Action needed to fix gender gap in cardiac rehab – News-Medical

Report on Gender Disparities in Cardiac Rehabilitation and Alignment with Sustainable Development Goals

Introduction: The Critical Role of Cardiac Rehabilitation in Achieving SDG 3

Cardiac Rehabilitation (CR) is a structured lifestyle management program essential for secondary prevention in cardiovascular disease. It is recommended by leading professional societies, including the American Heart Association, as a key strategy for promoting long-term health. The program’s alignment with Sustainable Development Goal 3 (Good Health and Well-being) is evident in its proven benefits.

• Improves key cardiovascular risk factors, including blood pressure, cholesterol, and fasting glucose levels.
• Reduces the risk of hospital readmission by 42% over a 6-12 month period.
• Lowers the risk of myocardial infarction and cardiovascular mortality.
• Enhances exercise capacity, metabolism, and mental health, particularly in women.

Evidence indicates that women may experience a more pronounced reduction in mortality risk from CR than men, underscoring its importance in public health strategies.

The Gender Gap: A Challenge to SDG 5 and SDG 10

Despite its efficacy, a significant gender gap exists in CR participation, undermining progress toward Sustainable Development Goal 5 (Gender Equality) and Sustainable Development Goal 10 (Reduced Inequalities). Women are less likely to be referred to, enroll in, attend, and complete CR programs. This disparity is driven by a range of systemic, socioeconomic, and personal barriers.

Factors Restricting Women’s Access to Cardiac Rehabilitation

• Systemic and Clinical Barriers: Lower referral rates for women are a dominant factor, potentially stemming from clinician bias or a lack of qualifying cardiovascular diagnoses. Eligible women are often older and present with more comorbidities, which may influence referral decisions.
• Socioeconomic and Logistical Barriers: Challenges include lack of insurance, transportation issues, and financial constraints.
• Sociocultural and Personal Barriers: Family responsibilities, social isolation, and limited opportunities for self-care disproportionately affect women.
• Intersectional Inequalities: The issue is compounded for women from underrepresented racial and ethnic groups. Non-Hispanic Black, Hispanic, and Asian women exhibit particularly low participation rates (often below 12%), facing additional barriers such as discrimination and a lack of culturally tailored programs, which directly contravenes the principles of SDG 10.

Strategic Interventions for Equitable Access and Participation

A multifaceted approach is required to close the gender gap in CR and advance global health and equality goals. The following strategies have been identified to improve access, enrollment, and completion rates for women.

1. Systemic and Technological Solutions (SDG 9 & 10): The implementation of automated electronic referral systems can increase CR participation in women by over tenfold. When combined with case management or liaison strategies, this approach addresses referral inequalities and raises awareness.
2. Women-Centric Program Design (SDG 5): Personalized CR programs designed for women can target unique behavioral, clinical, and psychosocial factors. Women-focused programs that offer a broader range of exercise choices and greater social support have been shown to increase participation.
3. Integrated Support Systems (SDG 3): Incorporating peer support and mental health services is crucial for improving self-efficacy, quality of life, and therapeutic adherence.
4. Innovative Delivery Models (SDG 9): Remote, virtual, and hybrid CR models powered by digital technologies can mitigate logistical barriers such as transportation and scheduling. These models offer flexibility, although further research is needed to confirm their efficacy and safety, especially for women.
5. Culturally Competent and Equity-Focused Approaches (SDG 10): There is a critical need for culturally sensitive programs that address the specific needs of women from diverse racial, ethnic, and socioeconomic backgrounds.

Special Considerations for Women’s Cardiovascular Health

Effective CR programs for women must account for sex-specific physiological and clinical factors.

• Cardiorespiratory Fitness: High-intensity interval training has proven superior for improving peak oxygen consumption (V̇O₂) in women with certain conditions, such as coronary artery dissection.
• Disease-Specific Models: CR models must be adapted for conditions that disproportionately affect women, including:
  • Spontaneous coronary artery dissection (SCAD)
  • Ischemia with nonobstructive coronary arteries (INOCA)
  • Myocardial infarction with nonobstructive coronary arteries (MINOCA)
  • Breast or gynecologic cancers
  • Stress-induced cardiomyopathy

Conclusion and Recommendations for Advancing Global Goals

The American Heart Association has proposed a clear roadmap to address the gender gap in cardiac rehabilitation. Closing this gap is a public health imperative and a critical step toward achieving SDG 3 (Good Health and Well-being), SDG 5 (Gender Equality), and SDG 10 (Reduced Inequalities). Key recommendations include:

• Increasing CR awareness and implementing automated referral systems to ensure equitable access.
• Exploring and validating alternative CR delivery methods, such as virtual and hybrid models, to overcome logistical barriers.
• Integrating peer-support and mental health services into standard CR programs.
• Developing and implementing culturally sensitive and equity-focused programs.
• Promoting research and innovation to create disease-specific CR interventions tailored to conditions that disproportionately affect women.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

   The article on the gender gap in cardiac rehabilitation (CR) primarily addresses three Sustainable Development Goals (SDGs):

   • SDG 3: Good Health and Well-being

     This is the most central SDG, as the article’s entire focus is on improving health outcomes for individuals with cardiovascular disease. It discusses cardiac rehabilitation as a life-saving program that reduces mortality, lowers the risk of hospital readmission, and improves risk factors like blood pressure and cholesterol. The article explicitly states that CR “saves lives” and improves “cardiovascular health and quality of life.”

