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Women's Experiences Accessing a Women-Centered Cardiac Rehabilitation Program: A Qualitative Study

Rolfe, Danielle E. MSc; Sutton, Erica J. MA; Landry, Mireille MSc; Sternberg, Len MD; Price, Jennifer A. D. MScN

The Journal of Cardiovascular Nursing: July-August 2010 - Volume 25 - Issue 4 - p 332-341
doi: 10.1097/JCN.0b013e3181c83f6b
ARTICLES: Cardiovascular Risk

Background and Research Objective: The health benefits of cardiac rehabilitation (CR) for women living with heart disease are well documented, yet women remain underrepresented in traditionally structured CR programs. This health service delivery gap has been attributed to a number of sex-related factors experienced by women, including lower rates of physician referral, travel-related barriers, competing work and caregiving responsibilities, greater cardiovascular disease severity, and number of comorbid health conditions. Whether a program specifically designed for women is able to address these barriers and facilitate women's participation is a question that has seldom been explored in the CR literature. As part of a larger study exploring whether 6 predefined principles of women's health (empowerment of women, accessible programs, broad definition of health care, high-quality of care, collaborative planning, and innovative and creative approaches) are reflected in the practices of the Women's Cardiovascular Health Initiative (WCHI) (a comprehensive CR and primary prevention program designed for women), the objective of this analysis was to explore how the principle of "accessible programs" is experienced by women participating in the WCHI.

Participants and Method: Fourteen women previously enrolled in the WCHI program participated in a single, in-person qualitative interview. Transcripts were analyzed using a constant-comparative approach to identify relevant themes related to program accessibility.

Results: Key themes identified included participants' experiences with acquiring physician referral, negotiating transportation issues, and navigating program schedules. Women discussed how peer support and staff members' willingness to address their health-related concerns facilitated their participation.

Conclusion: While a women-centered CR/primary prevention program may facilitate and encourage women's participation by providing flexible program schedules as well as peer and professional support, efforts are still required to address persistent barriers for women related to physician referral and transportation to programs.

Danielle E. Rolfe, MSc Research Associate, Women's Cardiovascular Health Initiative, Women's College Hospital, Toronto, Canada.

Erica J. Sutton, MA Research Associate, Women's Cardiovascular Health Initiative, Women's College Hospital, Toronto, Canada.

Mireille Landry, MSc Physiotherapist, Women's Cardiovascular Health Initiative, Women's College Hospital, Toronto, Canada.

Len Sternberg, MD Director of Cardiology, Women's Cardiovascular Health Initiative, Women's College Hospital, Toronto, Canada.

Jennifer A. D. Price, MScN Advanced Practice Nurse, Cardiology, Women's Cardiovascular Health Initiative, Women's College Hospital, Toronto, Canada.

Support for this project was generously provided by grants from the Ontario Nursing Foundation and Sunnybrook and Women's Health Sciences Centre and the Canadian Nurses Federation.

Correspondence Danielle E. Rolfe, MSc, 76 Grenville St, 7th Floor, Cardiology, Women's College Hospital, Toronto, Ontario, Canada, M5S 1B2 (

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Women in Cardiac Rehabilitation

Clinical Effectiveness and Women's Participation

There is a substantial body of literature providing evidence of the effectiveness of cardiac rehabilitation (CR) for patients living with cardiovascular disease (CVD).1 Many studies, however, have focused and reported solely on outcomes involving men, without the inclusion of adequate samples of women to allow comparisons to be made between sexes.2 Despite national policy initiatives insisting that sex-based analyses be incorporated into the design of health research,3 such analyses are seldom conducted.1,4 The exclusion of women from CR research has resulted in our limited knowledge about the clinical outcomes of CR among women.5

More recently, some health researchers have begun to address this gap by conducting sex-based analyses of CR outcomes involving mixed-sex and women-only samples. As a result, we now know that women benefit equally from participation in CR, even though, compared with men, they generally have poorer health status upon entry to CR.6-11 Despite this clinical finding, sex inequity remains at a health service level, such that only 10% to 15% of eligible women access CR compared with 25% to 31% of men.12-17 Although a number of health researchers have highlighted this disparity in health services accessibility,13,18 little change has resulted, and women's CR participation has not significantly improved over the past decade.19

