Original Article
A Contemporary Phone-Based Cardiac Coaching Program: Evolution and Cross Cultural Utility

https://doi.org/10.1016/j.hlc.2017.07.008Get rights and content

Background

The Hospital Admission Risk Program (HARP) Cardiac Coach Program at Royal Melbourne Hospital has evolved to include a Greek and Italian service, developed in response to the diverse local community and supported by evidence that Culturally and Linguistically Diverse (CALD) groups both perceive health and respond to health care services and information, differently. This paper aims to evaluate if a phone-based cardiac coaching program can be adapted to the Greek and Italian populations using the English cohort as a comparator.

Methods

We retrospectively analysed cardiovascular risk profiles at recruitment into and at discharge from the program. Patients (n = 383) were recruited after an acute coronary event or intervention between June 2011 and June 2013. Recruitment was into the English (n = 301 patients (79%)) Greek (40 (10%)) or Italian (42 (11%)) model. Data was collected on demographic information and risk factor status at entry and discharge from the program: waist circumference, weight, height, lipid profile, HbA1c, smoking status and physical activity. A comparison of the proportion of patients meeting the defined targets across the English, Italian and Greek cohorts was performed, with multivariate logistic regression analysis applied to adjust for differences in baseline variables.

Results

There were baseline differences in age, smoking history, total cholesterol and cholesterol fractions, diastolic blood pressure, weight and physical activity between the cohorts. At discharge, the proportion of patients meeting targets within each cohort were similar.

Conclusion

A phone-based integrated disease management program can be adapted to CALD patients, achieving comparable outcomes as compared with an English-speaking cohort. Health services need to respond to their local needs and be flexible in program delivery in order to benefit as many patients as possible.

Introduction

Cardiovascular disease affects more than 1.1 million Australians (5% of population, 2 years or older) [1] and in an increasing and ageing population, with economic pressure for later retirement [2], it is critical that people attain and maintain ‘best health’ after a significant cardiac event [3]. The concept of phone coaching for secondary prevention is accepted and utilised in many Australian hospitals, as it has been shown to improve control of modifiable cardiac risk factors [4] such as high blood pressure, high cholesterol, being overweight, smoking status, and physical inactivity [5]. However, evidence [6], [7], [8], [9], [10] suggests that culturally and linguistically diverse (CALD) groups perceive health issues and respond to health care services and information, differently.

Health literacy, as measured by the Adult Literacy and Life Skills survey (ALLS), is described as the knowledge and skills needed to understand and use information relating to health including disease prevention, medication use, treatment decisions and staying healthy [11]. The ALLS survey categorises people into five levels of health literacy where 5 is the highest attainable result. Level 3 is regarded as the minimum required for coping with the demands of complex work, life and health issues [11]. An Australian ALLS survey 2006 demonstrated significant issues with health literacy nationally, with 59% of Australians found to be at Level 1 (19%) or Level 2 (40%) [11].

In comparison, health literacy in people whose first language is not English is lower, with 25% achieving a minimum of Level 3 on the ALLS survey as compared to 44% of people in whom English is a first language [11]. This may mean that people from non-English speaking backgrounds are less likely to access services and understand issues related to their health [12]. Recognising this challenge is vital as lower levels of health literacy are associated with higher use of health services, lower levels of knowledge and poorer health outcomes [13].

Additionally, evidence from the UK demonstrates that CALD groups experience disproportionate levels of morbidity and mortality associated with cardiovascular disease [14], [15]. A large investigation by the National Institute for Health Research in the UK highlighted the lack of evidence for the adaptation of health promoting interventions in different CALD groups compared to White Europeans, though noting improvements in acceptability, uptake, trust and retention of the interventions where the intervention was language specific [16]. Furthermore, a recent meta-analysis and literature review by Neubeck et al. (2012) identified language as a main barrier to participation in a cardiac rehabilitation secondary prevention program and that a language specific or remote flexible model had been shown to increase uptake and participation [17]. This highlights the importance of a culturally sensitive and holistic (whole person) approach.

The Hospital Admission Risk Program (HARP) Cardiac Coach Program at the Royal Melbourne Hospital (RMH) commenced in 2003 and is based on the Coaching On Achieving Cardiovascular Health (COACH) Program, which was developed in St Vincent’s Hospital, Melbourne in 1995 [4]. At the RMH, the model has developed and evolved over time in response to the Health Independence Program (HIP) Guidelines [18] and patient need. As well as risk factor modification, it now incorporates holistic assessment and identification of other needs, including referral to appropriate community services. This evolved model includes pain and wound management post coronary artery bypass grafting (CABG), glyceryl trinitrate (GTN) use and angina management advice, mood screening for depression, smoking cessation intervention and, most recently, recognition of the proportion of patients from a CALD background who attend our hospital.

Section snippets

Objectives and Aim

In response to the diversity demonstrated within our local health system, we investigated and established that, other than English, Greek and Italian were the two most commonly spoken languages, (27% and 25% respectively), in our geographical catchment. Consequently, the Greek HARP Cardiac Coach pilot was established in 2008, with further expansion of the program to include an Italian HARP Cardiac Coach in 2011. Australia wide, 1.5% of the population speaks Italian and 1.2% speaks Greek at home

Design

We retrospectively analysed cardiovascular risk profiles at recruitment and discharge in 383 patients recruited into the HARP Cardiac Coach program between 23 June 2011 (commencement of the Italian Cardiac Coach pilot) to 24 June 2013. During this period, 301 patients (79%) were cared for under the English model, 40 (10%) under the Greek model and 42 (11%) under the Italian model (Figure 1). During this period, there were three staff working as HARP Cardiac Coach clinicians. They were either a

Statistical Analysis

Descriptive statistics for each cohort are presented as frequency and percentages for categorical variables, mean ± standard deviation for normally distributed continuous variables and median and inter-quartile ranges for non-normal continuous variables. Comparison between cohorts was undertaken with Students t-tests, if normally distributed, and Kruskal-Wallis and Mann-Whitney tests for non-normally distributed continuous variables. Chi-squared tests were used to compare categorical variables

Baseline Variables

There were significant differences in patient characteristics and risk factor variables between the English, Italian and Greek languages at entry to the program (please see Table 2). English-speaking patients were 10 years younger than the Italian and Greek cohorts (p < 0.001). The Greek-speaking patients had the lowest rates of having ever smoked. Statistically significant differences were also observed, in comparison to the English-speaking cohort. The Italian cohort had lower levels of total

Discussion

This paper shows that the HARP Cardiac Coach program can be adapted from English to both a Greek and an Italian population. Although there were significant differences in baseline variables between the three language cohorts, the program was able to achieve an improvement in the proportion of all NHFA target variables met for secondary prevention of cardiovascular disease, other than a change in HDL.

Anecdotally, there were differences between the Greek and Italian patients, in comparison to the

Study Limitations

This study is limited by the small sizes of the populations of both the Italian and Greek cohort and the fact that there were some statistically significant differences between the groups at baseline. As described however, these were adjusted for in the statistical analysis as possible.

It is possible that past medical history and previous participation in a secondary prevention program differed between the groups. We are not aware, however, of any secondary prevention programs operating under

Conclusions

Adaptation of the HARP Cardiac Coach program to other CALD groups, specifically the Italian and Greek population, results in comparable outcomes in target risk factor variables for secondary prevention of cardiovascular disease compared with English speaking patients. This study demonstrates the effectiveness of a targeted, culturally appropriate secondary prevention intervention, highlighting the importance of health service flexibility in patient management.

Disclosures

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

None.

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