INTEGRATIVE LITERATURE REVIEWS AND META-ANALYSES

Cultural aspects of adjustment to coronary heart disease in Chinese-

Australians: a review of the literature

John Daly PhD RN FINE FCN FRCNA

Professor of Nursing and Head, School of Nursing, Family and Community Health, College of Social and Health Sciences,

University of Western Sydney, Sydney, Australia

Patricia Davidson ICNC BA MEd RN MRCNA

Adjunct Associate Professor of Nursing, School of Nursing, Family and Community Health, College of Social and Health

Sciences, University of Western Sydney and Clinical Nurse Consultant, Department of Cardiology, St George Hospital, Sydney,

Australia

Esther Chang BAppSc MEdAdmin PhD RN CM

Professor of Nursing and Director, International Programs and Business, School of Nursing, Family and Community Health,

College of Social and Health Sciences, University of Western Sydney, Sydney, Australia

Karen Hancock BSc PhD

Research Consultant and Director, Compugenics, Sydney, Australia

David Rees MBBS PhD FRACP

Consultant Cardiologist, Department of Cardiology, St George Hospital, South-Eastern Sydney Area Health Service, New

South Wales, Australia

and David R. Thompson PhD RN FRCN

Professor of Nursing, School of Health, University of York, York, UK

Submitted for publication 12 October 2001

Accepted for publication 30 April 2002

� 2002 Blackwell Science Ltd 391

Correspondence:

John Daly,

School of Nursing,

Family and Community Health,

College of Social and Health Sciences,

University of Western Sydney,

Locked Bag 1797,

Penrith DC 1797,

NSW,

Australia.

E-mail: j.daly@uws.edu.au

DALY J DAVIDSON P CHANG E HANCOCK K REES D . & THOMPSON D RDALY J., DAVIDSON P., CHANG E., HANCOCK K., REES D . & THOMPSON D.R.

(2002)(2002) Journal of Advanced Nursing 39(4), 391–399

Cultural aspects of adjustment to coronary heart disease in Chinese-Australians:

a review of the literature

Background. The burden of illness associated with Coronary Heart Disease

(CHD) has determined this as a key focus for research at a basic science, indi-

vidual and population level. Although considerable research has been conducted

on specific aspects of the experience of CHD, such as anxiety or depression, there

is a lack of research investigating the global aspects of the illness experience from

the individual’s perspective. Furthermore, there is a paucity of research examining

the cross-cultural experiences of patients from Non-English Speaking Back-

grounds (NESB). Given the multicultural nature of Australian society, and that

health and illness are culturally constructed experiences (Manderson 1990), it is

important to include the perspectives of people from minority cultures in health

related research in order to provide culturally sensitive and appropriate health

care and information during an illness. Further, the potential to prevent and

modulate the course of CHD, by strategies such as smoking cessation and lipid

Introduction

Local context

Australia has a culturally diverse population of 18Æ5 million,

with 24% born overseas, and a further 27% with one or both

parents born overseas (Australian Bureau of Statistics [ABS]

1999). The most common ethnic groups are people from

England, New Zealand, Italy, former Yugoslav Republics,

Vietnam, China, Greece and Germany, with China propor-

tionally the fastest growing of these groups (ABS 1999). From

a multicultural perspective, there are a large number of

Australian people whose needs and expectations may be

different from what would be expected within a unicultual,

Anglo-Celtic society. In terms of health care, these needs

should be recognized, acknowledged and met �in accordance

with the principles of social justice, including fairness, equity

and access� (Cameron-Traub 2000, p. 239).

Australia has a relatively well public-funded universal

health insurance system (called Medicare) compared with

other developed countries such as the United States of

America (USA). Although such public funding means that

people who do not have private health insurance have access

to quality health care service, the Australian government has

recently taken steps to encourage Australians to undertake

private insurance to lower the ever-increasing burden on its

health system.

Cardiovascular disease in Australia

Cardiovascular disease is Australia’s greatest health problem

in terms of mortality and its health and economic burden

(Australian Institute of Health and Welfare 2000). The

Australian Government has set national goals and targets for

all major causes of morbidity and mortality, specifically in the

areas of cardiovascular disease, mental health, injury and

cancer. One of the ongoing priority areas for cardiovascular

health identified in the National Health Priority Areas report

on cardiovascular health (Commonwealth Department of

Health and Aged Care and Australian Institute of Health &

Welfare) is to develop, review and implement better practice

guidelines.

In the establishment of evidence based best practice and

evaluation of health outcomes, it is necessary to investigate

all aspects of health care, including nursing practice.

Coronary Heart Disease (CHD) is one area of heart disease

that is increasingly recognized as an area needing research in

terms of best-practice, to the extent that the National Health

and Medical Research Council (NHMRC) (1996) of Aus-

tralia established a working party which developed guidelines

to the management of acute coronary syndromes (ACSs). The

term ACS describes variable presentations related to vulner-

able coronary artery lesions including: unstable angina

pectoris; ST segment elevation myocardial infarction (MI);

and non-ST segment elevation MI. (Veghiazarians et al.

management, mandate a health promotion agenda based on equity and access for

all members of society.

