Perceptions of Adolescent Patients of the "Lived Experience" of Type 1 Diabetes.

The care and management of adolescents with type 1 diabetes presents numerous challenges that are inherent to the fears, attitudes, and perceptions of their illness. This qualitative study aimed to explore the "lived experience" of individuals with type 1 diabetes. In-depth interviews were conducted with 20 patients diagnosed with type 1 diabetes in their adolescent years to elicit their views, perceptions, and concerns regarding living with diabetes. All interviews were conducted and analyzed using the principles of grounded theory. Five categories defining the patients' lived experience were elicited: Barriers, Develop Skills, Manage Emotion, Social World, and Health Care Professionals. The problems experienced by adolescents with type 1 diabetes are multifactorial. Existentially, type 1 diabetes affects their daily activities and impinges on their academic achievement and personal aspirations. They have great difficulty coping with their health status and highlight a lack of empathy from health care professionals (HCPs). Their major fear is of hypoglycemia, resulting in their subsequent focus of preventing hypoglycemic episodes. Indeed, regardless of consequence, blood glucose levels are often deliberately kept above recommended levels, which serves to decrease the effectiveness of their health care management. This study shows that the quality of care provided for adolescent patients with type 1 diabetes is failing to meet their expectations and falls short of the essential standards commensurate with current health care policy. Improvements in long-term care management for these patients require changes in both patients' and professionals' understanding of the disease and of the ways it is managed.

Outcomes after acute myocardial infarction in South Asian, Chinese, and white patients.

BACKGROUND: Cardiac mortality rates vary substantially between countries and ethnic groups. It is unclear, however, whether South Asian, Chinese, and white populations have a variable prognosis after acute myocardial infarction (AMI). To clarify this association, we compared mortality, use of revascularization procedures, and risk of recurrent AMI and hospitalization for heart failure between these ethnic groups in a universal-access healthcare system. METHODS AND RESULTS: We used a population cohort study design using hospital administrative data linked to cardiac procedure registries from British Columbia and the Calgary Health Region Area in Alberta (1994 to 2003) to identify AMI cases. Patient ethnicity was categorized using validated surname algorithms. There were 2190 South Asian, 946 Chinese, and 38479 white patients with AMI identified. There was no significant difference in use of revascularization procedures between ethnic groups at 30 d and 1 year. Short-term (30-day) mortality was higher among Chinese relative to white patients (odds ratio, 1.23; 95% confidence interval, 1.02 to 1.48). There was no significant difference in 30-day mortality between South Asian and white patients. South Asian patients had a 35% lower relative risk of long-term mortality compared with white patients (hazard ratio, 0.65; 95% confidence interval, 0.57 to 0.72). There was no significant difference in long-term mortality between Chinese and white patients. Among AMI survivors, Chinese patients had a lower risk of recurrent AMI, whereas there was no difference between South Asian and white patients. CONCLUSION: The ethnic groups studied have striking differences in outcomes after AMI, with South Asian patients having significantly lower long-term mortality after AMI.

Cardiac medication prescribing and adherence after acute myocardial infarction in Chinese and South Asian Canadian patients.

