Commentary on Galdas PM & Kang HBK (2010) Punjabi Sikh patients’ cardiac rehabilitation experiences following myocardial infarction: a qualitative analysis. Journal of Clinical Nursing 19, 3134–3142

Abstract

The provision of cardiac rehabilitation services remain poor, especially for women, older people, ethnic minority groups and remote and rural populations (Beswick et al. 2004). Poor access and uptake are common amongst certain minority ethnic and cultural groups such as South Asians in the UK (Jolly et al. 2004, Chauhan et al. 2010) and Canada (Banerjee et al. 2007, 2010, Grewal et al. 2010). Although they are at significantly higher risk of mortality, there remains a dearth of research examining the experiences of such patients (Webster et al. 2002, Astin et al. 2008, Chauhan et al. 2010, Banerjee et al. 2010). Information of this type is sorely needed if culturally and linguistically appropriate cardiac rehabilitation services are to be designed and used. Comparatively little data exist regarding the experiences of Punjabi Sikh patients and the study by Galdas and Kang (2010) is, therefore, a welcome contribution to the literature. Galdas and Kang (2010) conducted in-depth interviews with 15 Punjabi Sikh patients (five women and 10 men) attending a cardiac rehabilitation programme after a myocardial infarction. A solid qualitative approach was employed using grounded theory methods of coding and constant comparative analysis from which four themes emerged: ‘making sense of the diagnosis’, ‘practical dietary advice’, ‘ongoing interaction with peers and the multi-disciplinary team’ and ‘transport and attendance’. Some of these themes have been reported previously by other authors (e.g. Webster et al. 2002, Jolly et al. 2004, Astin et al. 2008), namely the need for nutritional/dietary information and education, transportation concerns, linguistic barriers and the belief in fate. Regarding the latter, even though the concept of fate and predetermined destiny is known to be grounded in many religious traditions of South Asian populations, Galdas and Kang (2010) clearly demonstrated that their Punjabi Sikh patients additionally incorporated a strong sense of individual responsibility to make recommended health promotion changes. In the same vein, Astin et al. (2008) identified a number of cultural differences between South Asian and White-European cardiac rehabilitation patients alongside similarities, which they described as representative of generic characteristics of recovery after a cardiac event. Collectively, these findings highlight the importance of avoiding homogeneous generalisations of the impact of religious beliefs and willingness to adhere to lifestyle modifications. Although there is a need to be more aware of a person’s cultural and religious beliefs, what is more important is the ability to be able to respond to these appropriately. Common issues, especially in South Asian populations for example, are those such as linguistic barriers and a need to address additional nutritional information. However, it should also be understood that not every difficulty a person encounters whilst engaging in cardiac rehabilitation can be attributed to ethnic differences (Astin et al. 2008). Somewhat disparate from previous research (Webster et al. 2002, Astin et al. 2008, Chauhan et al. 2010, Banerjee et al. in press) was that the importance of family/carer support was not identified by Galdas and Kang (2010) as a salient key theme identified in the Punjabi Sikh experience of cardiac rehabilitation. It is well-established in the cardiac literature that in South Asian culture family is an important and close network of immediate and extended family members that have been shown to strongly influence a decision to participate in cardiac rehabilitation (Banerjee et al. 2010). As such, a common theme emerging from other investigations into South Asian patients’ experience of cardiac rehabilitation has been the need for partners/carers to be included in rehabilitation sessions and for health care providers to recognise and support their cultural preferences, needs and expectations. This study by Galdas and Kang (2010) has extended current limited evidence into the experience of cardiac rehabilitation of an important minority population who have a higher risk of mortality from myocardial infarction than the general UK population. Whilst some factors previously identified in South Asian populations engaging in cardiac rehabilitation were confirmed, yet family/carer support was not, the willingness of these individual’s to adhere to cardiac rehabilitation advice and make lifestyle adjustments was a significant finding in itself. Avoiding ethnic generalisations and focusing on culturally relevant tailored rehabilitation strategies may be the initial step from which to improve the appropriateness of cardiac rehabilitation programmes for this minority group.