1. Women participating in Phase 3 Cardiac Rehabilitation: a comparison between mixed and female only exercise groups? Shirley Ingram, Elaine Hand, Noeleen Fallon, Caroline Finn, Nora Flynn, Joan Love Cardiac Rehabilitation Dept Adelaide & Meath Hospital, Dublin, Ireland shirley.ingram@amnch.ie

2. CHD in Women Young males (35-44 years) have a C.H.D. rate 6 times higher than that of women of the same age (University of Glasgow, 2001). Young males (35-44 years) have a C.H.D. rate 6 times higher than that of women of the same age (University of Glasgow, 2001). As women reach menopause, they lose the high levels of circulating oestrogen that confers protection from heart disease. In post-menopausal women, C.H.D. has been found to be the leading cause of death and disability. As women reach menopause, they lose the high levels of circulating oestrogen that confers protection from heart disease. In post-menopausal women, C.H.D. has been found to be the leading cause of death and disability. CVD kills 55% of women and 43% men (ESC 2005) & women develop C.H.D. an average of 10 years later in life than men (Castelli, 1988). CVD kills 55% of women and 43% men (ESC 2005) & women develop C.H.D. an average of 10 years later in life than men (Castelli, 1988). CVD is more lethal in women, one year post MI 42% will be dead (compared to 24% of men) Graham 2005 ESC CVD is more lethal in women, one year post MI 42% will be dead (compared to 24% of men) Graham 2005 ESC

3. Initiatives for women AHA go red for women 2004 AHA go red for women 2004 AHA guidelines for CVD prevention in women. (Mosca et al Circulation 2004;109;672-693) AHA guidelines for CVD prevention in women. (Mosca et al Circulation 2004;109;672-693) ESC 2005 ESC 2005

4. Women and CR Women were not included in most of the early studies of CR Women were not included in most of the early studies of CR Women benefit from CR in terms of functional capacity at least as much as men (Brezinka & Kittel, 1996) Women benefit from CR in terms of functional capacity at least as much as men (Brezinka & Kittel, 1996) The benefit may be to a greater extent due to greater overall improvements in exercise capacity (Lavie & Milani 1995) and quality of Life (Verril et al 2001) The benefit may be to a greater extent due to greater overall improvements in exercise capacity (Lavie & Milani 1995) and quality of Life (Verril et al 2001)

5. Women and CR men have been found to be more likely to be referred to and attend rehabilitation than women (Benz Scott et al 2002) men have been found to be more likely to be referred to and attend rehabilitation than women (Benz Scott et al 2002) Physicians who care for women do not refer to CR (Benz Scott et al 2002) despite a physicians recommendation being a powerful enrolment predictor (Ades et al 1992) Physicians who care for women do not refer to CR (Benz Scott et al 2002) despite a physicians recommendation being a powerful enrolment predictor (Ades et al 1992) Even when referred women less likely to attend. The number of female participants in CR programmes ranges between 4.4% and 11%. Jolliffe et al (2002) Even when referred women less likely to attend. The number of female participants in CR programmes ranges between 4.4% and 11%. Jolliffe et al (2002) Fewer women complete CR (Richardson et al 2000) Fewer women complete CR (Richardson et al 2000)

6. Barriers to women attending CR Many barriers: older age, transport, lack of social support (Benz Scott et al 2002) Many barriers: older age, transport, lack of social support (Benz Scott et al 2002) Staff perceptions of barriers: male orientated, lack of privacy (Thomas 1996) Staff perceptions of barriers: male orientated, lack of privacy (Thomas 1996) When women were asked: disliked male priority, “mens club” feeling, not enough talking and social interaction (Moore at al 1996) When women were asked: disliked male priority, “mens club” feeling, not enough talking and social interaction (Moore at al 1996)

7. Aim Perception that CR programs are male- orientated, with regards to class schedules, educational materials, and privacy of facilities.’ Evenson and Fleury (2000) Perception that CR programs are male- orientated, with regards to class schedules, educational materials, and privacy of facilities.’ Evenson and Fleury (2000) It has been suggested that tailoring CR programmes to women may increase participation. The aim of this study was to compare variables between women who attended female only phase 3 exercise groups to women who attended phase 3 in groups with males. It has been suggested that tailoring CR programmes to women may increase participation. The aim of this study was to compare variables between women who attended female only phase 3 exercise groups to women who attended phase 3 in groups with males.

8. Methodology Women were randomly assigned to mixed v female only phase 3 exercise groups as they were removed from the waiting list and offered phase 3 for an 8 week period. Women were randomly assigned to mixed v female only phase 3 exercise groups as they were removed from the waiting list and offered phase 3 for an 8 week period. HADS (Zigmond & Snaith1983) HADS (Zigmond & Snaith1983) DASI (Hlatky et al 1989) DASI (Hlatky et al 1989) Attendance Attendance Compliance > 60% (Oldridge & Jones 1983) Compliance > 60% (Oldridge & Jones 1983) Paired t tests were used to compare scores pre and post treatment. Paired t tests were used to compare scores pre and post treatment.