BACKGROUND: Failure to adhere to cardiac medications after acute myocardial infarction (AMI) is associated with increased mortality. Language barriers and preference for traditional medications may predispose certain ethnic groups at high risk for non-adherence. We compared prescribing and adherence to ACE-inhibitors (ACEI), beta-blockers (BB), and statins following AMI among elderly Chinese, South Asian, and Non-Asian patients. METHODS: Retrospective-cohort study of elderly AMI survivors (1995-2002) using administrative data from British Columbia. AMI cases and ethnicity were identified using validated ICD-9/10 coding and surname algorithms, respectively. Medication adherence was assessed using the 'proportion of days covered' (PDC) metric with a PDC ≥ 0.80 indicating optimal adherence. The independent effect of ethnicity on adherence was assessed using multivariable modeling, adjusting for socio-demographic and clinical characteristics. RESULTS: There were 9926 elderly AMI survivors (258 Chinese, 511 South Asian patients). More Chinese patients were prescribed BBs (79.7% vs. 73.1%, p = 0.04) and more South Asian patients were prescribed statins (73.5% vs. 65.2%, p = 0.001). Both Chinese (Odds Ratio [OR] 0.53; 95%CI, 0.39-0.73; p < 0.0001) and South Asian (OR 0.78; 95%CI, 0.61-0.99; p = 0.04) patients were less adherent to ACEI compared to Non-Asian patients. South Asian patients were more adherent to BBs (OR 1.3; 95%CI, 1.04-1.62; p = 0.02). There was no difference in prescribing of ACEI, nor adherence to statins among the ethnicities. CONCLUSION: Despite a higher likelihood of being prescribed evidence-based therapies following AMI, Chinese and South Asian patients were less likely to adhere to ACEI compared to their Non-Asian counterparts.

Tackling health literacy: adaptation of public hypertension educational materials for an Indo-Asian population in Canada.

BACKGROUND: Indo-Asians in Canada are at increased risk for cardiovascular diseases. There is a need for cultural and language specific educational materials relating to this risk. During this project we developed and field tested the acceptability of a hypertension public education pamphlet tailored to fit the needs of an at risk local Indo-Asian population, in Calgary, Alberta, Canada. METHODS: A community health board representing Calgary's Indo-Asian communities identified the culturally specific educational needs and language preferences of the local population. An adaptation of an existing English language Canadian Public Hypertension Recommendations pamphlet was created considering the literacy and translation challenges. The adapted pamphlet was translated into four Indo-Asian languages. The adapted pamphlets were disseminated as part of the initial educational component of a community-based culturally and language-sensitive cardiovascular risk factor screening and management program. Field testing of the materials was undertaken when participants returned for program follow-up seven to 12 months later. RESULTS: Fifty-nine English-speaking participants evaluated and confirmed the concept validity of the English adapted version. 28 non-English speaking participants evaluated the Gujarati (N = 13) and Punjabi (N = 15) translated versions of the adapted pamphlets. All participants found the pamphlets acceptable and felt they had improved their understanding of hypertension. CONCLUSIONS: Involving the target community to identify health issues as well as help to create culturally, language and literacy sensitive health education materials ensures resources are highly acceptable to that community. Minor changes to the materials will be needed prior to formal testing of hypertension knowledge and health decision-making on a larger scale within this at risk community.

Examining and establishing translational and conceptual equivalence of survey questionnaires for a multi-ethnic, multi-language study.

AIM: This paper is a report of techniques used to examine and establish translational and conceptual equivalence of survey questionnaires. BACKGROUND: A major concern arose about standardization of translated survey questionnaires, when preparing to evaluate differences in acute coronary syndrome presentation in European (White), Chinese and South Asian patients. METHODS: The survey questionnaires were first translated by an accredited translation company. Between July and November 2009, materials were taken to like-speaking healthcare reviewers to ensure that the clinical meaning was appropriate. Like-speaking lay reviewers were then asked to make comment about grammar; meaning and understanding of questions; and any concerns about the suitability of graphics. A key informant from each language group reviewed all comments and worked with the investigators and the translation company to create final sets of survey questionnaires. RESULTS: Readability of the questionnaires (too complex or too basic) was the most common concern. A major discrepancy between ethnic groups arose about a graphic of 'squeezing' pain. A hand grasping a balloon was considered appropriate for European and South Asian groups, while a picture of a towel being wrung out was identified as more appropriate for the Chinese. There were no negative comments about the graphics. Soliciting key informants who were highly fluent in both English and the language under study was critical to ensure that the participants' feedback was appropriately reconciled. CONCLUSION: Traditional forward-backward translation of study materials is insufficient. Translation must be accompanied by a process whereby equivalence and acceptability are also established.