Aims. This article discusses cultural aspects of CHD in relation to nursing and

allied health care during the recovery phase of an acute cardiac event. It reviews

the research that has been conducted in this area, focusing on the Chinese-Aus-

tralian population.

Literature search. The CINAHL, MEDLINE, FAMILY (Australian Family and

Society Abstracts Database), PsychINFO, and Multicultural Australian and im-

migration Studies (MAIS) databases were searched, identifying literature pub-

lished from 1982. Keywords used were Chin* (Chinese, China), Asia* (Asia,

Asian), experience, adjustment, psychological, heart, coronary, cardiac, health

and services. Reports not written in English were excluded. Australian Govern-

ment reports were also searched, as well as hand searching of nursing and

medical textbooks. These searches resulted in over 1000 articles. However, only

around 50 were relevant for this review.

Implications. Chinese-Australians are one of the fastest growing populations in

Australia, and are at increased risk of CHD upon settling to Australia. Recom-

mendations for future research and for the practice of nursing are provided.

Keywords: cross-cultural, coronary heart disease, nursing, adjustment, Chinese-

Australians

J. Daly et al.

392 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(4), 391–399

2000). Although the death rate from CHD has been falling

since the mid-1960s, unstable angina has increased in

prevalence as an admission diagnosis (NHMRC Media

release 1996).

Adjustment following a diagnosis of ACS

This period of time is reported to be a stressful, vulnerable

one for survivors (Thompson et al. 1994, 1995, Davies

2000). Vulnerability may be composed of factors of anxiety,

inferiority, insecurity, lack of intimacy and disconfirmation

(Lidell et al. 1998). Examples of stressors experienced by

people with cardiac conditions include interpersonal, family

and financial problems; therapy and self-care obstacles; and

work or physical difficulties (Stewart et al. 2000). Anxiety

and depression are frequently experienced following CHD

(Conn et al. 1991a, Crowe et al. 1996, Shapiro et al. 1999),

with approximately one-third of patients experiencing con-

tinuing anxiety and depression following MI (Conn et al.

1991b). Spouses have also been found to experience anxiety

and depression (Thompson & Cordle 1988, Coyne & Smith

1991). Beach et al. (1992) found that these reactions can

interfere with the adjustment of MI survivors.

These responses have significant implications for adjustment

of patients and their spouses to life following an ACS

admission, with potential influences on morbidity, mortality

and appropriate modification of lifestyle risk factors

(Thompson et al. 1994, 1995, Shapiro et al. 1999). For

instance, Levine et al. (1996) found that depression was an

important predictor of rehospitalization among persons

admitted with CHD. Depression is associated with increased

mortality following a MI (Frasure-Smith et al. 1999, Shapiro

et al. 1999). Ongoing anxiety is associated with a reduced

likelihood of returning to work, greater hospital readmissions

and higher mortality rates (Webster & Christman 1988).

Return to work appears to be important in adjusting to MI, as

evidenced by research by Tooth et al. (1999), who found that

poor psychological status was greater in those not working.

Social support is another factor that has been found to

influence adjustment to CHD. Lin et al. (2000) found that

patients with CHD who had low social support and higher

uncertainty were more likely to have worse psychological

well-being. Drory et al. (1999) found that depression, sense

of coherence and social support at discharge predicted

psychosocial adjustment in most life domains 3–6 months

after MI, and that medical variables were partly mediated by

psychological variables. It is considered that reversion to

previous risk factors, e.g. smoking and lack of exercise is

potentially related to anxiety and depression. It is also

possible that reversion to previous behaviours may be due to

lack of support and reinforcement of health promotion

strategies (Rodeman et al. 1995).

Uncertainty is another factor that may influence adjust-

ment to CHD. Carroll et al. (1999) found that an increased

perception of uncertainty was related to decreased perception

of health status and quality of life up to 6 months later.

Christman et al. (1988) found that patients reporting more

uncertainty also reported greater distress. Lin et al. (2000)

also found a significant negative relationship between uncer-

tainty and psychological well-being. Related to uncertainty is

perceptions of control. Moser and Dracup (1995) found that

patients with high perceptions of control were less likely to

experience anxiety and depression.

Adjusting to CHD may be also hampered by an inad-

equately resourced health care service that is characterized by

shortened periods of hospitalization allied with lack of

continuity of care when the patient is discharged (New South

Wales Health Council 2000).

Although considerable research has been conducted on

specific aspects of the experience of MI, such as anxiety or

depression, there is a lack of research investigating the global

aspects of the illness experience from the survivor’s perspec-

tive (Johnson & Morse 1990, Thompson et al. 1995).

Furthermore, the postexperiences have commonly been

examined using questionnaires that do not allow a more

detailed, fuller exploration of the psychological experiences

or issues influencing their recovery (Stewart et al. 2000).

Further research is necessary that investigates this area using

both quantitative and qualitative research methods.

