Applying a gender impact assessment to a cardiac rehabilitation program

Name of initiative: Cardiac Rehabilitation Program
Policy/program/service: Program
New or up for review: Up for review
Sector: Public Health

This case study has been drawn from real examples, however the narrative is fictional.

Overview

Sally and her team are reviewing a cardiac rehabilitation (CR) program for a large regional hospital. This program is reviewed every 24 months, and as it directly and significantly impacts the public, a Gender Impact Assessment (GIA) is required.

The program is designed to assist recovery from heart attacks, surgery, or other forms of heart disease and treatment. It offers education and support for a variety of lifestyle changes such as exercise, healthy eating, maintaining a healthy weight and smoking cessation.

CR programs typically start in hospital but continue after discharge, either at home or in a community health center. Programs can run for 6-10 weeks depending on the patient’s recovery and condition, and they are also designed to support the family and carers of patients (Heart Foundation 2022).

Step 1: Define the issues and challenge assumptions

Sally and her team explore the issue the program is trying to address. They do this by applying a gendered lens to across the program to consider the needs and experiences of women, men, and gender diverse people.

The team recognise that they need to consider intersectionality in the program’s design to acknowledge the complexity of barriers and structures that people in the community face. Gender inequality can be compounded by other forms of disadvantage or discrimination people may experience on the basis of other aspects of their identity. Their culture, ethnicity, sexual orientation, religion, disability, and age (as well as other factors) may also influence the needs and experiences of people, and the program should consider this.

What is the issue the program is trying to address?

Sally and her team are aware of the high prevalence and incidence of cardiovascular disease among the population. They have a strong understanding of the importance of quality CR for the health and wellbeing of patients and their families.

The current program aims to deliver CR to people recovering from a cardiac event. This review will help show whether there are any gaps or challenges people are experiencing in accessing the program as it’s currently delivered.

Challenging assumptions

Sally and the team discuss that although all people are at risk of heart disease, there is an assumption that heart disease is a “men’s problem” and that women do not experience it at the same rate. However, the team initially assume that everyone who accesses the CR program will have similar needs, regardless of gender.

The gender impact assessment provides an opportunity to challenge these initial assumptions to ensure they are equitable for all. As such, team consider the following:

Are there gender differences in how someone accesses this program?
Do we believe everyone who accesses the program will have the same needs?
How do the social roles and responsibilities between men and women impact on the way this program is accessed?
Have we considered the additional parts of someone’s identity and their needs?

This gender impact assessment provides the team an opportunity to think critically about how gender and intersecting aspects of a person’s identity may impact their experiences of heart disease and recovery. It works to dismantle the unintentional barriers faced by people of different genders.

Broadening the issues with a gendered lens

Applying a gender lens and taking an intersectional approach, Sally and her team think about the different experiences of people in the community. They discover:

Women often have caring responsibilities for children and families and may access or need to access this service differently to men, who are often not primary carers or traditionally have fewer caring responsibilities
Women are less likely to seek help for heart disease due to differing experiences and symptoms to men, and therefore may be more likely to result in fatality
Women tend to develop symptoms of heart disease at a much later stage of the illness than men
Masculinity influences men’s decision to seek or delay seeking medical help which in turn also impacts outcomes and recovery for heart disease.
Women are more likely to experience heart disease later in life and therefore can impact how treatment is prioritised
Menopause transition is associated with increased risk of coronary heart disease
Aboriginal and Torres Strait Islander people experience heart disease at higher rates than non-Aboriginal and Torres Strait islander people
Women can have added risk factors for pre-eclampsia or gestational diabetes (during pregnancy), which may increase the chances of developing heart disease later in life.

Step 2: Collecting evidence – data, research and consultation

Through identifying the issues and challenging assumptions, Sally and the team have established areas they would like to explore further. To do that, they will need to gather additional information to help shape their understanding. The key questions they must consider are:

Who is likely to be affected?
What are the lived experiences of these diverse groups?
What different impacts may be likely for different people?

Sally and her team will gather this information through a variety of ways such as internal data, desktop research, consultation, and meaningful stakeholder engagement.

Using internal data

Sally and her team commence their search by looking at the data they collect in their organisation including:

Sex disaggregated incidence data of cardiovascular disease through internal systems (e.g., TRAK)
Sex disaggregated data of referral, uptake, and completion of cardiac rehabilitation programs
Patient enquiries and complaints handling data.
Program evaluation and feedback data.

This information shows the team a snapshot of the current service. It will help them to understand patient usage and any gaps in accessing the services. This will help inform further desktop research and stakeholder engagement.