Home care utilization and outcomes among Asian and other Canadian patients with heart failure.

BACKGROUND: Heart failure (HF) is a major cause of hospitalization and death in the aging population around the world. Home care utilization is associated with improved survival for the patients with HF, and varies by ethno-culture. The purpose of this study was to investigate the difference in hospital readmission rate and mortality between Asian and other Canadian HF patients. METHODS: HF patients were identified using hospital discharge abstracts from March 31, 2000 to April 1, 2006 in Calgary Health Region. Readmission and one-year mortality for HF were determined by linking hospital discharge and vital statistics data. Stratified by home care services use, readmission and mortality rates were compared between the Asians and other Canadians while controlling for age, sex, comorbidities, and household income. RESULTS: Of 26,171 HF patients discharged from hospital, 56.6% of Asians and 58.0% of other Canadians used home care services [adjusted odds ratio (OR) for Asian: 0.84, 95% confidence interval (CI): 0.74-0.89]. The hospital readmission rate was similar between Asians and other Canadians regardless of home care services use. Mortality was similar between those who used home care services (adjusted OR for Asian: 0.96, 95% CI: 0.81-1.13). For patients who did not use home care services, Asians had significantly lower mortality than other Canadians (adjusted OR for Asian: 0.76, 95% CI: 0.60-0.86). CONCLUSION: Mortality was similar between Asian and other Canadian patients when home care services were utilized. However, among those without home care, Asian patients had a significantly lower mortality than other Canadian patients.

Functional and psychosocial outcomes 1 year after mild stroke.

BACKGROUND: Mild stroke survivors are generally discharged from acute care within a few days of the stroke event, often without rehabilitation follow-up. We aimed to examine the recovery trajectory for male patients and their wife-caregivers during the 12 months postdischarge. METHODS: A descriptive study was undertaken to examine functional outcomes, quality of life (QOL), depression, caregiver strain, and marital function in a prospective cohort of male survivors of mild stroke and their wife-caregivers during the 12 months postdischarge. Data from each point in time were summarized and repeated measures analyses undertaken. Logistic regression was used to determine which baseline demographic and biopsychosocial variables influenced or predicted marital functioning 1 year postdischarge. RESULTS: A total of 38 male patients (mean age 63.4 years) and their wife-caregivers (mean age 58.5 years) were examined. The median discharge National Institutes of Health Stroke Scale score was 1.5, modified Rankin Scale score was 1.0, Barthel Index was 100.0, and Stroke Impact Scale-16v2 score was 78.5. The patients' modified Rankin Scale (function) and QOL scores improved significantly over time (F (2) = 4.583, P = .017; and F (6) = 5.632, P < .001, respectively). However, the wife-caregiver QOL scores did not change. Multivariate analysis revealed overall worsening of depression for both the patient and wife-caregivers (F (6, 32) = 3.087, P = .017) and marital function (F (6, 32) = 3.961, P = .004), although the wife-caregivers' perceptions of caregiver strain improved (F (6, 32) = 3.923, P = .007). None of the measured variables were associated with marital functioning 1 year postdischarge. CONCLUSIONS: Despite improvement in patients' functional status, other patient and wife-caregiver psychosocial outcomes during the 12 months postdischarge may be negatively affected. Thus, attention needs to focus on recovery beyond functional outcomes.

Using social exchange theory to guide successful study recruitment and retention.

Participant attrition (withdrawal or loss after entering a study) is a major threat to the completion of valid studies. It can result in systematic error (selection bias), thus decreasing the statistical power of studies and limiting the generalisability of study findings. This paper demonstrates how key social exchange theory principles form the theoretical context for our practice, which, in turn enables us to form enduring relationships with study participants.

Risk-taking attitudes and their association with process and outcomes of cardiac care: a cohort study.