Cultural aspects of health seeking behaviourin Australia

Culture may be described as �the sum total ways of living

built up by a group of human beings, which is transmitted

from one generation to another� (Macquarie Dictionary

2002). Australia is characterized by its cultural diversity,

with preliminary estimates for 1999 identifying 24% born

overseas, and almost 14% from non-English speaking back-

grounds (NESB) (ABS 1999). Migrants from different socio-

cultural and linguistic backgrounds have been found to

possess varying perceptions of illness and health (D’Cruz &

Tham 1993). Given the multicultural nature of Australian

society, and that health and illness are culturally constructed

experiences (Manderson 1990), it is important to include the

perspectives of people from minority cultures in health

related research in order to provide culturally sensitive health

care during an illness. Furthermore, as one’s experience of

health and illness is likely to be influenced by their culture,

culture may affect and have implications on the patient’s

Integrative literature reviews and meta-analyses Adjustment to coronary heart disease

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(4), 391–399 393

recovery process. Thus it is also important to research the

experiences of such individuals during recovery from illness

in order to better understand and meet their needs following

discharge from hospital.

Although the manner in which people from NESB com-

munities seek health services in Australia is not well under-

stood, it is well documented that people of NESB are less

likely to make use of health services when in need (Rissel &

Rowling 1991, Cass 1995, Grypma 1997, Ziguras et al.

1998). Not only do they lack knowledge of services they can

access, but they often have difficulties gaining access to health

and welfare services (Duong 1993, Lau 1995, Ziguras et al.

1998). Accessibility to health services is not the only issue,

with inequity in the quality of care of services provided being

reported (Lopez & Fazzalori 1995, Macintyre & Dennerstein

1995). The quality of nursing care delivery is one area that

has been criticized, with evidence to suggest that the nursing

profession has failed to provide nursing services to preserve

the cultural backgrounds and meet the needs of NESB

patients that nurses serve (Kanitsaki 1993, Gorman 1995).

Research has also demonstrated that other health profes-

sionals have failed to provide culturally appropriate health

care to NESB people (Lopez & Fazzalori 1995, Macintyre &

Dennerstein 1995, Pardy 1995), with some health profes-

sionals defending their position by arguing that migrants

should not receive �special� treatment (Mitchell 1989, Lopez

& Fazzalori 1995).

It is of concern that an inequitable service is being provided

in the health system in terms of meeting cultural needs,

especially when one considers the growing multicultural

nature of Australia’s population. It is important that recom-

mendations for the nursing care of cardiac patients are based

on the heterogeneous nature of the Australian culture,

especially as the mandate of the Australian governments is

to strive for equity, access, justice, inclusiveness and colla-

boration in all aspects of health service delivery (New South

Wales Health Council 2000). The NSW Government has

increased its focus on consumer participation in health care

(New South Wales Health 1999) by involving consumers

collaboratively with health professionals in health service

planning, delivery, monitoring and evaluation. Consumer

participation enhances the acceptability of services because

consumers can express their health service needs. Thus, it is

important to gain the perspectives of individuals from NESB

concerning their health-seeking behaviours and experiences.

Although access and equity in health services remains a

significant problem for NESB populations in Australia, there

is a growing focus on meeting their specific health needs in a

culturally sensitive manner (Thompson & Retasas 1998).

Thompson and Retasas (1998) argue that one of the reasons

for this is that the demographic profile of Australia has

changed due to immigration policies which encouraged

migrants, and because of increased life expectance, better

nutrition and health of people from NESB. Rather than

expecting migrants to adopt the Anglo-Australian way of life,

the Australian Government has adopted a policy of multi-

culturalism and acceptance of different values and traditions

(Blackford & Street 2000). While in theory health care

institutions are expected to ensure equity and access to health

care services for all Australians, in practice the necessary

structures have not been put in place to facilitate this

(Henenberg & Pardy 1995, Multicultural Affairs Unit 1997).

Culturally specific research investigating psychosocial

responses to CHD

The cardiac rehabilitation literature lacks information on

social, psychological and particularly cultural implications of

heart disease. Exploration of individuals’ experiences during

this period may increase knowledge and understanding of

health problems and needs of survivors of CHD which may

assist in the planning of nursing support services during

convalescence. Although there is abundant literature on the

recovery process for survivors of MI (Johnson & Morse

1990, Thompson et al. 1994, 1995) there is a paucity of

research investigating a specific cultural group’s experiences

during the recovery process following an CHD. Studies have

been conducted on the spouses of Taiwanese (Yeh et al.

1994) Finnish (Hentinen 1983) and Lebanese-Australian

(Daly et al. 2000) survivors of MI, but not on the experiences

of survivors of MI of specific cultural groups.

