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Keywords:

  • cardiac rehabilitation;
  • ethnicity;
  • myocardial infarction;
  • patients’ experience;
  • qualitative study

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. Conflicts of interest
  11. Source of funding
  12. References

Aims and objectives.  To explore the cardiac rehabilitation experiences of Punjabi Sikh patients post myocardial infarction.

Background.  Punjabi Sikh people are at significantly higher risk of mortality from myocardial infarction compared with those of European descent. Punjabi Sikh patients’ participation in cardiac rehabilitation post myocardial infarction is therefore likely to yield considerable benefits. However, uptake of cardiac rehabilitation by South Asian people has been reported to be modest. Previous investigators have seldom provided insight into experiences of Punjabi Sikh patients post myocardial infarction and the steps that can be taken to improve the appropriateness of cardiac rehabilitation programmes for this at-risk patient group.

Design.  Interpretive qualitative design.

Method.  In-depth interviews, based on the McGill Illness Narrative Interview schedule, with 15 Punjabi Sikh patients post myocardial infarction attending a cardiac rehabilitation programme in British Columbia, Canada, were conducted; thematic analysis using grounded theory methods of coding and constant comparative analysis was employed.

Results.  Four mutually exclusive themes emerged relating to the salient aspects of participants’ cardiac rehabilitation experience: ‘making sense of the diagnosis’, ‘practical dietary advice’, ‘ongoing interaction with peers and the multi-disciplinary team’ and ‘transport and attendance’.

Conclusions.  The themes identified point towards some of the ingredients necessary for providing culturally appropriate cardiac rehabilitation interventions for Punjabi Sikh patients following myocardial infarction. The findings highlight the importance of providing culturally relevant rehabilitation advice about diet and lifestyle changes and providing time for ongoing dialogue with support from health care professionals and peers. The findings from this study also illustrate the need to avoid generalisations about the impact religious beliefs may have on South Asian individuals’ willingness to adhere to cardiac rehabilitation advice and make lifestyle adjustments.

Relevance to clinical practice.  This study raises awareness of some of the salient features of experiences of Punjabi Sikh patients with post myocardial infarction that can help guide nurses to provide culturally appropriate cardiac rehabilitation and coronary health promotion.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. Conflicts of interest
  11. Source of funding
  12. References

Substantial variations in the prevalence of coronary heart disease (CHD) have been observed among people of differing ethnic origin. Individuals of Punjabi Sikh ethnic origin, those originating from the northern province of Punjab in India and who practice Sikhism, experience CHD at a significantly younger age on average and have a higher morbidity rate compared with people of European origin. Epidemiological studies have shown migrant South Asian populations such as Punjabi Sikhs to have a three- to five-fold greater risk of premature death from myocardial infarction (MI), as well as a higher risk of further coronary events following MI, compared with populations of European descent (Sheth et al. 1999, Yusuf et al. 2004, Joshi et al. 2007).

Although established risk factors such as those identified in the INTERHEART study (i.e. smoking, dyslipidemias, diabetes, abdominal obesity, stress, poor diet and lack of physical exercise) account for most CHD risk globally (Yusuf et al. 2004), abdominal obesity and insulin resistance, in particular, have been noted to explain the increased CHD risk in migrant South Asian populations (Gupta et al. 2002, 2006, Gupta & Brister 2006). The accumulation of visceral adipocytes (abdominal obesity) has been shown to lead to metabolic derangements, including insulin resistance, which heighten the risk of CHD morbidity and mortality (Cnop et al. 2003). Therapeutic strategies that address these specific risk factors through the promotion of physical exercise and weight loss thus confer considerable benefits to Punjabi Sikh patients who suffer MI (Banerjee et al. 2007). These important lifestyle modifications are typically offered through cardiac rehabilitation (CR) programmes.