The underrepresentation of women in CR is most often attributed to a lack of physician referral of women to CR.7-9,12-14,16,20-24 The exact cause of this sex bias at the physician level remains unclear.13 Some researchers have suggested that physicians' attitudes toward CR in general24 and their perception of women's ability to participate may be contributing factors.25 Additional variables that have been shown to predict CR nonparticipation and may also influence physician referral rates include women's older age at CVD onset (typically 10-20 years older than men),13 greater disease severity,21,22,24 and multiple noncardiac comorbidities (eg, diabetes, arthritis, and osteoporosis).7,14,20,21,26

Women's psychological and social profile upon CR entry is also different from men and may play a role in determining their CR participation. For example, more women than men with CVD experience depressive symptoms, anxiety, and a decreased quality of life,8,9,14,16,21,23,27,28 all factors that have been shown to predict lower rates of CR enrollment.18,24 Women are also more likely to live alone, be unemployed or retired, and experience scheduling-related barriers as a result of their roles as primary caregivers to dependent spouses, parents, children, and/or grandchildren.20,21,29 One study has suggested that physicians' awareness of these issues may influence their decision about whether to refer women to CR given their conflicting demands and responsibilities.25 Additional social factors, such as safety concerns (eg, when walking in inclement weather or at night) and lack of both social support networks and transportation, likely contribute to women's underrepresentation in CR.14,16,21,22,30,31

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Women-Focused Cardiac Rehabilitation: The Women's Cardiovascular Health Initiative

Given the number of barriers faced by women and the complex interplay that likely exists between physician-, individual- and program-level factors affecting women's CR participation,18,24 recommendations have been made within the literature to develop innovative CR programs that are structured to increase women's access to and enrollment in CR.5,16,32 Yet, currently very few women-focused CR programs are described in the literature.33,34

The Women's Cardiovascular Health Initiative (WCHI), located in Toronto, Canada, is one such program and offers a comprehensive CR (for women living with heart disease) and primary prevention (PP) (for women with risk factors for heart disease) program in a women-focused and women-only environment. The WCHI offers clients the opportunity to participate in either a 6-month CR or a 3-month PP program. Both programs include group heart health education classes, individual counseling, psychosocial support, individualized exercise prescription and supervision, and links to community resources. Founded in 1996 to address the gap in women's access to and participation in CR, the WCHI was structured based on input from female cardiac patients and guided by 6 predefined women's health principles (Table 1). The principles of women's health are considered integral to the delivery of these services, with the overarching aim of addressing the needs of a diverse socioeconomic, ethnic, and cultural community of women by providing an inclusive, safe, noncompetitive environment (see Price et al33 for a full description of how each principle is incorporated into the design and structure of the WCHI).



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Study Purpose and Research Questions

While the clinical effectiveness of the WCHI program and the high rate of program completion among participants (85% compared with much lower rates in traditional coeducational environments) have been presented previously,2,35 staff members at the WCHI sought to answer the research question of whether, from the perspective of program participants, the principles of women's health are reflected in the WCHI structure and practices. To address this broad research question, a qualitative study was conducted with past program participants. As a component of this larger study, the objective of this analysis was to explore whether participants experienced the principle of "accessible programs" during their referral to and participation in the WCHI program. Because accessibility is a key issue in the participation of women in CR and has been the focus of many studies,2,18,22,36,37 the results of this analysis have the potential to shape the development of new and innovative programs to increase women's access to CR by reducing barriers typically faced by women.

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Study Group Recruitment

Following institutional review board approval, a program staff member (D.E.R.) engaged in purposive sampling to recruit past program participants, varying in age and involvement in either the CR or PP program. The rationale for recruiting past PP program participants in addition to CR participants was 2-fold. First, given that CR and PP participants are often integrated within classes and clinically managed by the same WCHI staff, their experiences with the WCHI are likely similar with respect to program access issues such as scheduling and transportation. Second, because women participating in the PP program exhibit 2 or more risk factors for CVD, understanding their experiences with accessibility can inform the development of programs that address the needs of women at the earlier stages of CVD onset. Thus, the aim of conducting purposive sampling in this manner was to generate a diverse study group (in terms of participant age and program participation) representing a broad range of participant experiences accessing and participating in the WCHI program. To achieve this variation within the study group, the program database was used to generate a list of potential participants who were either younger than 60 years or 60 years or older and who had previously participated in either the CR or PP program. The names of 20 past participants were then randomly selected such that equal numbers of women representing each of these subgroups were invited to participate in the study. These individuals were then telephoned to explain the purpose of the study and to invite them to participate in a qualitative interview.