Chinese/Asian cultural influences on the experience

of cardiovascular conditions

Australia has a significant Asian population as part of its

cultural diversity representing 26% of all settler arrivals in

1998–1999. The Chinese population is one of the fastest

growing in Australia, with Chinese (Cantonese and Manda-

rin) the third most common languages spoken at home,

behind Italian and Greek (ABS 1999). Although the Asian

population has traditionally represented a low-risk group in

terms of CHD, the increased Westernization of this group has

led to a concomitant increase in CHD (Webster 1997, Lien

et al. 1998). In Australia, while Asian mortality from

cardiovascular disease is significantly less than the Austra-

lian-born population, rates tend to increase after their first

10 years of residence in Australia (National Heart Founda-

tion 1996). In the United Kingdom (UK) the incidence of

CHD in Asians is high, with mortality from CHD in the four

J. Daly et al.

394 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(4), 391–399

main groups of Asians (Gujarati Hindus, Punjabi Sikhs and

Muslims from Pakistan and Bangladesh) living in England

and Wales 36% higher in men and 46% higher in women

compared with non-Asians, with the percentage growing

each year (Webster 1997). The apparent growing of Asian

susceptibility to CHD, fuelled by factors such as changing

dietary behaviours and high incidence of smoking behav-

iours, reinforces the importance of identifying Asian

migrants’ knowledge, beliefs and health seeking behaviours

about CHD in order to plan culturally sensitive future

services.

Most studies of Chinese survivors of CHD have examined

specific responses such as anxiety, depression and coping

methods rather than their experiences (Yeh et al. 1994,

Chiou et al. 1997, Shih et al. 1998, Taylor-Piliae &

Molassiotis 2001). Little is known about the needs of

Chinese CHD survivors. An important reason for studying

the needs of Chinese survivors of CHD is that some aspects of

their cultural tradition may hamper their equity of access to

health services. For example, Lui and MacKenzie (1999)

studied the rehabilitation needs of Chinese stroke patients,

and suggested that the priorities, interpretations and expres-

sions of need are affected by Chinese upbringing and family

values, particularly among the elderly population. In contrast

to Western populations, who focus on individual need,

Chinese people have a strong emphasis on collectivism (Bond

1995). Hence, Chinese people traditionally are less inclined

to express individual need unless encouraged to do so. Lui

and Mackenzie (1999) found that most Chinese elderly

people tend to take a passive role in expressing their needs,

which is particularly related to their educational, social and

cultural background. Webster (1997) also found that nurses

perceived that Asian MI patients were more passive than

other patients, often preferring to stay in bed rather than

being involved actively in their rehabilitation. They tended to

receive the support they needed from their extended family

rather than cardiac rehabilitation programs. Taylor-Piliae

and Molassiotis (2001) suggested that traditional Chinese

philosophies of Confucianism, Taoism and Buddhism pro-

vide perspectives on health and share an approach to the

management of life stresses among Chinese. The Chinese

view is that these stresses are determined by fate and any

associated suffering is valued because it develops character

and repays the debts of previous lives. Confucian values also

emphasize the centrality of the family in the management of

life problems. Thus one possible explanation of Webster’s

(1997) findings is that it may be possible that the Chinese

patients tend to be more passive and stay in bed because they

believe adoption of a �do nothing� approach allows fate to

take its course. Further, they may not seek help from

nurses so much because of their heavy reliance on their

family.

Webster’s (1997) study found that nurses also felt that the

care they offered to Asian MI patients was inferior to that

offered to other patients. The most common reason reported

was a perceived lack of knowledge of the needs and

expectations of Asian patients and their families. Thus the

implication of these studies is that many Chinese patients

may have unmet needs because nurses do not know these

patients’ requirements. This research highlights the need for

more information on the experiences of Asian patients so that

nurses can provide more culturally sensitive care.

Use of health services by Chinese-Australians

There is a paucity of Australian research investigating the

health needs of Chinese patients and of those in the

community. There is also a lack of research investigating

access and use of health services by Chinese-Australians.

However, Chan and Quine (1997) conducted a qualitative

study using focus group to explore experiences of 27 Chinese

migrants in utilizing Australian health care services (main-

stream and ethno-specific). They found that Chinese migrants

preferred to use Chinese-speaking general practitioners, there

were insufficient interpreter services and a lack of knowledge

about the existence and role of ethnic health workers. They

also found that Hong Kong migrants tended to use available

health care services more than migrants from China. Almost

all participants reported that if western treatment failed,

alternative methods such as herbalism, acupuncture and

cupping were used. The National Health Survey conducted

by the ABS in 1992 found that the use of doctors by ethnic

Chinese was low; there were problems with access, and some

had chosen other sources of health service (Young & Coles

1992). These studies suggest a need for improving the quality

and quantity of interpreter services; promotion of the

availability of ethnic health workers; and the importance of

producing Chinese-written pamphlets.

Research in cardiovascular nursing

Knowledge of patients’ perceptions and interpretations of

their illness can have a significant impact on how they adjust

and behaviour during their recovery (Thompson et al. 1995).