Data, statistics and desktop research

Sally and the team begin their search with peak body organisations that specialise in cardiovascular disease. When looking through the data and statistics, the team identified there were gaps when it came to the experiences of gender and intersectionality. The team searched the website of the Commission for Gender Equality in the Public Sector (Commission), where they found data sources that specialised in the experiences of different genders and identities.

The Heart Foundation (Australian Heart Maps)
Australian Bureau of Statistics
Australian Institute of Health and Welfare
Rainbow Health
Women’s Health Atlas
LGBTIQA+ Health Australia
National Aboriginal Community Controlled Health organisation
National Centre for Farmer Health
World Health Organisation

The team also used open source, peer reviewed journal articles and research papers and verified websites, for example, state and federal government health websites and peak bodies such as the Heart Foundation.

Stakeholder engagement

Sally and her team found a variety of different evidence and research papers to support their review. Following the guidance of the Commission, the team understand the importance of meaningful consultation. This will aim to capture the experiences of the local community that may assist in connecting local stories to the data captured above.

Sally and her team identified the following groups and organisations to consult with:

Previous patients and program users
Local women’s groups
LGBTIQ+ groups and peak bodies (e.g., Rainbow Health).
Local Aboriginal and Torres Strait Islander community groups and Co-operatives
Local disability services and advocacy groups
Older people’s advocacy groups
Local community health groups (exercise groups, planned activity groups)
Local community groups for culturally linguistically diverse (CALD) people and those from non-English speaking backgrounds
Rural and remote communities via community health hubs

In addition, the team consult with the hospital’s internal Aboriginal and disability liaison officers who provide support and advocacy to patients and their families. The liaison officers contribute valuable insights into the experiences of people they support. As a result of this consultation, the officers offered ongoing support on improving service provision and delivery.

Through meaningful consultation, the groups provide Sally and the team with their experiences of accessing services like CR programs. Where the team could not engage local groups for consultation, they engaged with peak bodies to ensure they captured the diverse range of intersectional factors. This process further highlights the compounding impacts that gender and intersectionality can pose on individuals accessing their programs.

Evidence collected by Sally and her team

Through using a range of data collection methods and sources, Sally and the team have gathered invaluable information for their review. The team has explored the different experiences of different genders and intersecting factors. Overall, the evidence did not support their initial assumption that everyone who accesses the program will have the same needs from it.