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Data Collection

Interview questions included in the interview schedule followed a structure similar to an earlier study that explored the meaning of the women's health principles and identified what women value in health care practice (Tassone et al, unpublished data, 2004). Additional questions were integrated within the interview guide to elicit participants' responses that addressed their experiences accessing and participating in the WCHI program. Prior to initial data collection, individual pilot interviews were conducted with 2 women who were currently participating in the WCHI program. The purpose of these pilot interviews was to ensure that interview questions were clearly worded and understood by the participants. No significant modifications to the interview guide were made as a result of the pilot interviews.

Following the pilot interviews, semistructured, in-person interviews were conducted over a 3-month period from late 2005 to early 2006 by a trained qualitative researcher with no prior affiliation with the program (E.J.S.). Interviews lasted between 30 and 90 minutes and were audio recorded and transcribed verbatim. Field notes were also made during and after each interview to document the interviewer's ongoing thoughts and preliminary analyses.38

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Data Analysis

The research team reviewed the transcripts and discussed themes that emerged from the qualitative data using a constant-comparative approach.39 Terms and concepts were compared for similarities and differences and were assessed for their degree of consistency and meaning, which led to the development of categories or themes.39,40 Open, axial, and selective coding was used to develop a coding scheme based on identified terms, categories, and themes.39 The coding scheme was then applied to each transcript. Analytic memos were also developed to explain the properties of categories and interpretations. The computer software program, Ethnograph,41 was used to store and manage the text-based data. All research processes were recorded to provide an "audit trail" detailing how analytical decisions were made.42 Qualitative descriptive methods were used to create a comprehensive summary of women's experiences regarding accessibility during their participation with the WCHI program.40,43,44

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Fourteen women previously enrolled in the WCHI program volunteered to participate in the study (see Table 2 for a description of participant demographics and health characteristics). Five participants were recruited who had participated in the CR program and were younger than 60 years. Five participants had participated in the CR program and were 60 years or older. One participant had participated in the PP program and was younger than 60 years, and 3 participants had participated in the PP program and were 60 years or older. Because data saturation was achieved (ie, no new information or themes were revealed by subsequent participants),39 no additional participants were recruited to participate in the study. To maintain participant confidentiality, pseudonyms are used to distinguish participants in the following sections.



Interviews conducted with the participants resulted in rich descriptions of women's experiences related to accessing the WCHI program. Key themes discussed by participants included how they experienced and negotiated challenges to their participation including referral to the program, transportation, and program scheduling. Participants also described how staff members' willingness to address their noncardiac health-related concerns encouraged their participation. Finally, the role of the women-only environment and psychosocial support received from peers was also discussed.

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Acquiring Physician Referral: The Role of Recommendation, Information Sharing, and Self-advocacy

Like many CR programs in Ontario, Canada, physician referral to the WCHI program is required to initiate participant intake and to ensure the transfer of relevant medical information to guide the development of individualized exercise prescriptions. The fewest barriers to participation in the WCHI program were experienced by women whose physicians both provided them with a referral to the program and strongly endorsed their participation. As such, physician recommendation was cited by a number of women as the reason they enrolled in the WCHI program:

I trusted [my doctor when she recommended the program]. I felt that, you know, she would give me good advice. (Sylvia)

I found out about the program through my heart doctor… [who] insisted I come here… I was going to join a fitness club, [but] he didn't think that I was well enough to do [that]… So that's the reason I came [to the program]. (Carmen)

I didn't do any research [about the program] 'cause [my doctor who is affiliated with the program] told me what it was all about. (Jillian)

A strong physician recommendation was not received by all participants, however, and many explained how information about the WCHI program was acquired through program brochures, recommendations by allied health professionals, and personal connections. Having gained awareness of the WCHI program, these women were then motivated to negotiate with their physician to acquire a referral to the program:

When I was [in hospital after having a heart attack and surgery], a social worker came in and… told me there was this cardiac program… [She asked], "Would I be interested?" They thought it was a good thing for me to do… I [also] have a friend… who works [at the cardiology department at the hospital where the program is run], so… they brought me [into the program]… (Alison)