There is limited Australian literature describing the personal

experiences of survivors of CHD in the initial discharge

period. Daly et al. (1998, 2000) have conducted a series of

studies in this area. In the first study, Daly et al. (1998)

undertook a qualitative, exploratory-descriptive study of

the experiences of seven Lebanese-born female spouses of

Integrative literature reviews and meta-analyses Adjustment to coronary heart disease

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(4), 391–399 395

survivors of MI in the initial discharge period. Qualitative

data analysis uncovered three themes: struggle to resolve

distress, intensive monitoring of the survivor and searching

for avenues of support. The research participants experienced

the first 4 weeks following the discharge of their spouse as a

period involving considerable distress comprised of a number

of emotions, oversolicitousness toward the survivor, psycho-

somatic symptoms, fear of recurrence of the acute myocardial

infarction (AMI) or loss of the spouse, searching for support,

and anticipating the future. These findings parallel those

uncovered in previous studies of female spouses of AMI

survivors (Thompson & Cordle 1988, Marsden & Dracup

1991, Moser et al. 1993, Thompson et al. 1995). However,

cultural issues impacted on gender and family roles. The

women experienced a lack of support during a stressful

family crisis, a sense of isolation and they suborned their

needs to that of the survivor (even when this resulted in a

deterioration in personal health and quality of life). However,

the participants were able to maintain a sense of hope that

their circumstances would return to normal in the future.

While the study findings were not generalizable, they provide

useful information on how to improve nursing support to the

target group in the community.

In the second study, Daly et al. (2000) sought to explore

health status, perceptions of coping, and social support

among survivors of a recent AMI in the 3 weeks after

discharge from hospital in South-western Sydney. In this

study a descriptive, exploratory approach with a triangulated

methodology was used to assess the experiences of 38

survivors (26 males and 12 females), detect patterns in these

experiences, explore the health-support needs of the survi-

vors, and determine changes in health status in the first

3 weeks after discharge. Analysis of qualitative data from the

12 female survivors revealed both similarities to and differ-

ences from the data of male survivors. Similarities included

anticipating resumption of valued tasks and activities and

emotional flux. As in the male survivors, this emotional flux

was manifested as anxiety, depression, ambiguity and uncer-

tainty, fear of recurrence of the AMI, and fear of further

deterioration in health. Female survivors also reported a

struggle to integrate changes in their lifestyle. The women

tended to seek external support as well as from family,

including church groups and the National Heart Foundation.

These findings support those of Riegel and Gocka (1995),

who compared 32 women and 32 men with a first AMI and

found that women reported wanting, receiving and giving

more support than men did at 4 months. That is, the women

appeared to activate their social support system more

effectively than the men after AMI.

In the third study, Jackson et al. (2000) undertook serial

interviews with women survivors of first-time MI. These

interviews were conducted at 7, 14 and 21 days posthospital

discharge, and aimed to explore the recovery experiences and

needs of women survivors of first-time MI in the initial

postdischarge period. Findings revealed the 3 weeks following

hospital discharge was a period of intense introspection,

which involved examination and contemplation of many

previously taken-for-granted aspects of their lives. The

women described feelings of exhaustion, fear and marked

emotional lability. Their major unmet need was for informa-

tion about the MI and implications for lifestyle arising from it.

Svedlund and Axelsson (2000) examined the meaning of

lived experiences after and AMI in nine women and their

partners. The experience of AMI contained two themes:

�rehabilitation needed� and �loss of freedom�. The women

reported that they felt distressed and vulnerable but struggled

against the fear the illness means. The partner’s role was one

of trying to adapt to the women’s experiences of the illness.

Although the generalizability of these studies is limited by

their small sample size and predominant use of qualitative

research methods, together they suggest that the postdis-

charge period is a stressful, uncertain one in which informa-

tion about their illness is an important need. The results

support the role that nurses have in discharge planning and

providing ongoing information and support for survivors of

AMI in the recovery period. However, evidence-based

cardiac research needs to focus more on specific cultural

groups in order to identify their postdischarge nursing needs.

Unless nurses appreciate individual’s needs in relation to

information, services and care they risk delivering interven-

tions and care plans on assumptions that are not meaningful,

appropriate or based on evidence. The authors plan a study to

evaluate systematically the health seeking behaviours and

belief models of Chinese-Australians.

This study will use a triangulated methodology that allows

both generalizability and depth of insight into the postdis-

charge experiences of Chinese CHD patients. This study

seeks to partly replicate the Daly et al. (2000) study in a

Chinese-Australian population. It will investigate the health

patterns, information and adjustment of experiences of

Chinese individuals who have been recently hospitalized

with ACS in Southern and Western Sydney. It will also

conduct a community study of Chinese migrants to determine

whether their health seeking behaviour regarding cardiac

conditions is conventional, and their awareness of the

services they can access. This will be a collaborative study

with Hong Kong, UK and the USA to explore the similarities

and differences of needs, beliefs, health seeking practices and

J. Daly et al.

396 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(4), 391–399

experiences of Chinese cardiac patients in Australia as

compared with those in Hong Kong, UK and USA.