- Cardiovascular disease (CVD) is the leading cause of death and morbidity in women and men globally (World Health Organisation)
- However, women who suffer an acute coronary event are more likely to experience death or morbidity within the first year of recovery compared to men (Samayoa 2014)
- Due to the greater risk of death and morbidity, secondary prevention (SP) is essential among women (Samayoa 2014)
- The under-recognition of heart disease and the differences in presentation of symptoms among women lead to less aggressive treatment strategies and a lower representation of women in clinical trials (Mass 2010)
- Women are significantly less likely to access CR programs than men. A US study found that women are 12% less likely to be referred programs, less likely to enroll, attend session or complete the program (Smith 2022)
- Women are often the predominate care givers to cardiac patients, whether that be a spouse or other family member. The physical, social, emotional, and financial strain experienced by carers can be an independent risk factor for coronary heart disease (Aggarwal 2009)
- Older women are much more likely to have CVD, be hospitalised due to CVD, and die from CVD (AIHW 2019).
- Cardiovascular disease is the leading cause of death among men in Australia (Australian Institute of Health and Welfare, 2022)
- The role of masculinity influences men’s decision to seek or delay seeking medical help which in turn impacts outcomes and recovery for cardiovascular disease (Galdas 2007)
- Men are more likely to develop CVD at a younger age, mortality rates are typically higher for middle-aged men that middle aged women (Bots 2010)
- Men were more likely to decline referrals for CR programs due to younger age perceptions and considerations and employment (Angus 2015).
- Gender inequities mean that women, trans and gender diverse people are more frequently subject to social risk factors. These can lead to mental illness and may also influence how health professionals and support services respond to them. This experience can compound distress and trauma (WHV 2023)
- Over 90% of transgender and gender diverse people aged 14 to 21 reported experiencing high or very high levels of psychological distress (LGBTIQ+ Health Australia 2021)
- Transgender and gender diverse people confront significant discrimination and prejudice because their existence challenges the widespread norm of binary gender difference (WHV 2023)
- Trans and gender diverse people often don’t trust medical professionals due to ongoing myths that their identity is seen as a mental disorder. This means that they are less likely to access health care and social services (O’Shea 2020).
- LGBTIQ+ communities are more likely to experience discrimination and marginalisation. This has profound impacts on mental health and stress, which may increase modifiable risk factors for cardiovascular disease such as tobacco, alcohol, and drug use. This puts the community at greater risk of cardiovascular disease compared to heterosexual individuals (Caceres 2017)
- LGBTIQ+ communities are vulnerable to discrimination in public based settings such as hospitals or community services and therefore may feel unsafe to attend programs or services in these settings, resulting in low uptake and completion of programs (Caceres 2017)
- In addition, for some LGBTIQ+ people the fear of discrimination and receiving poor quality care in health settings resulted in people not accessing services all together (O’Shea 2020)
- Cardiovascular disease is the leading cause of death for Aboriginal and Torres Strait Islander people and have high rates of CVD than non-Aboriginal and Torres Strait Islander people (Hamilton 2016)
- Aboriginal and Torres Strait Islander women undertake take critical roles such as leader, mother, carer, and nurturer. They sustain families and communities and often carry significant cultural responsibility within the kinship network. Given women’s increased responsibility, services may often be inadequate in their availability, accessibility, and appropriateness (McBride 2020)
- Cardiovascular disease occurs at a younger age for Aboriginal and Torres Strait Islander Australians, specifically 10 years earlier than non-Aboriginal and Torres Strait Islander Australians (Hamilton 2020)
- People from CALD backgrounds face multilevel issues and challenges accessing healthcare. For example, at a macro level there are structural disadvantages and vulnerabilities, there is also a poor health system response for CALD communities. At the community level, there may be low literacy, health literacy and cultural conflicts in the healthcare system (Khatri 2020)
- Cardiac rehabilitation referral, access and attendance are low for all people who live in rural and remote areas of Australia. This is due to the lack of health professionals, lack of services and lack of transport (Field 2018)
- One study reported that women with physical disabilities are not partners in decision making concerning their health. Furthermore, women felt ‘’pushed to the side’’ and left out from voicing their questions or concerns about heart disease (Parry 2021)
- Women with physical disabilities also reported that some healthcare settings did not accommodate their physical needs and that buildings and community centers were inaccessible (Parry 2021)
- In Australia, people living in rural and remotes areas often have higher cardiovascular risk factors, and higher rates of cardiovascular disease hospitalisations and are more likely to die of cardiovascular disease compared to those living in urban or metropolitan areas (National Rural Health Alliance 2015)
- The onset of cardiovascular disease for women is usually later in life and on average older than men. Older women also have a higher expression of cardiovascular risk factor due to preeclampsia and menopause (Mass 2010)
- For older women who are widowed, not able to drive or lack the support they need to get to rehabilitation sessions may require support workers to access CR (Kuehn 2017).
- Aggarwal B and Mosca L (2009) ‘Heart Disease Risk for Female Cardiac Caregivers’, Female Patient (Parsippany), 34(2):42-45.
- AIHW (Australian Institute of Health and Welfare) (2019) Cardiovascular disease in Australian women – a snapshot of national statistics, AIHW, accessed April 11 2023.
- Angus JE, King-Shier KM, Spaling MA, Duncan AS, Jaglal SB, Stone JA and Clark AM (2015) ‘A secondary meta-synthesis of qualitative studies of gender and access to cardiac rehabilitation’, Journal of Advanced Nursing, 71(8):1758-1773.
- Bots SH, Peters SAE and Woodward M (2017). ‘Sex differences in coronary heart disease and stroke mortality: a global assessment of the effect of ageing between 1980 and 2010’, BMJ Global Health, accessed 10 April 2023
- Caceres BA, Brody A, Luscombe RE, Primiano JE, Marusca P, Sitts EM and Chyun D (2017) ‘A Systematic Review of Cardiovascular Disease in Sexual Minorities’, Am J Public Health, accessed 10 April 2023
- Field PE, Franklin RC, Barker RN, Ring I and Leggat PA (2018) ‘Cardiac rehabilitation services for people in rural and remote areas: an integrative literature review’, Rural Remote Health, accessed 10 April 2023.
- Galdas P, Cheater F and Marshall P (2007) ‘What is the role of masculinity in white and South Asian men’s decisions to seek medical help for cardiac chest pain?’, Journal of Health Services Research & Policy, accessed 12 April 2023.
- Hamilton S, Mills, B, McRae S (2016) ‘Cardiac Rehabilitation for Aboriginal and Torres Strait Islander people in Western Australia’, BMC Cardiovascular Disorders, 16:150.
- Heart Foundation (2022) What is Cardiac Rehabilitation, Heart Foundation, accessed April 11 2023.
- LGBTIQ+ Health Australia (2021) Snapshot of Mental Health and Suicide Prevention Statsitics for LGBTIQ+ People, LGBTIQ+ Health Australia, accessed 14 April 2023.
- McBride KF, Rolleston A, Grey C, Howard NJ, Paquet C and Brown A (2021) ‘Māori, Pacific, Aboriginal and Torres Strait Islander Women’s Cardiovascular Health: Where Are the Opportunities to Make a Real Difference?’, Heart, Lung and Circulation, 30(1):52-58.
- Khatri RB and Assefa Y (2022) ‘Access to health services among culturally and linguistically diverse populations in the Australian universal health care system: issues and challenges’, BMC Public Health, accessed 12 April 2023.
- Kuehn BM (2017) ‘Women May Benefit from Cardiac Rehabilitation Programs Tailored to Their Specific Needs’, Circulation, 135:612-613.
- Maas AH, Appelman YE (2010) ‘Gender differences in coronary heart disease’, Netherlands Heart Journal, 18(12):598-602.
- National Rural Health Alliance (2015), Cardiovascular Disease in Rural Health Fact Sheet, National Rural Health Alliance, accessed April 5 2023.
- O'Shea A, Latham JR, McNair R, Despott N, Rose M, Mountford R and Frawley P (2020) ‘Experiences of LGBTIQA+ People with Disability in Healthcare and Community Services: Towards Embracing Multiple Identities’, International Journal of Environmental Research and Public Health, 17(21).
- Parry M, Bjørnnes AK, Harrington M, Duong M, El Ali S, O'Hara A, Clarke H, Cooper L, Hart D, Harvey P, Lalloo C, McFetridge-Durdle J, McGillion MH, Norris C, Pilote L, Price J, Stinson J and Watt-Watson J (2021) ‘"Her Heart Matters"-Making Visible the Cardiac Pain Experiences of Women with Physical Disabilities and Heart Disease: A Qualitative Study’, CJC Open, 4(2):214-222.
- Samayoa L, Grace SL, Gravely S, Scott LB, Marzolini S and Colella TJ (2014) ‘Sex differences in cardiac rehabilitation enrollment: a meta-analysis’, Canadian Journal of Cardiology, 30(7):793-800.
- Sandsæter HL, Horn J, and Rich-Edwards, JW (2019) ‘Preeclampsia, gestational diabetes, and later risk of cardiovascular disease: Women’s experiences and motivation for lifestyle changes explored in focus group interviews’, BMC Pregnancy Childbirth, 19(448).
- Smith JR, Thomas RJ, Bonikowske AR, Hammer SM, Olson TP (2022) ‘Sex differences in cardiac rehabilitation outcomes’, Circulation Research, 130(4):552-565.
- WHV (Women’s Health Victoria) (2023) Towards a gendered understanding of women’s experiences of mental health and the mental health system, WHV, accessed 14 April 2023.