The importance of CR following MI – which is aiming at promoting recovery, maximising quality of life and reducing recurrence of cardiac illness – is well recognised. The content of CR programmes is variable but generally includes exercise, education and relaxation and is usually offered in hospital settings (Beswick et al. 2004, Jones et al. 2007). Meta-analyses of clinical trials have shown the net benefits from structured CR for patients with CHD to be a 20–26% reduction in total mortality and improvements in social and emotional health and well-being (Oldridge et al. 1998, Taylor et al. 2004). Given that Punjabi Sikh people are at significantly higher risk of mortality from MI compared with the risk of those of European descent, their participation in CR is likely to yield considerable benefits. However, the provision and uptake of outpatient CR programmes by ethnic minorities have been reported to be modest (Beswick et al. 2004). Patients with MI of South Asian ethnic origin, in particular, have been found to substantially underuse CR programmes and have a higher attrition rate once enrolled in a programme compared with ‘white’ individuals (Jolly et al. 2004). In a retrospective analysis of ‘South Asian’ (n = 220) and white (n = 980) patients participating in two outpatient, hospital-based CR programmes over three years, Banerjee et al. (2007) found ‘South Asian’ patients were significantly less likely than white patients to complete the entire programme (43 vs. 51%; p = 0.04). Despite combinations of factors related to non-participation in and non-adherence to CR having been identified (Daly et al. 2002, Jackson et al. 2005), previous investigators have seldom provided insight into patients’ experiences of CR and thus the steps that can be taken to improve the design, delivery and appropriateness of CR programmes (Jones et al. 2007).

Webster et al. (2002) conducted one of the only qualitative investigations, to date, of the post MI experiences of South Asian people (Gujrati Hindu patients). Although the study did not address the experiences of CR per se, the findings highlight some reasons why current CR services may not be meeting the needs of South Asian populations. In particular, the researchers suggested that a lack of accessible, culturally appropriate information about CHD, its management and prognosis may influence South Asian patients’ post MI behaviour (such as physical inactivity and other lifestyle behaviours) and therefore their adherence to CR recommendations.

However, a paucity of research has explored Punjabi Sikh patients’ actual experiences of CR post MI. There is neither a theoretical nor empirical basis for the design of CR interventions that are accessible and appropriate to this high-risk population (Webster et al. 2002). The aim of this study was to explore the experiences of Punjabi Sikh patients with post MI attending a CR education programme to identify some of the elements or components necessary to provide relevant, culturally appropriate CR programmes.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. Conflicts of interest
  11. Source of funding
  12. References

Design

An interpretive qualitative approach was used to develop better understandings of the social processes associated with Punjabi Sikh patients’ experiences of CR post MI. Qualitative research methods involve the systematic collection, organisation and interpretation of data derived from discourse or observation (Morse & Field 1995, Strauss & Corbin 1998, Mays & Pope 2000). The study employed a thematic approach to data analysis using grounded theory methods of coding and constant comparison, as described by Strauss and Corbin (1998) and Charmaz (2000). Although this study is not presenting a grounded theory per se, the techniques used in conventional grounded theory are widely used as pragmatic ‘tools’ in exploratory qualitative research studies seeking to explore and describe social situations and to understand social phenomena (Charmaz 2000). This made the approach ideally suited to explore the meaning Punjabi Sikh patients ascribed to their CR experience post MI (Jolly et al. 2004).

Study setting

The setting for the study was a hospital-based comprehensive CR education programme in keeping with current clinical guidelines (CACR 2009) that served an ethnically diverse population in an urban centre of British Columbia, Canada. The programme was offered weekly and included exercise, health and lifestyle-oriented education and risk reduction and rehabilitation advice. The attendees were able to meet with and ask questions of health professionals on a one-to-one basis and undergo monitoring of blood pressure, blood glucose and weight/waist-to-hip ratio. During some of the CR sessions (dependent on availability), a bilingual (English and Punjabi speaking) pharmacist, nurse, physiotherapist, dietician or occupational therapist was available to answer questions and to provide advice. A resource binder for the programme, translated from the English-language programme into Punjabi, was offered to each of the Punjabi-speaking participants during the first week of the programme. Supplementary materials including pamphlets translated from English into Punjabi were also available to the participants.

Participants and sampling

South Asians are a heterogeneous group with varying diets, culture, lifestyles and religious affiliations. Broad, catch-all ethnic categories such as ‘South Asian’ have been criticised for failing to capture this diversity and ‘othering’ minority ethnic groups (Bradby 2003). The use of religious belief as a grouping, when used in conjunction with a person’s ethnic identity, has been shown to be a more effective approach with which to explore diversity (Nazroo 1997, Darr et al. 2008). Accordingly, our sample was drawn on the basis of patients who self-identified as Punjabi Sikh. Spirituality, religious practice and health are entwined in intricate balance for Punjabi Sikh (Labun & Emblen 2007), and they comprised 90% of the South Asian population from which the study sample was drawn (Statistics Canada 2001). CR attendees were eligible to participate in the study if they were:

  • 19 years of age or older (the legal age of consent in British Columbia, Canada);
  • • 
    Diagnosed with MI in the past 12 months;
  • • 
    Self-identified as Sikh; and
  • • 
    Self-identified as Punjabi speaking.