Conclusion and suggestions for future research

Aspects of the illness experience and recovery phase of CHD

in Chinese-Australians remain unexplored and poorly under-

stood because of the lack of research in this area. However,

the research that does exist indicates that cultural aspects do

influence the experience of Chinese patients, in terms of their

passive health-seeking behaviours and reliance on family

members rather than nursing services. Future research should

focus on comparing the needs of Chinese patients vs. patients

from Western backgrounds rather than limiting its focus to

one sample. Furthermore, research in this area would be

more generalizable by using larger sample sizes, and the use

of both valid quantitative and qualitative research methods.

Such research will provide insights into the initial recovery

period and increase the knowledge and understanding of

Chinese patients’ recovery and their discharge needs after

CHD in comparison with Anglo-Celtic patients.

Given the multicultural nature of Australian society and

the growing awareness of inequity in use of and access to

health services by people of NESB, it is imperative to include

the perspectives of people from minority cultures in health-

related research. Barriers to inclusion often centre around the

expense of interpreters and translations together with the lack

of availability of validated and reliable measures. Cultural

aspects related to perceptions of confidentiality and research

can also hamper recruitment of specific cultural and ethnic

groups. Despite the challenges, these obstacles are not

insurmountable and mandate attention by policy makers,

clinicians and researchers. This may serve to reduce the

obstacles to cross-cultural care within nursing practice and

inform a research agenda and planning for service delivery.

References

Australian Bureau of Statistics (1999) 1996 Census of Population and

Housing Australia. Commonwealth of Australia, Canberra.

Australian Institute of Health and Welfare (2000) Australia’s Health

2000. AIHW Cat, no. 19, Canberra.

Beach E., Maloney B., Plocica A., Sherry S., Weaver M., Luthrunger L.

& Utz S. (1992) The spouse: a factor in recovery after acute myo-

cardial infarction. Heart and Lung 21, 30–38.

Blackford J. & Street A. (2000) Nurses of NESB working in a mul-

ticultural community. Contemporary Nurse 9, 89–98.

Bond M.H. (1995) The Psychology of Chinese People. Oxford Uni-

versity Press, Hong Kong.

Cameron-Traub E. (2000) Meeting health care needs in Australia’s

diverse society. In Contexts of nursing: an introduction (Daly J.,

Speedy S. & Jackson D. eds) MacLennan & Petty, Sydney,

pp. 235–247.

Carroll D.L., Hamilton G.A. & McGovern B.A. (1999) Changes in

health status and quality of life and the impact of uncertainty in

patients who survive life-threatening arrhythmias. Heart and Lung

28, 251–260.

Cass N. (1995) Migrant women managing change. BIMPR Bulletin

15, 5.

Chan Y. & Quine S. (1997) Utilisation of Australian health

care services by ethnic Chinese. Australian Health Review 20,

64–77.

Chiou A., Potempa K. & Buschmann M. (1997) Anxiety, depression

and coping methods of hospitalised patients with myocardial

infarction in Taiwan. International Journal of Nursing Studies 34,

305–311.

Christman N., McConnell E., Pfeiffer C., Webster K., Schmitt M. &

Ries J. (1988) Uncertainty, coping, and distress following myo-

cardial infarction: transition from hospital to home. Research in

Nursing and Health 11, 71–82.

Commonwealth Department of Health and Aged Care and Austra-

lian Institute of Health & Welfare (1999) National Health Priority

Areas Report: Cardiovascular Health AIHW, Cat no. PHE 12,

Canberra.

Conn V.S., Taylor S.G. & Abele P. (1991a) Myocardial infarction

survivors: age and gender differences in physical health, psycho-

social state and regimen adherence. Journal of Advanced Nursing

16, 1026–1034.

Conn V.S., Taylor S.G. & Wiman P. (1991b) Anxiety, depression,

quality of life and self-care among survivors of myocardial in-

farction. Issues in Mental Health Nursing 12, 321–331.

Coyne J. & Smith D. (1991) Couples coping with a myocardial

infarction: a contextual perspective on wives’ distress. Journal of

Perspectives on Social Psychology 61, 404–412.

Crowe J.M., Runions J., Ebbesen L.S., Oldridge N.B. & Streiner D.L.

(1996) Anxiety and depression after acute myocardial infarction.

Heart and Lung 25, 98–107.

Daly J., Jackson D., Davidson P.M., Wade V., Chin C. & Brimelow

V. (1998) Illuminating the experiences of female spouses of sur-

vivors of acute myocardial infarction (AMI): a pilot study of

Lebanese-born women in South Western Sydney, Australia. Jour-

nal of Advanced Nursing 28, 1199–1206.

Daly J., Elliott D., Cameron-Traub E., Salamonson Y., Davidson

P.M., Jackson D., Chin C. & Wade V. (2000) Health status, per-

ceptions of coping, and social support immediately after discharge

of survivors of acute myocardial infarction. American Journal of

Critical Care 9, 62–69.

Davies N. (2000) Patients’ and carers’ perceptions of factors influ-

encing recovery after cardiac surgery. Journal of Advanced Nursing

32, 318–326.