9. 10 th MARCH 2005 -14 TH march 2006 Total Phase 1 seen 725 Male 530 (73%) Female 195 (25.8%) Proceed to Phase 3 AMNCH (% of phase 1) Male (38%) Female (31.2%) Commenced Phase 3 AMNCH (% of referred) Male 229 (65.6%) Female 78 (66%) Completed >60% Phase 3 Male 170 (74.2%) Female 40 (62.8%) Compliance > 60% FO 22 (63%) FM 27 (63%) Female only (FO) 35 (45%) Female mixed (FM) 43 (55%) Total referred for Phase 3 Male 349 (65.8%) Female 118 (60.5%)

10. Results 35 Female only group (FO) (Average age =64.6yrs) 35 Female only group (FO) (Average age =64.6yrs) 43 Mixed group (FM) (Average age=60.7yrs) 43 Mixed group (FM) (Average age=60.7yrs) Nursing int. FO 21(60%) FM 26 (60.4%) Nursing int. FO 21(60%) FM 26 (60.4%) Nursing interventions Male 137 (59.8%) Nursing interventions Male 137 (59.8%) Smoking status current FO (28.5%) FM (30%) Smoking status current FO (28.5%) FM (30%) SO attendance FO (5.7%) FM (4.6%) SO attendance FO (5.7%) FM (4.6%)

11. Results: Anxiety & Depression 68.5% in the FO group and 60.4% in the FM group completed the HADS pre & post CR 68.5% in the FO group and 60.4% in the FM group completed the HADS pre & post CR there was a decrease in anxiety scores for all after cardiac rehab (p<0.0001) there was a decrease in anxiety scores for all after cardiac rehab (p<0.0001) decrease in depression scores for all at the end of cardiac rehab (p<0.0001) decrease in depression scores for all at the end of cardiac rehab (p<0.0001) no significant difference in anxiety (p = 0.1798) and depression between groups (p = 0.1056). no significant difference in anxiety (p = 0.1798) and depression between groups (p = 0.1056). Past history of depression Past history of depression FO group 3 (8.5%) FM group 9 (20.9%)

12. Results: Physical Function increase in METS scores for all after rehab sessions (p<0.0001) increase in METS scores for all after rehab sessions (p<0.0001) no significant difference in the increase in METS scores between women who attended same sex groups and women who attended mixed groups (p = 0.2429). no significant difference in the increase in METS scores between women who attended same sex groups and women who attended mixed groups (p = 0.2429).

13. Discussion: referral rates 60.5% of women referred to Phase 3. 31.2% referred to AMNCH centre 60.5% of women referred to Phase 3. 31.2% referred to AMNCH centre Compares favourably to referral rates of 15-20% in literature (Ades 1992, Barber 2001) Compares favourably to referral rates of 15-20% in literature (Ades 1992, Barber 2001) This study showed commencement of phase 3 by 66% of women referred This study showed commencement of phase 3 by 66% of women referred Uptake was found to be 49% in men and 34% in women (p<0.001) (McGee & Horgan, 1992). of 583 surviving M.I. patients offered CR (415 males, 168 females), Uptake was found to be 49% in men and 34% in women (p<0.001) (McGee & Horgan, 1992). of 583 surviving M.I. patients offered CR (415 males, 168 females),

14. Compliance & Drop out What is compliance? What is “drop out”? What is compliance? What is “drop out”? >60% attendance >60% attendance –Oldridge N, Jones N. Journal of Cardiopulmonary Rehabilitation 1983; 3: 257-262 14% (FO) 18% (FM) did not start 14% (FO) 18% (FM) did not start 6% (FO) 5% (FM) dropped out in week one, majority gave no reason 6% (FO) 5% (FM) dropped out in week one, majority gave no reason

15. Good compliance of > 60% in both groups FO 22 (63%) FM 27 (63%) Comparable to males (74.2%)

17. Conclusion Good referral rate to Phase 3 at this centre Good referral rate to Phase 3 at this centre Good uptake of phase 3 Good uptake of phase 3 Low drop out Low drop out Good compliance > 60% of sessions Good compliance > 60% of sessions No difference between the 2 groups re uptake & compliance No difference between the 2 groups re uptake & compliance Favourable responses for all women post CR re anxiety, depression and DASI Favourable responses for all women post CR re anxiety, depression and DASI No significant differences between groups No significant differences between groups

18. Recommendations Continue to encourage women to avail of phase 3 Continue to encourage women to avail of phase 3 No need for special female only groups No need for special female only groups Need to research other aspects of women's participation i.e. the social aspect Need to research other aspects of women's participation i.e. the social aspect

19. “Women never have a half-hour in all their lives that they can call their own, without fear of offending or of hurting someone. “Women never have a half-hour in all their lives that they can call their own, without fear of offending or of hurting someone. Why do people sit up so late, or, more rarely, get up so early? Not because the day is not long enough, but because they have 'no time in the day to themselves.” [1852] Florence Nightingale http://womenshistory.about.com/librar y/qu/blqulist.htm#N