Approval was granted by the appropriate hospital and university research ethics boards. The programme was then visited on a weekly basis to identify individuals eligible for study participation. A theoretical sampling method was used to identify participants who were best able to articulate experiences relevant to the study’s research question. Eligible individuals were invited to take part in an in-depth interview with a bilingual interviewer in the language of their choice (English or Punjabi) at a time and place convenient to them. All of the enrolled participants chose to be interviewed in Punjabi and in their own homes.

Data collection

An interview guide based on the McGill Illness Narrative Interview (MINI) was developed for the study (Groleua et al. 2006). The MINI is a theoretically driven, semi-structured interview protocol designed to elicit illness narratives in health research (Groleua et al. 2006). Themes identified to be of theoretical relevance during data collection (because they were repeatedly present or notably absent) were developed into new interview questions, incorporated into the MINI guide and used in subsequent interviews to ‘test’ the emerging patterns. Data collection ceased when no new information pertaining to the research question was emerging during the interviews.

The interviews were digitally audio-recorded, translated into an English audio-recording by the (bilingual) interviewer and then transcribed verbatim. The use of translation in qualitative research has been criticised for its potential to bias the interviewer’s questions and the participants’ responses, as well as the overall interpretation of data (Larkin et al. 2007). Another bilingual, Punjabi-speaking researcher was therefore asked to validate the interviewer’s English translations with the original Punjabi audio recordings and to provide additional insight into the participants’ responses.

Data analysis

The interview transcripts were initially coded using a line-by-line analytical procedure that involved the examination of every line of a transcribed interview to search for similarities and differences in incidents and phenomena. Similar incidents and phenomena described by the participants were labelled as ‘open codes’. Coded data exemplars were then constantly compared between and in the transcripts to identify linkages between the open codes and patterns in the data set. A salient feature of the analytical process involved purposefully sampling ‘deviant cases’: participants with experiences that that ran counter to emerging patterns or that did not fit with our understandings of the data (Strauss & Corbin 1998). Deviant cases were recruited and interviewed and helped develop explanations for any observed variability through the refinement of themes. To illustrate, a theme emerged regarding participants’ transport difficulties; deviant cases (in this instance, those who did not experience transport difficulties) were recruited to refine our understanding and insight into the different circumstances associated with participants’ attendance at CR. Using the iterative constant comparative process, codes that were identified as coherent patterns – both within and across transcripts – were extracted and raised to conceptual themes that described the phenomena.

Rigour

The extracted themes were examined by a qualitative researcher not involved in the study who then met with the authors to discuss and compare coding decisions and conceptual propositions to stimulate consideration and exploration of additional perspectives and explanations and to prevent ‘premature closure’ of the search for meaning and patterns in the data (Long & Johnson 2000, Mays & Pope 2000). Disagreements about coding decisions were resolved through discussion, and the data set was revisited on several occasions to refine the analysis, reach a consensus and thus finalise the extracted themes. Data exemplars from each extracted theme were verified against the original Punjabi digital-audio recordings by two bilingual researchers to ensure that the themes and translated data accurately reflected the original data.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. Conflicts of interest
  11. Source of funding
  12. References

The study sample comprised 15 participants: five women and 10 men. Their ages ranged from 45–80 . All had been diagnosed with an MI within six months of their interview. All had been born in the Punjab region of Northern India and were now permanent residents of British Columbia, Canada (years in Canada ranged from 6–49).

The majority of the participants considered the CR programme to be beneficial to their post MI rehabilitation and recovery. Four mutually exclusive themes emerged from the analysis of the participants’ narratives relating to the salient aspects of their CR experiences. These were (i) making sense of the diagnosis; (ii) practical dietary advice; (iii) ongoing interaction with peers and the multi-disciplinary team; and (iv) transport and attendance. Contrary to previous studies on Sikh patients’ management of CHD (King et al. 2006, Bedi et al. 2008), we found no consistent gender, age or socio-economic differences associated with the themes identified in our study.

