MEXICAN- AND ANGLO-AMERICANS IN CARDIO REHABILITATION: DO CULTURAL DIFFERENCES MAKE A DIFFERENCE?

Transcription

1 MEXICAN- AND ANGLO-AMERICANS IN CARDIO REHABILITATION: DO CULTURAL DIFFERENCES MAKE A DIFFERENCE? Ada Wilkinson-Lee, Michael J. Rohrbaugh, Joshua Schoenfeld, and Varda Shoham University of Arizona National Council on Family Relations, Vancouver BC November 2003 Abstract Anglo- and Mexican American patients entering phase II cardiac rehabilitation at two hospitals (N=310) provided medical history information and completed questionnaire measures of psychological distress, self-efficacy for rehabilitation, and coping styles. The groups differed on several demographic and coping-style variables at admission, and psychosocial variables such as distress, self-efficacy, and confiding in significant others predicted patient participation and benefit over the next three months in different ways for the two culture groups. Taking culture into account appeared to improved prediction of outcomes, suggesting possible advantages of culturally-sensitive intervention programming. Background Cardiovascular disease (CVD), primarily manifested by coronary heart disease and cerebrovascular disease (stroke), is the leading cause of mortality and disability for all ethnic groups in the United States (Centers for Disease Control and Prevention, 2002; Perez-Stable, Juarbe, & Moreno-John, 2001). Because of its importance to the treatment of CVD, training in regular physical exercise has become the cornerstone of cardiac rehabilitation (CR) programs. Meta-analyses of clinical trials demonstrate that medically prescribed and supervised exercise can reduce mortality rates among patients with CVD and improve psychosocial functioning (Bock, Albrecht, Traficante, Clark, et al., 1997; Haskell, 1994; O Connor, Buring, Yusuf, Goldhaber, et al., 1989). Although some data exist documenting ethnic differences in cardiac morbidity and mortality, virtually no research has examined participation by Mexican-American patients in exercise-oriented CR. The present study compared Mexican- and Anglo-American patients entering two CR programs in order to (a) identify possible demographic and psychosocial differences between these groups at admission on variables such as psychological distress, selfefficacy for rehabilitation, social support, and ways of coping; and (b) identify possible ethnic differences in program participation and staff-rated benefit over the next three months. Beyond these mean-level differences, we were especially interested in whether patient characteristics predict outcome in different ways for the two groups because, if present, such cultural moderation could mean that CR is a fundamentally different experience for Mexican- and Anglo- American patients. Finally, because gender figures prominently in discussions of ethnic group differences (McGoldrick, Giordano & Pearce, 1996), we examined patient sex as a potential moderator of ethnic differences in short-term outcome and initial psychological distress.

2 Method 263 Anglo- and 47 Mexican-American patients entering phase II cardiac rehabilitation at two Tucson hospitals provided medical history information and completed questionnaire measures of psychological distress, self-efficacy for rehabilitation, and coping styles. Later, 12 weeks after admission, each patient's program participation (number of sessions attended) was recorded from the medical chart, and each patient's benefit was independently rated by two members of the CR staff. Because participation and staff-rated outcome were moderately correlated (r =.58) and data were more complete for the former than the latter, our prediction analyses focused mainly on number of sessions attended. Ethnic background was operationalized on the basis of a questionnaire item asking patients to self-identify themselves by ethnic group. Those choosing specific categories other than "Mexican American" or "Hispanic" were excluded from the main analyses, so that comparisons could be made between Hispanics and patients who identified themselves only as "Anglo-American" or "white." patients were also asked to rate the strength of their identification with their ethnic group on a 1-7 scale, and on this item mean scores were substantially higher for Mexican- than Anglo-Americans patients (p <.01). Psychosocial measures included (a) an abbreviated version of the Hopkins Symptom Checklist (HSCL-25; Heshbacher et al., 1978; Derogatis et al., 1974), used in previous studies of distress among heart patients (Coyne & Smith, 1991; Rohrbaugh et al., 2002), which offers a cut point above which patients would likely qualify for a diagnosis of depression or anxiety; (b) selected coping scales (from Carver's (1997) Brief COPE inventory); (c) a 14-item scale with good internal consistency measuring self-efficacy to participate in CR (e.g., managing medication, diet, exercise and controlling symptoms); and (d) a rating of how much the patient confide in others. Results Table 1 presents data comparing demographic and psychosocial characteristics of the Mexican- and Anglo-American patients at admission, as well their CR participation and staffrated benefit over the next three months. Here it can be seen that the Mexican-American heart patients tended to be younger, less educated, more religious, and more often obese (Body Mass Index > 30). On the psychosocial measures, Mexican Americans were somewhat more likely than Anglos to report confiding in others and to prefer acceptance and positive reframing as coping strategies; however, the groups did not differ overall in cardiac self-efficacy or psychological distress. As for participation and outcome, the number of sessions attended did not differ by group, although the (mostly Anglo) CR staff tended to view Anglo patients as benefiting more from the program than Mexican Americans. Interestingly, a somewhat different picture emerges with patient gender taken into account. For example, a significant statistical interaction indicates that distress levels were substantially higher for Mexican-American than Anglo men, whereas the direction of means was if anything opposite for women (Figure 1). Similarly, initial distress did appear more predictive of participation among Mexican-Americans than Anglos, but the direction of association was different for men than for women (Figure 2). 2

