The discrepancy between perceived and estimated absolute risks of coronary heart disease in Middle Eastern women : implications for cardiac rehabilitation

Coronary heart disease (CHD) is the major cause of morbidity and mortality globally. While primary and secondary prevention programmes indisputably reduce the burden of CHD and increase quality of life, they are often underused, particularly by women and ethnic minorities. Lower referral rate, inaccessibility of services, being female, lack of support, insufficient income, impaired health literacy, inappropriateness of the programmes and the failure of health care organisations and programmes to provide culturally competent care to diverse racial, ethnic and cultural groups are some contributing factors. The use of health care services also appears to be influenced by perceived vulnerability to CHD. An individual’s subjective judgment about the characteristics and severity of a risk, that is the perception of risk, and causal attributions play an important role in responding to risk. Attitudes towards CHD risk and the associated risk factors such as smoking, diet, physical activity and obesity are mainly underpinned within cultural beliefs and practices. The value placed on adopting favourable health seeking behaviours, and a willingness to comply with medical advice are also often related to cultural beliefs, values and experiences. There is, therefore, a need to explore CHD risk perception in culturally diverse populations. Understanding these risks can help health practitioners tailor health messages and services more effectively to facilitate behaviour change in target groups, which is critical in the management of CHD. This thesis aimed to explore the relationship between Middle Eastern women’s perceived and estimated absolute risk of CHD to inform primary and secondary prevention programmes. This thesis comprised two discrete, yet interrelated studies and employed a mixed method to elicit the participants’ perception of general and personal CHD risk. Focus groups were used to capture the collective views of migrant Turkish, Persian and Arab Middle Eastern women about their perceptions of the risk of developing CHD, causal attributions and risk reducing behaviours. The three main themes that emerged from the focus group discussions were: (a) Middle Eastern women underestimated the risk of CHD; (b) stress is a pervasive factor in the lives of Middle Eastern women; and (c) Middle Eastern women face many barriers to reduce their risk of CHD. Participants’ biological, behavioural and socio-economical risk factors showed that the study participants were at increased CHD risk due to high prevalence of some risk factors such as high blood cholesterol level, obesity, inactivity and psychological distress. Yet, the participants underestimated their personal CHD risk and perceived themselves to be at increased risk of psychological disorders such as depression. Further, those who perceived some level of increased CHD risk attributed it more to their psychological status rather than life style factors. Underestimation of the risk, inaccurate causal attributions, low socio-economic status and low health literacy accompanied with lack of culturally and linguistically competent programmes to assist women in protecting their cardiovascular health are some identified barriers to CHD risk reducing behaviours among Middle Eastern women. Findings of this study have significant implications for cardiac rehabilitation services to develop culturally and linguistically competent programmes to communicate Middle Eastern women while taking into account cultural differences in beliefs and traditions, socioeconomic status and health literacy. These differences should be considered in CR design, implementation and evaluation