Making sense of the diagnosis

The participants’ experiences showed that suffering an MI had a profound effect on them. Many expressed shock and disbelief about their diagnosis because they had considered their health to be good before their cardiac event. CR education and support were viewed unanimously by the participants as being important in helping them understand what had caused their MI and how they could reduce the risk of having future cardiac episodes:

Participant 01 (♀): …We really didn’t know because you don’t really think about these things, you know. You don’t have any pain, you don’t have anything, you don’t have any signs or symptoms so you don’t pay attention to these kinds of things … They [CR health professionals] talk about what causes it, why it happens, what makes it happen…

In making sense of their diagnosis, all the participants stressed the importance of religious faith in their lives. Two participants self-identified as being both Sikh and Hindu (a common practice among some Punjabi individuals (Puri 1992); the remaining 13 all identified as being Sikh. The participants readily shared their views on how the Sikh tenets of Kismet (fate) and their faith in Waheguru (Divine/God) had influenced their perceptions of their diagnosis:

Participant 03 (♀): He/she [Waheguru] is the one who keeps you and protects you. I didn’t lose faith … Whatever life I have written is what I’m going to have. Whatever pains and whatever suffering I have, those are all written. I’m going to have those. Whatever pain you were meant to have you’re going to have, no matter how much you take care of yourself. Whatever is in your kismet, whatever is written, that is what is going to happen.

Although Kismet was as an overarching concept that informed the faith values of the participants, personal responsibility was also frequently acknowledged. The concept of Dharam dee Kirat Karnee– one of the three pillars of the Sikh way of living that requires Sikhs to engage in honest and hard-working pursuits to care for themselves, their families and their wider communities – was often linked with individual health promotion changes. Participant 06, for instance, spoke of his belief in a predetermined destiny (Kismet) but also how he took individual responsibility for altering his health-related behaviour:

Participant 06 (♂): You know… if it’s a matter of faith you know we, I ate, we ate bad things, my cholesterol increased and that’s why it built up in my arteries. Waheguru didn’t make that, I made that [change], that happened by my mistake. If I change my behaviour around my eating and around my health and continuing to take my medications, which I have to eat now.

Practical dietary advice

Diet featured strongly in the participants’ narratives. The majority of the participants expressed confusion and uncertainty about which types of traditional Indian food and cooking methods were considered healthful and therefore acceptable. Being able to learn about practical diet and nutritional choices in the CR programme was therefore highly valued. An unexpected finding pertaining to this theme was the frequency with which the participants identified their lack of knowledge about what fibre was and how it related to a healthful cardio-protective diet:

Participant 06 (♂): I want to know about more practical things that I could do like eating fibre or and I don’t know what fibre meant so I tried to figure that out. I wanted to know more things like what is fibre in, um, what does fibre look like. And yeah, that kind of thing would help. If you could actually see what fibre is in, then that would help. If you just keep talking you just don’t know so you need some more practical things to know and then you can understand what you need to understand. You understand everything that it helps.

Opportunities for receiving ongoing support and reassurance were widely seen as a critical element. For instance, Participant 03 discussed her need for further confirmation that the dietary changes she had recently made were beneficial. Indeed, the participants sometimes used the study interview as an opportunity to clarify CR advice and to ask questions. Having opportunities to discuss rehabilitation measures was paramount to validating the effectiveness of the lifestyle changes that had been made and how they could continue to improve their health and recovery:

Participant 03 (♀): Well I really want to know if there’s any harm in heating up skim milk and drinking skim milk. Is there a problem with that?

Interviewer (♀): You know the nutritionist that came, did you speak to her?

Participant 03 (♀): Yes, I asked. She said that I could drink it - that there’s no harm in it and even I can make yogurt from it because at night we usually heat up a cup of hot milk and we usually drink it. But is that a problem? Is that dangerous?

Ongoing interaction with peers and the multi-disciplinary team

A key finding in our study was the importance the participants placed on having the opportunity to have regular private discussions about the changes they were making with the CR health care professionals:

Participant 05 (♂): … We can tell them [the CR healthcare professionals] what we’re doing, but afterwards we can phone them and say this is what we did because of the lessons that you’ve taught us. This is how much I’ve decreased my waist measure. This is how much my cholesterol has gone down. So it’s a good thing, this work that they’ve done. There’s success around it.