D’Cruz J.V. & Tham G. (1993) Nursing and Nursing Education in

Multicultural Australia: a Victorian Study of Some Cultural Cur-

riculum and Demographic Issues. David Lovell Publishing, Mel-

bourne, in collaboration with. Centre for Comparative and Policy

Studies in Education, La Trobe University.

Drory Y., Kravetz S. & Florian V. (1999) Psychosocial adjustment in

patients after a first acute myocardial infarction: the contribution

of salutogenic and pathogenic variables. Israel Study Group on

Integrative literature reviews and meta-analyses Adjustment to coronary heart disease

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(4), 391–399 397

First myocardial Infarction. Archives of Physical Medicine and

Rehabilitation 80, 811–818.

Duong X. (1993) Vietnamese women’s health. Integration 1, 21–31.

Frasure-Smith N., Lesperance F., Juneau M., Talajic M. & Bourassa

M. (1999) Gender, depression, and one year prognosis after

myocardial infarction. Psychosomatic Medicine 61, 26–37.

Gorman D. (1995) Multiculturalism and transcultural nursing in

Australia. Journal of Transcultural Nursing 6, 27–33.

Grypma R. (1997) Language, psychologists and the mental health of

older immigrants. Synapse: Bulletin of the Australian Transcultural

Mental Health Network 1, 1–2.

Henenberg C. & Pardy M. (1995) It’s like we don’t have a mouth:

women, interpreting, health. Health Sharing Women 6, 8–12.

Hentinen M. (1983) Need for instruction and support of the wives of

patients with myocardial infarction. Journal of Advanced Nursing

8, 519–524.

Jackson D., Daly J., Davidson P., Elliott D., Cameron-Traub E.,

Wade V., Chin C. & Salamonson Y. (2000) Women recovering

from first-time myocardial infarction: a feminist qualitative study.

Journal of Advanced Nursing 32, 1403–1411.

Johnson J.L. & Morse J.M. (1990) Regaining control: The process of

adjustment after myocardial infarction. Heart & Lung 19, 126–135.

Kanitsaki O. (1993) Acute health care and Australia’s ethnic people.

Contemporary Nurse 2, 122–127.

Lau M. (1995) Some health issues affecting ethnic communities and

their impact on women from non-English speaking backgrounds.

In Insight, Courage and Purpose Potential Unlimited: Proceedings

of the Conference (Pfitzner B. ed.) Steering Committee, Non-Eng-

lish Cultural Background International Women’s Conference,

Adelaide, 1995, p. 61–66.

Levine J., Covino N., Slack W., Safran C., Safran D., Boro J., Davis

R., Buchanan G. & Gervino E. (1996) Psychological predictors

of subsequent medical care among patients hospitalised with

cardiac disease. Journal of Cardiopulmonary Rehabilitation 16,

109–116.

Lidell E., Fridlund B. & Segesten K. (1998) Vulnerability factors

from a pre- and post-myocardial infarction perspective: a qualita-

tive analysis. Coronary Health Care 2, 72–80.

Lien W.P., Lai L.P., Chen J.J., Hwang J.J., Lin J.L., Lei M.H., Huang

P.J. & Tsai K.S. (1998) Retrospective hospital-based Study of

coronary risk factors in Taiwan. Analysis of patients with estab-

lished diagnoses. Japanese Heart Journal 3994, 435–444.

Lin S., Ku N., Yang S. & Wu J. (2000) Social support, uncertainty

and psychological well-being of patients during the first three

months after percutaneous transluminal coronary angioplasty.

Journal of Nursing Research 8, 529–541.

Lopez R. & Fazzalori L. (1995) Immigrant Women’s Health Project:

Hospital-Based Research Report. Mercy Hospitals Incorporated,

Melbourne.

Lui M.H. & & Mackenzie H.E. (1999) Chinese elderly patients’

perceptions of their rehabilitation needs following a stroke. Journal

of Advanced Nursing 30, 391–400.

Macintyre M. & Dennerstein L. (1995) Shifting Latitudes, Changing

Attitudes: Immigrant Women’s Health Experiences, Attitudes,

Knowledge and Beliefs. Key Centre for Women.s Health, Mel-

bourne.

Macquarie Dictionary (2002) Macquarie Dictionary Revised, 3rd

edn. The Macquarie Library Pty. Ltd, Sydney.

Manderson L. (1990) Introduction: does culture matter? In The

Health of Immigrant Australia: a Social Perspective (Reid J. &

Trompf P. eds) Harcourt Brace Jovanovich Group Pty Ltd, Sydney,

Australia, pp. xi–xvii.

Marsden C. & Dracup K. (1991) Different perspectives: the effect of

heart disease on patients and spouses. AACN Clinical Issues in

Critical Care Nursing 2, 285–292.

Mitchell G. (1989) Health policy for a multicultural Australia. In The

Challenge of Diversity: Policy Options for a Multicultural Aus-

tralia (Jupp J. ed.). Government Publishing Service, Canberra,

Australian, pp. 204–217.