BACKGROUND: Prior research reveals that processes and outcomes of cardiac care differ across sociodemographic strata. One potential contributing factor to such differences is the personality traits of individuals within these strata. We examined the association between risk-taking attitudes and cardiac patients' clinical and demographic characteristics, the likelihood of undergoing invasive cardiac procedures and survival. METHODS: We studied a large inception cohort of patients who underwent cardiac catheterization between July 1998 and December 2001. Detailed clinical and demographic data were collected at time of cardiac catheterization and through a mailed survey one year post-catheterization. The survey included three general risk attitude items from the Jackson Personality Inventory. Patients' (n = 6294) attitudes toward risk were categorized as risk-prone versus non-risk-prone and were assessed for associations with baseline clinical and demographic characteristics, treatment received (i.e., medical therapy, coronary artery bypass graft (CABG) surgery, percutaneous coronary intervention (PCI)), and survival (to December 2005). RESULTS: 2827 patients (45%) were categorized as risk-prone. Having risk-prone attitudes was associated with younger age (p < .001), male sex (p < .001), current smoking (p < .001) and higher household income (p < .001). Risk-prone patients were more likely to have CABG surgery in unadjusted (Odds Ratio [OR] = 1.21; 95% CI 1.08-1.36) and adjusted (OR = 1.18; 95% CI 1.02-1.36) models, but were no more likely to have PCI or any revascularization. Having risk-prone attitudes was associated with better survival in an unadjusted survival analysis (Hazard Ratio [HR] = 0.78 (95% CI 0.66-0.93), but not in a risk-adjusted analysis (HR = 0.92, 95% CI 0.77-1.10). CONCLUSION: These exploratory findings suggest that patient attitudes toward risk taking may contribute to some of the documented differences in use of invasive cardiac procedures. An awareness of these associations could help healthcare providers as they counsel patients regarding cardiac care decisions.

Using the cardiac depression scale in men recovering from coronary artery bypass surgery.

AIMS: To examine the utility and validate the use of the Cardiac Depression Scale in patients who had first-time coronary artery bypass graft surgery. BACKGROUND: The Beck Depression Inventory, though frequently used, may not be sufficiently sensitive for use in cardiac patients. The Cardiac Depression Scale has been shown to identify the range of depression in medical cardiac patients. DESIGN: Survey. METHODS: The Beck Depression Inventory and Cardiac Depression Scale were administered to 120 men at hospital discharge, as well as six, 12 and 36 weeks postoperatively. Cronbach's alpha scores were calculated for the measures at each point. Changes in scores over time were analysed using repeated measures analysis of variance. Associations between the measures scores were calculated using Pearson product-moment correlations. Agreement between the measures' dichotomised scores (depression/no depression) was examined using Cohen's Kappa statistic. RESULTS: Internal consistency was similar for the Beck Depression Inventory (0.793-0.904) and Cardiac Depression Scale (0.859-0.910). Depression scores decreased over time with the Beck Depression Inventory [F(2.50, 175.29) = 22.27, p < 0.001] and Cardiac Depression Scale [F(2.68, 190.37) = 13.18, p < 0.001]. The measures had similar power [Cohen's f = 0.65 (Beck Depression Inventory) and 0.43 (Cardiac Depression Scale)] to reveal changes over time. The continuous scores were highly correlated at each point [0.737 (p < 0.001)-0.819 (p < 0.001)]. However, when dichotomised scores were compared, the chance corrected level of agreement was less impressive [0.198 (p = 0.014)-0.381 (p < 0.001)]. CONCLUSIONS: The Cardiac Depression Scale may have utility for use with surgical cardiac patients. However, continued examination of this measure of depression is warranted. RELEVANCE TO CLINICAL PRACTICE: Given the prevalence of depression and its negative impact on coronary artery disease, it is important to identify even mild depression in cardiac patients. Using a measure of depression specifically for cardiac patients, rather than a generic measure, may best accomplish this goal.

Health-Seeking Behavior of Afghan Women Immigrants: An Ethnographic Study.