In addition to their interactions with health care professionals, it was also clear from the participants’ narratives that peer support was a crucial element of their CR experience. Several participants identified the time made available to mingle and chat with other participants as being the most beneficial aspect of the entire programme:

Participant 05 (♂): When you’re able to speak to someone that’s like-minded you’re able to have a dialogue and you’re able to share your experiences and they’re able to understand you and there’s a lot of support in that.

The participants’ experiences also reflected the benefit of having practitioners from multiple disciplines provide specific advice at the CR programme (nurses, pharmacists, occupational therapists, physiotherapists and dieticians). Language barriers were an issue for some participants who did not get the opportunity to engage in a private discussion with a Punjabi-speaking practitioner (because of lack of availability):

Participant 13 (♂): …we have a bit of a problem with English. In Punjabi, we can ask something in full. We can ask questions in full, what is this, what is that, what isn’t it. In English, we don’t always understand everything.

Those who did get the opportunity to engage with Punjabi-speaking CR practitioners (an opportunity not available to all depending on the availability of the practitioners) spoke positively about the benefit of receiving practical, culturally appropriate rehabilitation advice. Participant 09 illustrated this in her description of the advice she had received regarding the cooking of Roti: a flat bread that is a staple in a traditional Punjabi diet:

Participant 09 (♀): … You know, the brown atta [flour used to make Roti] is what I think is better for you, that one is better and that’s where like the wheat germ is and all the nutrients are in that one, there’s fibre in there, there’s everything. Yeah we realise that, you know, the wheat germ is like the most important thing and that’s the thing that you should keep in the flour.

Transport and attendance

In addition to sharing the positive aspects of their CR experience, the participants also talked at length about the challenges they faced during the CR programme. Transportation was one of the main issues identified:

Participant 10 (♂): When I have the problem with the ride and I don’t have a ride and then, you know, my family members, the ones I live with, you know, my household members I mean they get frustrated as well and then that’s why I get mad at myself like, you know, ‘why can’t you drive?’.

A strategy that some participants applied to resolve their transportation challenges was to walk to the hospital. However, some family members were concerned about their relatives walking long distances, as was the case in Participant 07’s experience:

Participant 07 (♂): I’ve gone [to the CR programme] and I’ve walked there, you know. One day I went and walked and, you know, [my family] told me not to take a walk and they said they can just drop me off and pick me up that, you know, ‘its easy enough just to go drop you off and then pick you up’.

Although Participant 07’s family members were able to accommodate the timing of the CR programme, several other participants indicated that because their family members worked usual business hours (when the CR programme was delivered), attending the group was particularly challenging:

Participant 06 (♂): The time, sometimes it’s hard for somebody to drop me off and pick me up. That’s really hard, but other than that it’s totally fine, it’s just the timing that’s a bit off.

An additional challenge reported by the participants who were able to drive was the cost and availability of parking at the hospital. For patients who were not working (because of their recent MI), this cost was considered to be exorbitant when added to their fuel expenses:

Participant 13 (♂): No parking is the main problem there. You know and if you get there a bit early you can park a bit farther away and, you know, I try to park on the streets because then I can get a walk in, its farther.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. Conflicts of interest
  11. Source of funding
  12. References

A recent review of the literature addressing patient experience, uptake and adherence to CR programmes identified an absence of simple, practical interventions aimed at improving CR provision for specific patient groups (Beswick et al. 2005). Consideration of cultural differences when delivering health promotion has been suggested to improve adherence to CR among ethnic groups (Caulin-Glaser & Schmeizel 2000). However, there remains a dearth of research examining the actual rehabilitation experiences of patients with MI of South Asian ethnicity. This study explored the experiences of 15 Punjabi Sikh patients who were attending a CR education programme.

Several themes emerged that extend the findings of previous research. A key finding in this study was the importance participants placed on their religious faith in their attempts to make sense of their diagnosis. Webster et al. (2002) previously suggested that religious faith and a fatalistic attitude towards recovery may explain South Asian patients’ inactivity post MI. Other researchers have also identified fatalism as a key factor in South Asian people’s non-compliance with coronary health promotion (Naqvi 2003, Bedi et al. 2008). However, by contrast, our data clearly illustrated that the participants incorporated a sense of individual responsibility in a fatalistic framework of beliefs to make recommended health promotion changes. The participants made dietary and exercise changes and aligned these with the Sikh philosophy of Dharam dee Kirat Karnee (responsibility to one’s self). Although the concept of Kismet (fate) and Karma is shared by many religious traditions of the Indian subcontinent, these findings highlight the need to avoid homogenous generalisations about ‘South Asian’ patients and the impact religious beliefs may have on individuals’ willingness to adhere post MI to rehabilitation advice and to make lifestyle adjustments. Recognising diversity in the interplay of spirituality, religion and health is a key component underpinning culturally competent nursing care (Campinha-Bacote 2003). South Asian religious groups each have their own set of beliefs and practices that can have a varying impact on CHD-related behaviours and risk management that Western health care providers often do not recognise (Gupta et al. 2006, Labun & Emblen 2007).