3 Further analyses using culture group as a moderator variable provide additional evidence that patient characteristics may predict CR participation and outcome in different ways for Mexican-Americans and Anglo. In particular, frequency of attending religious services predicted number of sessions attended for Anglos but not Mexican-Americans, whereas rehabilitation selfefficacy and confiding in others, like psychological distress, appear to have greater prognostic significance for Mexican-Americans than Anglos. Conclusions and Implications The results highlight apparent differences in the CR participation of Mexican- and Anglo- American patients at two southwestern hospitals. In addition to expected demographic differences at admission, the groups differed on several psychosocial variables related to preferred coping styles and social support. Perhaps most important, psychosocial variables appeared to predict program participation in different ways for the two culture groups, and taking both culture and gender into account helped to explain variation in both patient distress and participation/outcome This suggests, in turn, that CR may be a fundamentally different experience for Mexican and Anglo-American patients, and that culturally-sensitive intervention programming could improve rehabilitation effectiveness. References Bock, B.C., Albrecht, A.E., Traficante, R.M., Clark, M.M., Pinto, B.M., Tilkemeier, P., & Marcus, B.H. (1997). Predictors of exercise adherence following participation in a cardiac rehabilitation program. International Journal of Behavioral Medicine, 4, Carver, C.S. (1997). You want to measure coping but your protocol s too long: Consider the brief COPE. International Journal of Behavioral Medicine, 4, Centers for Disease Control and Prevention (2002). Preventing Heart Disease and Stroke: Addressing the Nation s Leading Killers [On-line]. Available: Coyne, J.C., & Smith D.A. (1991). Couples coping with a myocardial infraction: A contextual perspective on wives distress. Journal of Personality and Social Psychology, 61, Derogatis, L.R., Lipman, R.S., Rickels, K., Uhlenhuth, E.H., & Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioral Science, 19, Haskell, W.L. (1994). The efficacy and safety of exercise programs in cardiac rehabilitation. Medicine and Science in Sports and Exercise, 26, McGoldrick, M., Giordano, j., & Pearce, J.K. (1996). Ethnicity and family therapy, 2 nd edition. New York: Guilford Press. O Connor, G.T., Buring, J.E., Yusuf, S., Goldhaber, S.Z., Olmstead, E.M., Paffenbarger, R.S., & Hennekens, C.H. (1989). An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation, 2, Correspondence address: Ada Wilkinson-Lee, Department of Family Studies and Human Development, University of Arizona, P.O. Box , Tucson, AZ ( adaw@ .arizona.edu 3

4 Table 1 Culture-Group Differences at Admission and 3-Month Follow-up Variable Anglo Mexican American Significance Sex (female) 34% 46% ns Age in years M = M = p =.015 Married 75% 76% ns College graduate 46% 16% p <.001 Others in household M = 1.3 M = 2.0 p =.012 Religious attendance M = M = p =.013 Obese (BMI > 30) 24% 45% p =.016 Distress (HSCL-25) M = M = ns Rehab self-efficacy M = M = ns Confides in others M = M = p =.048 Planning M = M = ns Positive reframing M = M = p =.004 Acceptance M = M = p =.003 Humor M = M = ns Self distraction M = ,9 M = ns Emotional support M = M = ns # of CR sessions M = M = ns Staff ratings of benefit M = M = p =.046 ns = not significant 4

5 Figure 1 Culture and Gender Differences in Distress: Percent in HSCL Clinical Range 45 Male Female % in clinical range n=171 n=90 n=24 n=20 Anglo (n = 261) Mex-Am (n = 44) Figure 2 CR Participation by Culture, Gender, and Psychological Distress 30 Mean sessions attended Male Female 5 0 Lo distress Hi distress Lo distress Hi distress 5