BACKGROUND: Nowadays, in light of gender inequity, new concern has been raised for health-seeking behavior of women in clinical setting. The aim of this study was to investigate the perceptions and health-seeking behaviors of Afghan immigrant women residing in Mashhad, Iran. METHOD: An ethnographic design was used to examine the health-seeking behavior of Afghan women. This study took place in Tollab Tabarsi area of Mashhad, Iran, from March 2013 to July 2014. For gathering of data, participant observations, fieldwork, and formal interviews were included. Data were analyzed using thematic analysis. RESULTS: Fourteen Afghan women immigrants and five health care professionals were interviewed. The overarching category derived from the data was gender inequity. The emergent three themes were cultural taboos, women position, and information gap. DISCUSSIONS: The displaced Afghan women were found to be at significant risk of adverse health events, which affected both their physical health and mental health.

Examining oral intake temperature in cardiac surgery patients.

The effect of restricting the temperature of cardiac surgery patients' oral intake to room temperature or warmer, over the first 3 postoperative days, on gastrointestinal (GI) symptoms was examined. In all, 57 patients were randomly assigned to receive the intervention or usual care. GI symptoms were measured daily over the first 5 postoperative days. Following hospital discharge, GI symptoms and return to function data were collected over 4 postoperative weeks. On Postoperative Day 1, 41% of patients reported having GI symptoms, and they were significantly associated with higher cross-clamp time. Symptoms dissipated over time. There were no differences between the study groups in GI symptoms or return to function. Nearly 70% of patients who withdrew from the study were randomized to the intervention group. Difficulty associated with adhering to the study protocol was their primary reason for withdrawing. Given these findings, a large-scale clinical trial may not be warranted.

Living alone, patient sex and mortality after acute myocardial infarction.

BACKGROUND: Psychosocial factors, including social support, affect outcomes of cardiovascular disease, but can be difficult to measure. Whether these factors have different effects on mortality post-acute myocardial infarction (AMI) in men and women is not clear. OBJECTIVE: To examine the association between living alone, a proxy for social support, and mortality postdischarge AMI and to explore whether this association is modified by patient sex. DESIGN: Historical cohort study. PARTICIPANTS/SETTING: All patients discharged with a primary diagnosis of AMI in a major urban center during the 1998-1999 fiscal year. MEASUREMENTS: Patients' sociodemographic and clinical characteristics were obtained by standardized chart review and linked to vital statistics data through December 2001. RESULTS: Of 880 patients, 164 (18.6%) were living alone at admission and they were significantly more likely to be older and female than those living with others. Living alone was independently associated with mortality [adjusted hazard ratio (HR) 1.6, 95% confidence interval (CI) 1.0-2.5], but interacted with patient sex. Men living alone had the highest mortality risk (adjusted HR 2.0, 95% CI 1.1-3.7), followed by women living alone (adjusted HR 1.2, 95% CI 0.7-2.2), men living with others (reference, HR 1.0), and women living with others (adjusted HR 0.9, 95% CI 0.5-1.5). CONCLUSIONS: Living alone, an easily measured psychosocial factor, is associated with significantly increased longer-term mortality for men following AMI. Further prospective studies are needed to confirm the usefulness of living alone as a prognostic factor and to identify the potentially modifiable mechanisms underlying this increased risk.

Use of epidural anesthesia and the risk of acute postpartum urinary retention.