[I found out about the program] through… my acupuncturist, who is also a nurse…at [another hospital]… I went to my doctor and told her [about the program]. And she sent the [referral] form in… (Ruth)

A friend of mine recommended [the program]. I think he read an article in the newspaper… He has a wife that… works as an analyst for the hospital… so she's very familiar with things as well. (Jane)

I think [I found out about the program] through reading something about it. And then my daughter knew about it and she was "gung-ho" about it. And she talked to my doctor, and she got me into [the program]…[and] I went… (Barbara)

I just saw the pamphlet in the hospital [where I was treated for my cardiac event] I think. It was in the [emergency room]… [I'd] never heard a doctor talk about it. (Betty)

The process of learning about the program and then acquiring physician referral was not easy for all participants despite a willingness and, in some cases, a strong desire to participate in a structured exercise program following a cardiac event. Two participants who were very motivated to participate in the WCHI program felt that they had to be persistent to get their doctor to provide them with a referral, mainly because their physicians did not feel that the program was necessary:

I had to fight with my doctor though to get him to approve it because he didn't think that it would have many benefits. But it definitely has though… I… said that I needed to at least have some type of exercise… [My doctor] just said, "Try not to do much." But… I couldn't sit still. [I needed] to do something. He wouldn't encourage [doing exercise] on my own… He said, "Well just, you know, walk. Walk where you have to. You know, just do small activities. (Betty)

What I found really interesting is I had open heart surgery and I was actually asking my cardiologist to be referred to an exercise program. And she was putting it off… And I actually had to insist. …I got the forms myself, I brought them in and had her sign it, everything. And I thought that was very interesting… that she didn't initiate [the referral process] herself. I think it's so important to get into an exercise program after something like heart surgery. (Jane)

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Travel to the Program: Negotiating Transportation

Travel and transportation are issues that many women cite as a barrier to their participation in traditional CR programs. However, given the downtown urban location of the WCHI program and the availability of public transit close to the hospital, most interview participants were able to complete the program without needing to make special arrangements for their travel. Evident in participants' comments about taking public transit and/or taxicabs to the program though is the fact that they were required to budget for the cost of their regular travel to the program:

I came [to the program] on [public transit because] it was …very easy to get [to the hospital]… Sometimes my husband would drive me, but mostly [I traveled to the program by public transit]. (Alison)

…There were occasions where I had to see the funny paradoxical side. I would take a cab here to take my exercise class. And I didn't really tell too many people about that, because it was a little chuckle. (Nancy)

In some cases, active support for their participation in the program was received when a spouse provided participants with a ride to and from the program:

My husband drove me all the time down [to the program], because he wants me to feel well. He doesn't want me to get sick. (laughing) …So he always looks forward to bringing me down. And he waited around for me until I was finished… He was really supportive… it [would] probably be just as easy to come on my own because I could go on the subway and just come off here. But he wanted to [drive me]. He likes to take me everywhere. (Jillian)

For most women, though, decisions (between modes of travel) and trade-offs (regarding convenience and cost) had to be made to travel to and participate in the program. For example, participants who had the option of driving to the program experienced greater control over their schedule, because driving allowed them to balance the many conflicting demands on their time more easily. These women described the trade-off that they made between the convenience of driving with having to find and pay for parking twice a week:

I drove myself [to the program]. It cost me a lot to go. It cost me… $8 every time for parking. [Interviewer: "Is that expensive for you?"] Yeah. Yeah, but it was worth it. (Ruth)

I never drove [to the program] because of the price of that stupid [hospital] parking lot. I mean, I just think it's ridiculous, [paying for parking] twice a week… [that's $8] 8 times a month. (Victoria)

In some instances, women made special arrangements (such as arriving early for class) to ensure that they could find a parking spot.

