: Indigenous health in Australia, New Zealand, and the staffing and funding of the service with specific rele- Pacific. Lancet 2006, 367(9524):1775-85. vance to Indigenous people 20. DiGiacomo M, Davidson P, Davison J, Moore L, Abbott P: Stressful life events, resources and access: key considerations in quit- ting smoking at an Aboriginal Medical Service. Aust NZ J Public Acknowledgements Health 2007, 31(2):174-6. We thank participants and health services for their time and gratefully 21. Daly J, Sindone A, Hancock K, Chang E, Davidson P: Barriers to par- ticipation in and adherence to cardiac rehabilitation pro- acknowledge colleagues Ms Francine Eades, Dr Tom Briffa, Ms Narelle Wil- grams: a critical literature review. Progress Cardiovasc Nursing son and Mr Trevor Shilton for their assistance with this project. We also 2002, 17(1):8-17. acknowledge the assistance of Royal Perth Hospital and the National Heart 22. Harris E, Harris M, Madden L, Wise M, Sainsbury P, MacDonald J, Gill Foundation WA. This research was supported by the WA Department of B: Working in disadvantaged communities: what additional Health through a State Health Research Advisory Council grant and competencies do we need? Aust NZ Health Policy 2009 in press. NHMRC Project grant ID 479222. Dr DiGiacomo is a post doctoral fellow supported by Curtin University and receives some salary support from NHMRC Capacity Building Grant ID 533547. References 1. 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Syd- ney: Allen & Unwin; 1999. scientist can read your work free of charge 13. Kitto S, Chesters J, Grbich C: Quality in qualitative research. "BioMed Central will be the most significant development for Med J Aust 2008, 188(4):243-6. disseminating the results of biomedical researc h in our lifetime." 14. Smith KB, Humphreys JS, Wilson MG: Addressing the health dis- advantage of rural populations: how does epidemiological Sir Paul Nurse, Cancer Research UK evidence inform rural health policies and research? Aust J Your research papers will be: Rural Health 2008, 16(2):56-66. 15. Davis DA, Thomson MA, Oxman AD, Haynes RB: Changing physi- available free of charge to the entire biomedical community cian performance: a systematic review of the effect of con- peer reviewed and published immediately upon acceptance tinuing medical education strategies. JAMA 1995, 274:700-6. 16. Grimshaw J, Russell I: Achieving health gain through clinical cited in PubMed and archived on PubMed Central guidelines II: ensuring guidelines change medical practice. yours — you keep the copyright Qual Health Care 1994, 3:45-52. BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 6 of 6 (page number not for citation purposes)

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Australia and New Zealand Health PolicySpringer Journals

Published: Dec 30, 2009

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