OBJECTIVE: We aimed to examine the relationship between the use of epidural analgesia during labor and acute postpartum urinary retention. STUDY DESIGN: A retrospective cohort study was conducted using 1994 labor and postpartum health records from 3 primary care centers. RESULTS: Logistic regression analysis revealed that a longer second stage of labor (odds ratio [OR] 2.62; 95% confidence interval [CI] 1.41-4.85), use of systemic narcotics (OR 1.63; 95% CI 1.04-2.57), perineal laceration (OR 1.73; 95% CI 1.02-2.91), and instrumental delivery (OR 1.86; 95% CI 1.16-2.97) predicted urinary retention. There was a trend toward association of epidural analgesia and urinary retention (OR 1.69; 95% CI 0.98-2.92). Propensity score analysis revealed that any effect of epidural analgesia was likely due to effect modification of other obstetric variables. CONCLUSION: Epidural analgesia during labor may increase the risk of developing urinary retention by up to 3 times. However, this effect is mediated by other obstetric variables.

Chinese immigrants' management of their cardiovascular disease risk.

The authors have undertaken a series of grounded theory studies to describe and explain how ethnocultural affiliation and gender influence the process that cardiac patients undergo when faced with making behavior changes associated with reducing their cardiovascular disease (CVD) risk. Data were collected through audiorecorded semistructured interviews (using an interpreter as necessary), and the authors analyzed the data using constant comparative methods. The core variable that emerged through the series of studies was "meeting the challenge." Here, the authors describe the findings from a sample of Chinese immigrants (10 men, 5 women) to Canada. The process of managing CVD risk for the Chinese immigrants was characterized by their extraordinary diligence in seeking multiple sources of information to enable them to manage their health.

First Nations people's challenge in managing coronary artery disease risk.

First Nations peoples bring a particular history and cultural perspective to healing and well-being that significantly influences their health behaviors. The authors used grounded theory methods to describe and explain how ethnocultural affiliation and gender influence the process that 22 First Nations people underwent when making lifestyle changes related to their coronary artery disease (CAD) risk. The transcribed interviews revealed a core variable, meeting the challenge. Meeting the challenge of CAD risk management was influenced by intrapersonal, interpersonal (relationships with others), extrapersonal (i.e., the community and government), sociodemographic, and gendered factors. Salient elements for the participants included their beliefs about origins of illness, the role of family, challenges to accessing information, financial and resource management, and the gendered element of body image. Health care providers need to understand the historical, social, and culturally embedded factors that influence First Nations people's appraisal of their CAD.

The telephone interview is an effective method of data collection in clinical nursing research: a discussion paper.

There are varying points of view regarding the advisability and utility of using the telephone to conduct research interviews. When undertaking the Women's Recovery from Sternotomy Study, we found the telephone was an effective mechanism for data collection. Our aim is to identify the advantages and challenges of using the telephone as a mechanism for data collection in clinical nursing research. The potential benefits associated with using telephone interviews as a mechanism of data collection include (a) using economic and human resources efficiently, (b) minimizing disadvantages associated with in-person interviewing, (c) developing positive relationships between researchers and participants, and (d) improving quality of data collection. The potential challenges to telephone interviewing include (a) maintaining participant involvement, (b) maintaining clear communication, (c) communicating with participants who offer extraneous information, (d) encountering participants with health concerns, and (e) communicating with a third party. Telephone interviewing can be an effective method of data collection when interviewers understand the potential benefits as well as challenges. We offer solutions to the identified challenges and make pragmatic recommendations to enhance researcher success based on the current literature and our research practice. Supportive training for interviewers, effective communication between interviewers and with research participants, and standardized telephone follow-up procedures are needed to ensure successful telephone data collection. We have found our 'Manual of Operations' to be an effective tool that assists research assistants to meet the requirements for successful telephone interviewing.

A randomized controlled trial of women's early use of a novel undergarment following sternotomy: the Women's Recovery from Sternotomy Trial (WREST).