[I'd] drive [to the program]. It wasn't great… But it's a trade-off for me for driving a car in the city. With my schedule it was the most workable way for me to get here, even though I live on the streetcar line. But usually if I drove around for a while and came a bit early, I would find a parking spot. So… it wasn't great, but it was ok. (Carole)

Significant barriers also had to be overcome by participants with disabilities who require the use of an accessible transit service to commute to the program. Anna, for example, felt that her participation was made more difficult by having to prearrange pickup and drop-off times well in advance of her intended travel times:

My problem was getting [to the hospital]. I take [the accessible transit]. [The service] is not as easy to get-it's very hard to get [through on the telephone] line [to prebook my pickup and drop-off times]. And if you don't get [through] before 7:30 [AM], the rides are mostly taken. (Anna)

For other individuals who rely on public transit and are required to walk short distances, the weather can be a barrier to their participation. For example, one woman identified the wintertime as a deterrent, explaining that by the time she is ready to go out, "it's too cold" (Carmen). More extreme temperatures pose an even greater barrier, particularly among participants living with other comorbidities:

Like from the subway… to walk [to the program] I had trouble… because I… had trouble like breathing and walking… It was just because in extreme weather, like extreme heat or extreme cold, I can't breathe, [even] when I'm… just walking… Walking in that temperature, it was really hard for me… just to move around in the winter. So it was probably in the winter when… I didn't feel like [attending]. But [otherwise] I always-I was pretty good with my attendance… (Betty)

Finally, for some women, a lack of transportation is the main reason why they do not complete the WCHI program. One participant explained that she had to withdraw from the program after she and her family moved to an area that was too far away for her to participate:

[I didn't] finish [the program]… because I moved [from] the…area. [After that, it wasn't] easy for me. (Gabriella)

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Women's Competing Responsibilities

Participation in the WCHI program involves twice-weekly attendance at a preset day and time. Clients are scheduled into a class based on available space and their expressed preference for a particular class time. Participants' responses underscored that the ability to choose a class time facilitated their participation:

I chose the time… I like the morning time… [the class started at] 9:30 AM… and it was good for me… I'm a morning person. [In] the afternoon I'm not that… good to do exercise. I like to do it in the morning, so that was ok. (Carmen)

I'm sure I could have set up another [time] if this didn't [work for me]. Yes, they had them at… 9:30 [AM] or something… it was too early for me. [The staff] were very adaptable. (Victoria)

Participants also appreciated the ability to select a particular class, because it allowed them to balance their participation with their other responsibilities related to work and/or caring for family members:

I came in the summer, and there were a couple times I had childcare issues [with] my [7-year old] daughter… and I brought her and she'd sit and read a book. So I liked that [the staff] were very hospitable about that. (Carole)

[The] morning time is really nice for me. Because [in the] afternoons… [since] my husband is in the nursing home… I have to go and visit [him]… And then I go home… [That schedule allowed me to] do my work… (Veda)

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Addressing Women's Noncardiac Health Concerns

Most women participating in the WCHI program are between the ages of 45 and 60 years (PP program) and 65 and 85 years (CR program), and many live with other chronic health conditions that affect their ability to participate in structured exercise programs. The mean age of participants in this study was 62 years (range, 28-83 years), and many older participants expressed their concerns about participating in an exercise program given their age and health concerns beyond their heart. For many women, exercising among similarly aged peers with comparable health problems provided them with a greater level of comfort:

In the program, there were people to talk to who knew what my problem was. But at the regular gym everybody was young and in a hurry. (Ruth, aged 52 years)

One participant described that the WCHI program helped her realize the importance of exercise to maintain her well-being, especially now that she is getting older:

I was very glad to have [participated] because it certainly made me recognize how important exercise was… It's fine to eat well… but if you're not getting any exercise, and especially as we get older, it's harder to push yourself to do that exercise on an ongoing basis. So if you don't [exercise], then you are not going to be well. (Sylvia, aged 71 years)

Prior to participating in the program, women living with other health conditions expressed some trepidation about their ability to engage in a structured exercise program. Those fears, however, were allayed when women learned that the programs were developed to meet their individual needs and allowed for shared decision making between participants and staff members to select exercises that women felt comfortable performing.

