Where is the client’s community? How many people of similar ethnocultural backgrounds live there? How does this community compare with the former community ? If the client is an immigrant, what were the conditions of his or her arrival? Is he or she in the United States legally? Ask: “How would you describe your community? How is it similar or different from your home community? How did you come to this country?” How are the client or the client’s parents employed? What is their socioeconomic status ? Ask: “What do you do for a living? How are you and your family doing ?nancially?” What parts of the community does the client perceive to be supportive? Is he or she a member of a spiritual community and, if so, what is the level of involvement? How does he or she view institutions such as government, schools, and so on? Ask: “Where do you go, or whom do you see when you need help with something? How important is spirituality to you? Do you practice any particular faith? How often do you visit with your children’s teachers? Are you comfortable visiting with your children’s teachers? How do you feel when you see a police of?cer?” Multicultural and Diversity Issues 3934. Are there any observable signs of racism, discrimination, or prejudice in his or her community? Does the client feel welcome or valued in the community? Ask: “Have you experienced prejudice or any racist behaviors in your community? What would you like me to know about these incidents?” The fourth domain of culture and context is communication style. It includes the extent to which a person is able to send and receive accurate information as he or she interacts with his or her environment. Certainly, a great potential for dif?culty exists in this domain because interpretation of verbal and nonverbal information is so dependent on cultural background. For example, direct eye contact can be interpreted as hostile and disrespectful behavior from the perspective of some cultures, while avoiding direct eye contact can be interpreted as resistant or disrespectful in others. In the same way, inability to adequately express yourself verbally to another presents dif?culties.

If they exist, what importance does the client place on meeting family expectations? Ask: “How would you describe the kind of life your family wants for you? What kind of life do you want for your own children? Have you ever done something that disappointed your parents? Would you tell me about it? Have you ever argued with your parents? What happened? What happens when your children argue with you?” What are the discrepancies between family expectations and those of the other systems the client interacts with? Ask: “I’m wondering if you ever feel as if you have to act differently at work than you do at home or with your neighborhood friends. What happens when you act as you do at work when you’re home?” Community environment is the third domain of culture and context. This domain involves structural aspects of the community where the client currently lives . For those who have recently immigrated, it also involves comparisons with former community environments and conditions under which migration occurred . For example, Sandhu, Portes, and McPhee reported less stress involved with voluntary migration as opposed to those who were forced to migrate, whereas involuntary minorities may view engagement with the dominant community as a threat to their identity, and thus resist accessing supportive structures .

The sociopolitical climate must also be considered in assessment of community environment. There is always the possibility that racism , bias, and discrimination contribute to community related stress.

Here are some things to listen for and ask about as you gauge your client’s community environment.

Although there is good evidence for the advantage of supervised exercise , home programmes have also been shown to be effective in increasing functional capacity and modifying risk factors . A review of well conducted randomised trials and observational studies supports ?ndings that Low to moderate intensity exercise for low to moderate risk patients can be provided as safely and as effectively in the home or community as well as in the hospital setting. Patients at high risk and those undergoing high intensity training should only exercise at venues with full resuscitation facilities and staff trained in advanced life support.

Increasingly, supervised phase III groups, traditionally held in the hospital setting, are held in the community. Phase III can also be structured to be sited in the hospital for the ?rst half, and in the community for the second half of phase III CR . This design helps to introduce patients early to a community setting, where phase IV will be based, thus exposing them to a less medical environment and using community facilities. In addition, these may be run as outreach programmes by hospitalbased CR professionals, to improve access to services for patients and to overcome space and equipment limitations in hospital sites, or they may be staffed by community health professionals. Recommendations from a British Heart Foundation survey of all CR programmes in England and Wales encouraged a joint funding approach between hospital and community trusts in order to improve collaboration between and integration of services and to provide a more economical approach.178 Exercise Leadership in Cardiac Rehabilitation The challenge for CR professionals is to match the appropriate programme model to suit the individual patients’ needs, overcoming any barriers and limitations, facilitating adherence, maximising bene?t and delivering a quality, evidence based service.

• SWT <level 7 with cardiac symptoms;

• unable to reach workload of 5METs/level 7 of SWT with non cardiac limitation;

• ETT ?5METs with cardiac symptoms/2mm ST depression/silent

ischaemia;

• poor LV function ;

• diagnosis of heart failure;

• post transplant;

• post ICD insertion;

• refractory angina;

• awaiting CABG;

• awaiting angiogram or PTCA;

• SBP >180mm hg at rest;

• DBP >100mm hg at rest.

Phase IV exercise leaders The BACR has also, in recent years, established an accredited quali?cation for community instructors providing exercise to cardiac rehabilitation phase III graduates.This has allowed CR professionals to consider more safely referral for patients who, in the past, would not have had the phase IV option and who would bene?t from supervision at that level.There remains a debate as to whether there should be specialist classes for cardiac patients or whether they should be integrated into mainstream exercise classes. Phase III cardiac classes are likely to be male dominated whereas mainstream community classes are more likely to be female dominated.Risk strati?cation should play the pivotal role in the type of class and supervision the exercise professional recommends to each patient, while taking into account their exercise preferences in order to encourage long term adherence to exercise.

However, even with a trained phase IV exercise leader the patients with complex cardiac histories, complex co morbidity or high risk features may require ongoing clinical supervision at a level that is unlikely to be achieved in a community phase IV environment. There is a clear and vital role for the highly skilled exercise professional providing phase III to provide suitable long term maintenance options for those patients least suited to exercise in the community .Risk Strati?cation and Health Screening for Exercise PRACTICE ISSUES Staf?ng Although CR is delivered by a multidisciplinary team of health professionals, the exercise component should be delivered by suitably trained exercise professionals, i.e. exercise physiologists, physiotherapists or phase IV BACR exercise professional. Current international guidelines vary in their recommendations for staf?ng levels, but all agree that the level of staf?ng required should be driven by the risk strati?cation of the CR participant within the exercise group. Staff to patient ratio is covered in Chapter 6.