The CR literature identifies a lack of accessible information and language issues as key factors in South Asian post MI patients’ experiences of health care and rehabilitation (Tod et al. 2001b, Webster et al. 2002, Jolly et al. 2004). UK-based studies have suggested that an inability to speak English fluently may represent a culture-specific barrier that limits the ability of South Asian patients to effectively participate in CR (Tod et al. 2001b, Webster et al. 2002, Jolly et al. 2004). Participants’ experiences in this study showed that being given the opportunity to interact with practitioners in their mother tongue had a profound and positive impact on their overall CR experience. One result of the study worthy of particular note was the importance the participants placed on receiving practical, culturally relevant dietary advice. Previous research has reported that the translation of educational materials and CR information is crucial for ethnic minority groups (Eftekhari et al. 2000, Beswick et al. 2004, Visram et al. 2008). Our study highlights the need to not only translate CR materials but also the need to make them culturally relevant; particularly with regard to diet. It was also notable that the participants in the study valued opportunities for ongoing engagement with health care professionals to validate the changes they were making. The general literature mostly emphasises the importance of physician’s involvement in CR (Beswick et al. 2004, 2005). With regard to health care professionals’ interactions, the men and women in our study spoke of the importance of having time for private, one-to-one question-and-answer sessions, access to practitioners from multiple disciplines, as well as having the opportunity to discuss their experiences and lifestyle changes with their peers.

An additional key finding in this study was the transport and financial difficulties the participants often faced in attending the programme. This is an issue of concern for maintaining patients’ adherence at CR programmes and has been previously reported (Tod et al. 2001a,b, Webster et al. 2002). Our findings would seem to support recommendations to offer CR classes at varying times of the day and week to suit patients and their families, such as before work and in the evening, and in differing locales, such as home- or community-based programmes (Jolly et al. 2004).

Limitations of the study

The aim of qualitative research is not to generate statistically generalisable results, but rather to uncover insight into the issues faced by the sample being engaged at the time. This was a small, exploratory study that used only one study setting, and generalised application of the findings therefore requires caution. However, as data were collected until the point of theoretical saturation, the themes that have been identified in this study provide useful insights that may be applicable to other Punjabi Sikh populations attending CR post MI. Further research with other South Asian religious groups is necessary to determine whether the themes identified in our study are relevant to other South Asian, religious and ethnic minority groups.

Conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. Conflicts of interest
  11. Source of funding
  12. References

This study raises awareness of some of the salient features of Punjabi Sikh post MI patients’ experiences of attending CR. In doing so, it points towards some of the ingredients necessary for providing more culturally appropriate CR interventions for this at-risk patient group. Further research in other settings and with other South Asian religious groups is required to explore in greater detail the themes identified in this study and to develop the work in this field. In particular, studies could be usefully conducted that explore the reasons for ethnic minority groups’ non-attendance at CR.

Relevance to clinical practice

Nurses can play a key role in improving CR services by providing individualised, culturally appropriate coronary health promotion. To improve CR provision for Punjabi Sikh patients, our study highlights the importance of providing practical, culturally relevant rehabilitation advice about diet and lifestyle changes, in addition to allowing time for ongoing dialogue with support from health care professionals and peers.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. Conflicts of interest
  11. Source of funding
  12. References

This research was supported by a Michael Smith Foundation for Health Research (MSFHR) grant. Thanks to Dr Pamela A Ratner for feedback on earlier manuscript drafts.

Contributions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. Conflicts of interest
  11. Source of funding
  12. References

Study design: PG; data collection and analysis: PG, BK and manuscript preparation: PG, BK.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusion
  8. Acknowledgements
  9. Contributions
  10. Conflicts of interest
  11. Source of funding
  12. References
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