I was terrified [before starting]. I didn't think I'd be able to handle any of the [exercise] equipment. Because I do have spinal stenosis, and it's quite painful at times. But when I got [to the program], I was pleasantly surprised… There were 2 machines there that I wasn't comfortable at all with. [But] the staff said, "Well just don't use that. Do double on the… treadmill." And I had never been on a treadmill in my life before either. But… I did [it]. I doubled up on [the treadmill] and on the [strengthening] exercises… And it worked out great… I enjoyed it more than I had expected to. (Barbara, aged 77 years)

I had been doing aqua fit. The problem with aqua fit is I have arthritic knees… And [because of the arthritis I was] not able to always go to the aqua fit… The exercise [I did at the program] is very beneficial because [the staff] were really caring about the fact that you had [arthritis]. [They'd say,] "You mustn't do this, and you mustn't do that kind of thing." They were being careful as they gave me the exercises that I was to do. So I was very impressed with [the exercises that] I was doing and the way [the staff] were [helping me to progress]. (Sylvia, aged 71 years)

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The Role of Peer Support and a Women-Only Environment

The women-only program format resulted in a number of benefits to participants. Women discussed how this environment increased their level of comfort and provided them with an opportunity to talk with other women. Six participants, including both Jane and Sylvia, described how the program format increased their level of comfort, which is likely the result of the efforts by the program staff members to create a welcoming, noncompetitive environment:

[Exercising at the program,] it wasn't like being in a gym, you know, [where] you walk in and you're really worried about how you look or you're really worried about the whole getting in shape or… body image thing. It was more like just people supporting each other. [It was] very comfortable… and very positive that way… I think with women we were sort of more relaxed about exercise in general… I don't think anyone in the group was in particularly good shape… so it was all pretty relaxed. And there was no competition or anything like that. (Jane)

I thought it was great [that it was only women]… [Because] you're more comfortable with women… I mean before you went home you were showering and, you know, and you're sweaty, and you're in these… tights and your sloppy tops and stuff like that… (Sylvia)

Women who felt self-conscious about their bodies or uncomfortable exercising with men expressed that they preferred a women-only setting if given a choice regarding program format:

[I] have to commend the people who started this program for making it a women's program. [I] support that in every way…. I don't mean that men are intimidating per se, but you know… most men are a great deal more physically… tough[er] than [women] are. And I think it just wouldn't be a very good mix. I think you're more comfortable with all women… A very good idea, [to have a] woman's program…[to] be exclusively [for women]… for once in our lives. (Victoria)

I'm more comfortable dealing with women. So that's another thing that appealed to me about this program, was that it was a women's program. …I know I shouldn't [feel that way], but [the] reality is [that] I'm more comfortable in this kind of a setting… I guess it's around the whole issue of feeling self-conscious and comfort[able]. And you tend to feel more comfortable with other women in that kind of a situation. (Carole)

Participants, such as Alison, also valued the opportunity to discuss their cardiac and general health concerns with other women:

I had a choice whether to come here or to go up to [a program at another hospital]… But it was coed. It wasn't the same [women-only format]… I chose to come here because I just felt more comfortable [with it] being all women. And, [with women who], you know, [have] roughly the same [health] problems as you… I just thought we could all relate a lot better. (Alison)

In contrast to the views expressed by many participants, however, 5 participants expressed that the women-only setting was inconsequential to their participation in the program. Although they recognized the benefits of the women-only format, they felt that their participation would not have been greatly affected by the inclusion of men in the program:

I think you're inclined to be more friendly with a woman than with a man…. I would go if there were men… But I think I would prefer the women [only] classes instead of a mixed class. But it wouldn't really determine [whether I participate] though. (Barbara)

[I] don't have any problem [with the women-only format]. …For sure the social environment is nice, it's very important. But the most important [thing] is [for women to] exercise… (Gabriella)

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The challenge that many participants in this study described with respect to acquiring physician referral to the WCHI program reflects the large body of evidence in the CR literature that many physicians do not refer their female patients, and/or feel that women who are older or more severely affected by a number of noncardiac health concerns will experience little benefit as a result of participation.7-9,12-14,16,18,20-23 The actions taken by some participants to acquire information about and a referral to the WCHI program demonstrate women's willingness and, in some cases, their strong desire to participate in a structured exercise and education program following a cardiac event. A number of participants in this study accessed information about the WCHI program through friends, family, and alternative medicine practitioners. This less-often cited finding18,45,46 suggests that advertising of CR and PP programs (including an explanation of the referral process) may be more effective at increasing women's participation if it is available within women's communities, such as at local health and recreation centers and through alternative health care providers.

