Breaking Down Barriers: Improving Cultural Competence of Cardiac Rehabilitation and Secondary Prevention of Heart Disease within the Turkish Speaking Community of North London
Cardiovascular disease remains the highest cause of mortality in the UK (Scarborough et al 2001). The World Health Organisation (WHO) indicated that ischaemic heart disease will move from 5th cause of death worldwide in 1990 to number one position in 2020 (Klein 2001).
The demographic pattern of the United Kingdom has altered significantly over recent decades and continues to constantly change. There are visible and marked increases in ethnic and cultural diversity which poses challenges to healthcare professionals and providers to ensure that the services provided are accessible and relevant to the local population.
The author practices as a cardiac rehabilitation nurse within a diversely populated area of North London, the main population group who access cardiac rehabilitation services and do not speak English are of Turkish origin. A high admission and attendance rate of Turkish speaking patients within the author’s area of practice is evident and this is reflective of the local ethnic population and community.
It has been well established that provisions in healthcare and especially preventive healthcare continues to remain poor within the NHS and the UK in regards to ethnic minority populations and certainly patients from ethnic diverse backgrounds are neglected within cardiac rehabilitation.
Cardiac rehabilitation has now been established as an integral component of effective cardiac care. The author strongly believes that it should be available to all patients who will benefit from it and delivered in a language and cultural format that is appropriate for the intended audience.
The author’s aim of this study was to visit experts in practice to gain knowledge and experience to ensure that cardiac rehabilitation services provided were relevant for the local Turkish speaking community and to establish an accessible and equitable service to improve levels of adherence and attendance with secondary prevention services.
It must be acknowledged that the Turkish population is a culturally, demographically and geographically diverse population and this necessitated a variety of healthcare sites across Cyprus and Turkey to be visited to reflect cultural differences within this population. The various sites also allowed for the author to obtain knowledge, opinions of many different experts and witness multiple health promotion strategies in progress.
The first visit of this project to Berlin allowed the author the opportunity to work with the cardiology team at the Jewish Hospital. This hospital was chosen because it is situated in an area of Berlin that has a large population of Turkish speaking residents. The Jewish Hospital of Berlin has a long history of treating cardiac patients from the Turkish community and has well established strategies in place to ensure these patients’ needs are met from a language and cultural perspective.
Two geographically different locations in Turkey were visited to help reflect the diversity of the population. This also allowed for a variety of different aspects of cardiac rehabilitation and health promotion strategies in practice to be observed. This opportunity also allowed the author to visit both public and private healthcare institutions within multiple locations, this also allowed for engagement with a larger number of healthcare professionals over various sites.
Northern Cyprus was also visited as the Turkish Cypriot community are the most established in London with first and second generation decedents now presenting with heart disease. This also allowed for a different component of cardiac rehabilitation to be observed and implemented in London.
The value of these professional visits and the wealth of information gained equipped the author with extensive knowledge and recommendations to implement with this population group in London. The initiatives observed in practice and engagement techniques utilised across sites are transferrable to the Turkish community in London to ensure greater engagement with this population group.
Therefore a multifaceted approach was decided upon using innovative and alternative forms of cardiac rehabilitation service delivery. Underpinning the focus of these recommendations are the necessity of self-management and ownership of health to address modifiable risk factors to alter and prevent the progression of coronary heart disease and improve outcomes for this population group. The most crucial component of delivering a cardiac rehabilitation service to non-English speaking patient lies in the engagement method used.
This multifaceted approach was chosen to allow a variety of initiatives to be implemented, this included a simplistic, easy to navigate, user friendly health website in Turkish is planned to engage Turkish speaking patients and their families focusing on both primary and secondary prevention of heart disease.
Evidence has suggested that cardiac patients use the internet to source health related information (Lear et al 2010). Technology has allowed for the use of health information systems to become easily and increasingly accessible through the use of internet and hand held devices. This use of internet based health information will be suitable to identified younger patient group. It is envisioned that older patients who may not be computer literate will be assisted by younger family members.
Regular health information and education days are planned and will cover core components of both primary and secondary prevention of coronary heart disease and healthy living. The focus is on health education to change health behaviours.
Topics will includes lifestyle risk factor management, physical activity and exercise, diet, cardio protective therapies and long-term management delivered by a Turkish multidisciplinary team. This multidisciplinary team not only speak the same language as the participants but come from the same cultural background and within this supportive environment participants can be more open regarding health beliefs, cultural beliefs and explore these issues together.
It was considered crucial to create health education materials and resources in the Turkish language to enhance the services provided covering key issues of heart conditions and modifying risk factors.
A recent mindfulness service has been offered to Turkish cardiac patient and they are offered a 6 session stress management and relaxation programme within a group setting. These groups are facilitated by Turkish speaking health psychologists experienced in running groups in Turkish.
Peer run support groups continue with the theme of support to promote self-management of long-term conditions. Patients are encouraged to share their personal stories and give testimonies of simple lifestyle changes they have made to prevent CVD and contribute to overall improved health status can be very effective at encouraging others.
This valuable opportunity allowed for the author to address and overcome the challenges of delivering cardiac rehabilitation services to a non-English speaking population within their area of practice. The knowledge and experience gained will directly impact on patients’ recovery from heart disease and allow them the opportunity to take ownership of their health and wellbeing.
This report presents a series of recommendations to further improve nursing practice and advance cardiac rehabilitation. The recommendations outlined are also transferable to other ethnic minority groups with long-term conditions that require self-management and ownership of care.