Step 3: Evaluate options

This evidence and research can now assist the team as they think of options to develop the program’s services and delivery. This will help improve experience of cardiac rehabilitation for all people who need this service.

The first option will explore the needs of CR programs specifically for older women, as the evidence points to a great and often overlooked need. They believe tailoring cardiac rehabilitation programs to the needs of older women will have the most impact.

Option 1 explores providing services for older women on a need’s basis. This flexible program option includes:
- Tailored exercise programs with support from occupational therapists.
- Medication and clinical support from district nursing.
- Providing home-based support for older women who may have impaired mobility.
- Lifestyle support such as counselling services provided over the phone.
Gendered cost and risks
- This option does not include women with physical disabilities who may prefer a home-based CR program, particularly if the healthcare setting does not cater for accessibility needs
- This option does not consider the needs of gender diverse people who often experience discrimination in healthcare settings and may wish to also choose an at home CR program
- Changing the services so that it focuses almost entirely on older women may discourage men who are existing patrons from using this service.
Gendered benefits
- This option would benefit older women, who experience high rates of cardiovascular disease but are less likely to seek care
- Offering at-home programs may increase uptake and completion of CR programs for older women with caring responsibilities
- Access to transport particularly for older women can be a barrier to accessing CR programs, offering an at home option may remove this.
Overall impacts
- This option benefits older women. However, does not consider the impacts of CR programs for all genders or intersecting factors
- Focusing specifically on older women only may further marginalise and discriminate against people who access and need programs.
- This option does not consider all genders and intersectionality and therefore, Sally and the team decide the gender impact of option 1 to be negative.
By capturing the evidence and research during step 2, the team found ways to consider gendered experiences and intersecting factors for people accessing CR programs. The team realise if they don’t think about these factors, it will further discriminate and marginalise people in the community. This would have profoundly negative impacts on people’s health.