BACKGROUND: Despite a lack of randomized trial evidence, clinicians often suggest that women use a brassiere to reduce poststernotomy pain and discomfort. We tested the effect of women's use of a special (compression) undergarment after sternotomy on pain, discomfort, and functional status. METHODS: Women (n = 481) having first-time sternotomy in 1 of 10 Canadian centers were randomized to receive the intervention or usual care. Pain and discomfort data (using numeric rating scales) were collected in person while participants were hospitalized. Thereafter, pain, discomfort, and functional status data (using Health Assessment Questionnaire) were collected by standardized telephone interview until 12 postoperative weeks. RESULTS: Overall, and until at least 6 weeks postoperatively, fewer women in the intervention than usual care group reported having incision and breast pain and discomfort. Breast pain scores were lower in the intervention than the usual care group at 2 weeks postoperatively (P = .04), and over time (OR 0.65 [95% CI 0.45-0.94], P = .02). For women discharged within 14 postoperative days, post hoc analyses revealed intervention group patients had a significantly reduced likelihood of breast pain (OR 0.46 [95% CI 0.32-0.66], P < .001) and breast discomfort (OR 0.62 [95% CI 0.44-0.86], P = .01) but not incision pain (OR 0.99 [95% CI 0.72-1.37], P = .95) or discomfort (OR 0.77 [95% CI 0.55-1.02], P = .06). There was no difference between groups in functional status. The effects were not influenced by age or brassiere size. CONCLUSIONS: Using a supportive undergarment during the early postoperative reduces breast pain. This finding is amplified and extends to include a reduction in breast discomfort, when women are discharged within 14 postoperative days.

Men and women managing coronary artery disease risk: urban-rural contrasts.

People's beliefs about health and making lifestyle changes associated with risk reduction and disease prevention can vary based on their gender and ethnocultural affiliation. Our objective was to describe and explain how gender and ethnocultural affiliation influence the process that people undergo when faced with making lifestyle changes related to their coronary artery disease (CAD) risk. A series of grounded theory studies were undertaken in Alberta, Canada, with men and women from five ethnocultural groups diagnosed with CAD. Here, we describe the cultural aspects associated with urban- and rural-living in 42 Euro-Celtic men and women. Data were collected through semi-structured, audio-recorded interviews and analysed using constant comparative methods. The core variable that emerged through the process was 'meeting the challenge'. There were three phases to the process of managing CAD risk: pre-diagnosis/event, liminal self, and living with CAD. Intra-personal, inter-personal, extra-personal, and socio-demographic factors influenced the participants' capacity to meet the challenge of managing their CAD risk. The influence of these factors was either direct or indirect through the intertwined elements of the participants' knowledge about CAD and perceived extent of necessary change. Each element of this process was influenced by the participants' gender and culture (urban- versus rural-living). When healthcare providers understand and work with the gender- and ethnoculturally based components that influence people's appraisal of their cardiac health and their decision-making, appropriate secondary prevention interventions and positive health outcomes are more likely to follow.

Gender-based challenges faced by older Sikh women as immigrants: recognizing and acting on the risk of coronary artery disease.

Gender and ethnocultural affiliation can influence people's health beliefs and their ability to make behavioural changes associated with risk reduction. The authors undertook a series of grounded theory studies aimed at describing and explaining how gender and ethnocultural affiliation influence the process that people undergo when faced with the need to make behavioural changes to reduce the risk of coronary artery disease (CAD). Here, they describe the gender-based influences associated with managing CAD risk in a small sample of older Sikh immigrants to Canada. Data were collected through semi-structured interviews, using an interpreter when necessary. Interviews were audiotaped to enable verification of interpretation and transcription. Data were analyzed using constant comparative methods. The core variable that emerged in the series of studies was "meeting the challenge." The process of managing CAD risk included pre-diagnosis or event, liminal or changing self, and living with CAD. Intra-, inter-, and extrapersonal factors as well as sociodemographic characteristics influenced the participants' ability to meet the challenge of managing CAD risk. Health-care providers and policy-makers have a responsibility to work with ethnocultural communities in order to (1) enhance the ability of health-care providers to provide ethnoculturally sensitive care, and (2) develop ethnoculturally relevant resources to enable health promotion and disease prevention. The ultimate aim is to improve health outcomes for Sikh immigrants as vulnerable members of society.