Laura Correia

Cardiac rehabilitation (CR) stands as one of the most powerful tools for secondary prevention of cardiovascular disease (CVD) (Dibben et al., 2021). Yet despite its proven benefits, participation in the United Kingdom (UK) remains starkly uneven; only around half of eligible patients attend, with women and patients from minority ethnic backgrounds persistently underrepresented (NACR, 2023a). These inequities raise urgent question. Why do such disparities exist? And more importantly, how can CR be redesigned to ensure it truly serves all who need it? This thesis addresses these questions head on, using intersectionality (Bowleg, 2012; Crenshaw, 1989) as a critical lens to uncover how social identities such as gender, ethnicity, cultural norms, and religion overlap to influence access, experience, and outcomes in CR. Through three interlinked studies, the research paints a layered, multidimensional picture of systemic and lived barriers while also pointing toward meaningful, inclusive solutions. The first study, a national Delphi process with 38 healthcare professionals (HCPs), revealed gaps in knowledge, fragmented referral pathways, and a lack of cultural sensitivity. HCPs highlighted the compounded disadvantage of women from minority ethnic backgrounds, particularly Asian women facing language barriers, who experience a “triple vulnerability” at the intersection of gender, ethnicity, and language challenges (see Chapter Four). The second study, building on the findings of the national Delphi process, drew on in-depth interviews with 10 HCPs and portrayed CR as a neglected “Cinderella service”: underfunded, poorly integrated, and lacking visibility across hospital and community contexts. HCPs stressed the need for tailored education, female inclusion training and cultural awareness. Critically, HCPs emphasised the lack of practical tools to help staff recognise and respond to the intersecting roles of culture, gender, and structural inequality in shaping access to CR (see Chapter Five). The third study placed centre stage the voices of 19 women from ethnically diverse backgrounds through focus groups. Their testimonies laid the realities of misdiagnosis, gendered caregiving expectations, cultural norms, discrimination, and structural disadvantage. These barriers were particularly pronounced for minority ethnic women, with the concept of cultural-health silence, a reluctance or inability to voice health needs, emerging as the most powerful barrier to CR access. Strikingly, women envisioned CR not only as a rigid, medicalised programme but as an inclusive, community anchored, culturally responsive space that honours women’s lived experiences and real-life responsibilities (see Chapter Six). Taken together, these three studies demonstrate that disparities in CR cannot be dismissed as matters of “patient choice”. Instead, they are deeply rooted in structural arrangements, professional practices, and sociocultural norms, and become particularly visible when viewed through the lens of intersectionality (Crenshaw, 1989). This thesis argues that achieving equity demands nothing less than for a fundamental reimagining of CR, from a marginal “add on” to a responsive, inclusive, and empowering intervention that truly reflects the needs of diverse patient populations.

Background Cardiac rehabilitation (CR) provides proven benefits, yet only 50% of eligible individuals participate, with females and ethnic minority groups being particularly underrepresented. This study aimed to explore healthcare professionals’ (HCPs) views on factors influencing referral and attendance to phase III CR services in the United Kingdom (UK), with the purpose of identifying evidence-based recommendations and strategies to enhance access and participation. Methods Thirty-eight HCPs involved in the cardiac care or rehabilitation of patients with coronary heart disease (CHD) participated in a three-round Delphi study. Participants were asked about staff competencies, CR core components, referral criteria, referral pathways, and the impact of sex and ethnicity on referral and attendance. Results 108 statements were proposed by the participants. Consensus was achieved on 53 statements covering 10 key aspects of CR. HCPs identified significant disparities in referral practices and attendance, attributing these to HCP knowledge gaps, lack of streamlined referral pathways, and non-inclusive referral processes. They emphasised the need for educational initiatives within general practitioner surgeries and the development of direct referral pathways to improve CR access. Additionally, HCPs highlighted the importance of educating ward staff on inclusive practices and cultural sensitivity to improve referrals, particularly for females and ethnic minority groups. Conclusions The study highlights disparities in CR referral and attendance, particularly by sex and ethnicity. It provides evidence-based recommendations to ensure equitable access to CR services. Future interventions should focus on tailored education for HCPs and streamlined, direct referral pathways to ensure inclusive access for diverse populations in the UK.

Background Cardiovascular rehabilitation (CR) is a crucial element in the management of coronary heart disease (CHD). However, only 52% of those eligible for CR participate in it, with lower engagement among females and minority ethnic groups. Despite reported barriers to participation, healthcare professionals’ (HCPs) perspectives on referral and attendance remains unexplored. Aim To explore the perspectives of HCPs on factors influencing referral and attendance to CR services in the UK. Methods A three-round Delphi study (May to September 2023) involved 38 HCPs recruited via snowball sampling. In Round One, 12 open-ended questions enquired about participants’ views on staff competencies, core components of CR, referral criteria, referral pathways, and the associations between sex and ethnicity related to referral and attendance. Content analysis informed a structured five-point Likert scale questionnaire used in Round Two. Consensus was defined a priori as ≥ 70% agreement among the participants. In Round Three, participants were asked to retake the questionnaire after receiving feedback for individual and group responses. Results Consensus was achieved on 53 of the 108 statements, covering 10 key aspects of CR. HCPs acknowledged significant disparities in UK CR programmes, attributing these to knowledge gaps. HCPs emphasised the need for educational initiatives within general practitioner (GP) surgeries and direct referral pathways as effective strategies for enhancing sex-specific referrals to phase III CR. Furthermore, HCPs suggested education for hospital ward staff on inclusion and cultural training, alongside building relationships with local communities, to improve ethnic-specific referrals to CR (table 1). Conclusion This study highlights HCPs perspectives on referral and attendance to CR programmes in the UK, focusing on sex and ethnicity. HCPs emphasised the urgent need for initiatives to enhance clinicians’ knowledge and ensure inclusivity in CR services. Future research should build on these findings to promote equitable access to CR for diverse UK populations.