Participants in this study typically lived within close proximity to the WCHI program and therefore were able to access public transit. Others had the use of a personal vehicle, which also eliminated the common barrier cited by women regarding having to travel too far to participate in CR.18,21,37,45 However, participants still faced challenges related to the cost of transportation given the frequency of their participation over a 3- or 6-month period. Other commuter obstacles included securing a parking spot, scheduling accessible transit services, and traveling in inclement weather. These findings reflect the commonly cited barrier of transportation13,18,47,48 but provide greater detail from participants' perspectives about how issues related to transportation may adversely affect women's CR participation.

This study supports the finding in the literature that many women entering CR live with a number of personal and health-related concerns beyond CVD7,14,18,20,21,26 and that this can affect their exercise and CR participation.26,48,49 Women in this study emphasized that their participation is often contingent upon WCHI staff being attentive to and addressing their noncardiac health concerns, a finding that corroborates existing literature.30,50,51 Less often discussed in the extant literature is our finding that social support received from both program staff and women's peers can encourage women's participation by addressing their personal and non-health-related concerns.51-54 Although the finding that participants must often balance their program participation with multiple responsibilities (such as caregiving and paid work) is not unique,20,21,29,48,55 it does suggest that CR programs that offer greater flexibility in scheduling participation times may better meet the needs of women. Finally, despite participants expressing a range of views as to whether a women-only environment was critical to their program participation, most women identified a natural ease and comfort that accompanied a women-only exercise environment. Given the body of literature that speaks to women's concerns surrounding group exercise and exercising in front of others,18,46,56,57 women-only CR programs might be one solution to appease such anxieties. In addition, a women-only format may be of particular importance to some women because of the opportunity it provides to discuss their health concerns with their peers.

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This study presents the lived experiences of 14 women accessing a unique women-only CR and PP program in Toronto, Canada. Many participants reported experiencing challenges related primarily to acquiring physician referral and transportation to the program. Consequently, the women in our program had to negotiate strategies (such as demanding a referral from their physician or seeking efficient modes of travel) to facilitate their access and participation. Despite this, the structure and functions of the WCHI program, which are predicated on 6 predefined women's health principles including the specific principle of providing accessible programs, helped many participants overcome these barriers to participation. Specifically, flexible class schedules and the willingness of staff members to address clients' noncardiac health concerns facilitated many women's participation. In addition, the opportunity to discuss their experiences and concerns with their peers and, for some women, the unique women-only environment encouraged their ongoing participation and completion of the program. While there is a growing body of literature that identifies (using primarily quantitative methods) the barriers that women face when accessing CR, this study makes a unique contribution in that it describes and discusses how some women actually experience and negotiate these barriers.

Based on the knowledge gained from the experiences of the women in this study, a number of clinical practice recommendations can be made. To reduce the commonly reported barrier of physician referral, policies for automatic referral should be implemented58 in addition to greater physician education regarding the benefits of CR, particularly for women who are older and who may live with a number of noncardiac health conditions. Owing to the fact that many women rely on nonphysician resources to acquire information about available programs, CR and PP programs should develop additional advertising strategies beyond physician recommendation. As such, other health care providers and community health workers can also be targeted to inform women about available programs and discuss the benefits of CR and PP programs, to assist women in obtaining referrals, and to encourage their participation in a structured program. To facilitate the participation of women who face travel-related challenges, recent innovations in methods of program delivery, such as home- or community-based CR programs,59-61 should also consider the development of women-focused programs. Whether CR/PP programs are offered in a hospital-, home-, or community-based setting, all programs aiming to increase their level of access and relevance to women should pay particular attention to the 3 key issues that are important to women. First, there is a need to address the impact of exercise on noncardiac health conditions as such conversations are vital to allay women's fears about exacerbating existing comorbidities (eg, arthritis), while participating in a CR program. Second, given that many women need to balance their CR participation with other responsibilities, such as paid work and familial caregiving, flexible and alternative (eg, evening classes) class schedules may also increase their ability to participate. Finally, whether through the provision of a women-only program or by simply providing a women-friendly environment, it is vital that opportunities be created for women to meet with members of their peer group. Such interactions provide women with a greater sense of comfort when exercising, and the support that they receive may encourage their ongoing participation.



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The authors wish to thank all of the women who volunteered to participate and share their experiences in this study. They also thank Debbie Childerhose, Faith Delos-Reyes, Lucinda Ling, Shelley Sharma, and Libby Groff for their editorial assistance and support throughout this project.

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cardiac rehabilitation; health services accessibility; program evaluation; women

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