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.


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.

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.

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.