The second option focuses on flexible CR programs considering both gender and intersectionality. Considering the overlapping forms of marginalisation and discrimination people experience when accessing health services means these concerns can be properly addressed. Offering flexible options for programs may also lessen the burden on family members or carers of patients.

Option 2 explores flexible program options that can be tailored and considers accessibility for all people, including:
- Home-based programs: the team will focus on developing at-home programs that will consider a range of accessibility options.
- Online support options: this will include education modules that can cater to various accessibility needs. The team will work with the education and IT teams to design an online platform for cardiac patients and carers to access lifestyle change support. Some key features of the online platform will include large print options for visually impaired patients and language options for those from non-English speaking backgrounds
- Remote support: this will include improving outreach and telehealth to smaller rural health services with a key focus on Aboriginal Community Controlled organisations.
- In addition to offering flexible CR program options, all cardiac practitioners will undertake gender equity training. This will build the capacity of staff to understand how gender and intersectionality impacts the experience of people accessing health care.
Improving service provision in rural and regional health centres may be costly. However, the team know that people living in these areas have higher rates of cardiovascular disease, and without improvements these health inequities will continue. Sally and the team will need to investigate grants to assist with costs for improving CR programs in their hospital and surrounding regions.

Gendered risks
- Online support options may not be accessible to older people, people living rurally and people with unstable internet. This means that women in such circumstances may be less likely to receive immediate help during their first year of recovery
- Men are more likely to decline CR programs due to employment considerations (however, offering flexible options may remove this barrier and improve uptake and completion of programs).
Gendered benefits
- Providing flexible options will allow people to tailor their program based on their specific needs associated with their gender and intersecting factors
- Offering outreach support will improve service provision in rural and remote communities. This may be particularly beneficial for Aboriginal and Torres Strait Islander women who are living remotely. Eliminating barriers such as transport and cost to patients will increase participation
- Flexible modes of program delivery can support program uptake and completion for women with care responsibilities. In addition, it may also support patient carers if they can access programs online or support loved ones at home.
Overall impact
- Sally and the team believe option 2 has an overall positive gender impact.

Step 4: Finalise recommendations

Sally recommends that the hospital proceeds with option 2. This option considers the experiences and needs of gender and intersectionality, aiming to remove barriers to access. Specifically, the recommendations put forward by the team include:

The team will develop a range of at-home and on-site recovery programs which will consider a range of accessibility options. Home-based programs: the team will focus on developing at-home programs that will consider a range of accessibility options
The team will work with the education and IT teams to design an online platform for cardiac patients and carers to access lifestyle change support. Some key features of the online platform will include large print options for visually impaired patients and language options for those from non-English speaking backgrounds
Sally will work with smaller rural health services to assist in establishing outreach and telehealth opportunities for people living in rural and remote communities. There will also be a strong focus on developing relationships and partnerships with rural Aboriginal Community Controlled Organisations
All hospital staff should undertake gender equity training, starting with cardiac service staff. This training will upskill staff on the barriers and impacts of accessing healthcare for people of all genders and intersecting factors.

Sally and the team recognise that this option will be costly but believe the changes are possible with the appropriate budget allocation and successful grant funding. They also recognise the great benefits this will have for all people which will outweigh the costs for improvements. By making these changes, it aims to break down the barriers contributing to marginalisation and discrimination because of someone’s gender and intersecting factors.

Preparing for progress reporting to the commission

Once the team completed the gender impact assessment, the team discussed how they will monitor changes to the program for their progress report for the Commission that is due every two years. The Commission requires the team to:

Identify all policies, programs and services that were subject to a gender impact assessment
Report on the actions taken because of the gender impact assessment.

The team established a monitoring and evaluation template where they can record and track necessary information about their GIAs. This will ensure that when it comes time to report, information will be readily available.

Summary of actions taken

All of Sally’s recommendations were approved, and the team are incredibly proud of the work they have done to advance gender equality. Sally now documents the actions taken as a result of completing the GIA, including:

Developing online education modules with a variety of accessibility options such as large font, language options and voice options
Developing hard copy materials for those who are unable to access the internet or prefer this option
The team received a grant to improve CR service delivery through installing telehealth equipment to three rural community health centres, including one Aboriginal owned organisation
All cardiac practitioners will receive gender equity and intersectionality training and will expand to all hospital staff via a staged approach.

Governance

Updated 28 June 2023