Moser D. & Dracup K. (1995) Psychosocial recovery from a cardiac

event: the influence of perceived control. Heart and Lung 24, 273–

280.

Moser D., Dracup K. & Marsden C. (1993) Needs of recovering

cardiac patients and their spouses: compared views. International

Journal of Nursing Studies 30, 105–114.

Multicultural Affairs Unit (1997) Responding to Diversity. Multi-

cultural Affairs Unit, Department of Premier and Cabinet, Mel-

bourne.

National Health and Medical Research Council Media Release

(1996) NHMRC Releases Guidelines on Unstable Angina. Dr

Andrew Tonkin, 13 November.

National Heart Foundation (1996) Heart and Stroke Facts 1996

Report. National Heart Foundation of Australia, Canberra.

New South Wales Health (1999) A Framework for Managing the

Quality of Health Services in New South Wales. NSW Health,

Sydney.

New South Wales Health Council (2000) Report of the NSW. Health

Council – A Better Health System for NSW. NSW Health, Sydney.

Pardy M. (1995) ‘Speaking of Speaking’: Experiences of Women and

Interpreting Clearing House on Migration Issues. Research report

of interpreting for women project, Melbourne.

Riegel B. & & Gocka I. (1995) Gender differences in adjustment to

acute myocardial infarction. Heart and Lung 24, 457–466.

Rissel C. & Rowling L. (1991) Towards a model for the provision of

comprehensive services for non-English speaking communities.

Drug Alcohol Review 10, 137–149.

Rodeman B., Conn V. & Rose S. (1995) Myocardial infarction sur-

vivors: social support and self-car behaviours. Rehabilitation

Nursing Research 4, 58–63.

Shapiro P., Lesperance F., Frasure-Smith N., O’Connor C., Baker B.,

Jiang J., Dorian P., Harrison W. & Glassman A. (1999) American

Heart Journ 137, 1100–1106.

Shih F., Meleis A.YuP., Hu W., Lou M. & Huang G. (1998) Tai-

wanese patients’ concerns and coping strategies: transition to car-

diac surgery. Heart and Lung 27, 82–98.

Stewart M., Davidson K., Meade D., Hirth A. & Makrides L. (2000)

Myocardial infarction: survivors’ and spouses’ stress, coping and

support. Journal of Advanced Nursing 31, 1351–1360.

Svedlund M. & Axelsson I. (2000) Acute myocardial infarction

in middle-aged women: narrations from the patients and their

partners during rehabilitation. Intensive and Critical Care Nursing

16, 256–265.

Taylor-Piliae R. & Molassiotis A. (2001) An exploration of the

relationships between uncertainty, psychological distress and type

of coping strategy among Chinese men after cardiac catheteriza-

tion. Issues and Innovations in Nursing Practice 33, 79–88.

J. Daly et al.

398 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(4), 391–399

Thompson D. & Cordle C. (1988) Support of wives of

myocardial infarction patients. Journal of Advanced Nursing 13,

223–228.

Thompson D.R., Ersser S.J. & Webster R.A. (1994) The experi-

ences of patients and their spouses one month after a heart

attack. In Conference Proceedings of the University of British

Columbia International Nursing Research Conference, Vancou-

ver, Canada.

Thompson D.R., Ersser S.J. & Webster R.A. (1995) The experiences

of patients and their partners one month after a heart attack.

Journal of Advanced Nursing 22, 707–714.

Thompson P. & Retasas A. (1998) NALOTE: neurological assess-

ment in languages other than English. Australasian Journal of

Neuroscience 11, 12–14.

Tooth L., McKenna K. & Maas F. (1999) Prediction of functional

and psychological status after percutaneous transluminal coronary

angioplasty. Heart and Lung 28, 276–283.

Veghiazarians Y., Braunstein J.B. & Stone P.H. (2000) Unstable

Angina Pectoris. New England Journal of Medicine 342, 101–114.

Webster R. (1997) The experiences and health care needs of Asian

coronary patients and their partners. Methodological issues and

preliminary findings. Nursing in Critical Care 2, 215–223.

Webster K. & Christman N. (1988) Perceived uncertainty and coping

post myocardial infarction. Western Journal of Nursing Research

10, 384–440.

Yeh M., Gift A. & Soeken K. (1994) Coping in spouses with acute

myocardial infarction in Taiwan. Heart and Lung 23, 106–111.

Young C. & Coles A. (1992) Women’s Health, Use of Medical Ser-

vices, Medication, Lifestyle and Chronic Illness: Some Findings

from the 1980–90 National Health Survey. Australian Government

Publishing Service (AGPS), Canberra.

Ziguras S., Lambert T., McKenzie D. & Pennella J. (1998) Psycho-

tropic medication and ethnicity. Connections: Newsletter of the

Victorian Transcultural Mental Health Network October, 102.

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(4), 391–399 399

Integrative literature reviews and meta-analyses Adjustment to coronary heart disease