   • SDG 5: Gender Equality

     The core issue presented is the disparity in access to and participation in cardiac rehab between men and women. The article highlights that “most women never enroll” and seeks to “fix [the] gender gap in cardiac rehab.” It details factors restricting women’s access, such as lower referral rates, clinician bias, and family responsibilities, directly linking the health issue to gender-based inequality.

   • SDG 10: Reduced Inequalities

     The article expands the issue of inequality beyond gender to include other demographic factors. It points out that “women from underrepresented racial or ethnic groups, including non-Hispanic Black, Hispanic, and Asian women, have particularly low participation rates” and face additional barriers like “financial constraints, discrimination, and lack of culturally tailored programs.” This directly addresses the goal of reducing inequalities based on sex, race, ethnicity, and economic status.

2. What specific targets under those SDGs can be identified based on the article’s content?

   Several specific SDG targets are relevant to the article’s content:

   • Under SDG 3 (Good Health and Well-being):

     • Target 3.4: “By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.” The article directly supports this target by advocating for cardiac rehab, which it states reduces “cardiovascular mortality” (a non-communicable disease) and improves “mental health.”
     • Target 3.8: “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services…” The article highlights barriers to accessing an essential health service (CR), such as “lack of insurance” and “transportation issues,” and proposes solutions like remote sessions to make this care more accessible for all.

   • Under SDG 5 (Gender Equality):

     • Target 5.1: “End all forms of discrimination against all women and girls everywhere.” The article points to systemic issues and “clinician bias” that result in lower CR referral rates for women, which can be seen as a form of discrimination that denies them equal access to life-saving treatment.
     • Target 5.c: “Adopt and strengthen sound policies and enforceable legislation for the promotion of gender equality…” The American Heart Association’s new “scientific statement” and “guidelines” described in the article represent a direct effort to establish sound policies to promote gender equality in cardiovascular care.

   • Under SDG 10 (Reduced Inequalities):

     • Target 10.2: “By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, …race, …ethnicity, …or economic or other status.” The article calls for an “intersectional approach that recognizes and responds to the diverse needs of women,” specifically mentioning the need for culturally sensitive programs for women from different racial, ethnic, and socioeconomic backgrounds.
     • Target 10.3: “Ensure equal opportunity and reduce inequalities of outcome…” The article’s main goal is to reduce the inequality of health outcomes between men and women who have experienced cardiovascular events. It proposes solutions like “automated referral systems” to eliminate practices that lead to unequal opportunities for receiving care.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

   Yes, the article mentions and implies several quantitative and qualitative indicators that can be used to measure progress:

   • Mortality Rates: The article states that CR leads to a “24% reduction in all-cause mortality” for women who engage in 300 minutes of aerobic activity per week. Tracking mortality rates from cardiovascular disease, disaggregated by sex, would be a direct indicator of progress toward Target 3.4.
   • Hospital Readmission Rates: The text mentions that CR can “reduce the risk of hospital readmission by 42%.” This is a clear, measurable indicator of the effectiveness and reach of CR programs.
   • CR Referral, Enrollment, and Completion Rates: The article identifies these as key problem areas. It states that “lower CR referral rates” are a dominant factor, women are “less likely to enroll in, attend, and complete CR,” and participation rates for minority women are “often below 12%.” Tracking these rates, disaggregated by sex, race, and ethnicity, would be a primary indicator for Targets 3.8, 5.1, and 10.3.
   • Cardiorespiratory Fitness (Peak V̇O₂): The article identifies “peak V̇O₂” as the “gold standard assessment for cardiorespiratory fitness” and a “vital prognostic indicator.” Measuring improvements in peak V̇O₂ among CR participants, especially women, can serve as a clinical indicator of program effectiveness.
   • Prevalence of Cardiovascular Risk Factors: The article notes that CR improves “smoking cessation, blood pressure, cholesterol levels, and fasting glucose levels.” Monitoring these health metrics in the population, particularly among women post-cardiac event, can indicate the broader impact of improved CR access.
   • Availability of Alternative and Women-Focused CR Programs: The article suggests “remote or virtual CR sessions” and “women-focused CR programs” as solutions. An indicator of progress would be the number and accessibility of such programs, measuring the implementation of strategies to overcome barriers.

4. Table of SDGs, Targets, and Indicators

   SDGs	Targets	Indicators
   SDG 3: Good Health and Well-being	3.4: Reduce premature mortality from non-communicable diseases and promote mental health.	Mortality rates from cardiovascular disease (disaggregated by sex). Hospital readmission rates for cardiovascular events. Prevalence of risk factors (blood pressure, cholesterol, etc.). Measures of cardiorespiratory fitness (Peak V̇O₂).
   	3.8: Achieve universal health coverage and access to quality essential health-care services.	Percentage of eligible patients referred to and enrolled in cardiac rehab. Availability and use of alternative delivery models (remote/virtual CR).
   SDG 5: Gender Equality	5.1: End all forms of discrimination against all women.	Cardiac rehab referral, enrollment, and completion rates (disaggregated by sex). Data on clinician bias in referrals.
   	5.c: Adopt and strengthen sound policies for the promotion of gender equality.	Number of healthcare systems implementing AHA guidelines for women. Number of women-focused CR programs established.
   SDG 10: Reduced Inequalities	10.2: Empower and promote the inclusion of all, irrespective of sex, race, ethnicity, or economic status.	Participation rates in CR among underrepresented racial/ethnic groups. Availability of culturally sensitive and tailored CR programs.
   	10.3: Ensure equal opportunity and reduce inequalities of outcome.	Disparities in CR referral and completion rates between different demographic groups (sex, race, socioeconomic status). Adoption rate of automated referral systems to reduce bias.

Source: news-medical.net