Introduction
The population of South Africa totals approxi- mately 46 million people and is ethnically and economically diverse. The diversity is reflected in the patterns of urbanization with nearly 50% of the black population residing primarily in rural or peri-urban areas compared to fewer than 20% of white South Africans or those of mixed ancestral or Asian origin (South African National Census 2001). However, urbanization of the black popula- tion has been increasing rapidly, particularly since 1994. Furthermore, this rapid urbanization com- bined with globalization has been accompanied by large shifts in the health patterns of South Africans, increasing the prevalence of non- communicable disease.1 The South African National Burden of Disease study for the year 2000 estimated that 17% of all deaths were due to car- diovascular diseases.2 Of these deaths, ischemic heart disease and stroke each accounted for 35%
of cardiovascular deaths, hypertensive heart disease 15%, inflammatory heart disease 6%, and other causes including rheumatic heart disease accounted for 9%. It is of interest to note that in South Africa HIV/AIDS is the leading cause of death and accounts for 30% of all deaths.
Prevalence of Risk Factors for Heart Disease
Along with the increased burden of non- communicable diseases, there has been an associated increase in the prevalence of a
number of known risk factors associated with heart disease including smoking, sedentary lifestyle, and increased intake of dietary fat.3–5 Furthermore, South Africans have a high preva- lence of overweight and obesity, with over 50% of women and more than 20% of men considered overweight by World Health Organization (WHO) standards (body mass index (kg/m2) >25). Indeed, the World Health Survey 2003, published by the WHO, suggests that the prevalence of physical inactivity in South African adults is greater than 60% for both males and females. In fact, nearly 60% of all South African adults have at least one major reversible factor. Thus, the need for both secondary and indeed primary intervention initiatives including cardiac rehabilitation is large.
Historical Perspective
Cardiac rehabilitation was officially started in Johannesburg by Dr John Sim in 1970. This program began with a handful of patients who used a parking lot in the premises of the Johannesburg Civic Centre to conduct their exercises. This initiative was shortly followed by the University of Cape Town program, initiated under the guidance of Professor Tim Noakes, who gained much local fame for encouraging cardiac patients to get fit and eventually run a full marathon.
In 1990 the South African Association of Cardiovascular and Pulmonary Rehabilitation was initiated. This association was recently
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Cardiac Rehabilitation: South Africa
Wayne E. Derman
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9. Cardiac Rehabilitation: South Africa 45
incorporated into the South African Sports Medicine Association (www.sasma.co.za).
Contemporary Cardiac Rehabilitation Programs in South Africa
South Africa is divided into nine provinces.
Formal cardiac rehabilitation programs exist in most of these provinces associated with academic universities or private hospitals. Although there have been initiatives to arrange rehabilitation ser- vices at governmental hospitals, these services have been fragmented and severely limited due to staff and financial shortages. Some provincial gov- ernment hospitals’ physiotherapy units provide some phase I rehabilitation following cardiac surgery.
Most outpatient cardiac rehabilitation pro- grams are conducted from private gymnasia, gymnasia or biokinetic practices associated with private hospitals or private practices under the auspices of Universities or Sports Science/Sports Medicine departments. These programs vary in size and have an attendance of typically between 10 and 100 patients per day. Services can vary from provision of exercise rehabilitation only to exercise rehabilitation, patient education, dietary and psychological intervention.
The programs which provide medical monitor- ing and comprehensive services as listed above tend to be costly and quite exclusive whilst the university-based programs tend to be less expen- sive and have a wider patient base.
However, despite an increasing worldwide trend for cardiac rehabilitation to be considered an important part of patient care, it is estimated that only 15–20% of eligible private cardiac patients are referred to rehabilitation services.
This figure is even less in the public sector.
Although cardiac rehabilitation services are underutilized in South Africa, the increasing demand for these services has come to the atten- tion of the health insurance industry and medical insurance schemes. In general most schemes rec- ognize patient claims for reimbursement for cardiac rehabilitation. However, a few still refuse to assist their members in paying for cardiac rehabilitation.
One medical insurance scheme leads the way in South Africa by encouraging members with an incentive-based system based on rewards for attending cardiac rehabilitation or indeed under- taking a primary intervention program to lower and manage their risk factors. It is interesting to note that this company has in a short period become the largest medical insurance company in South Africa.
This company has also promoted the teaching and science of cardiac rehabilitation by initiating
“best practice teaching symposia” around the country and has a committee which assesses and rates the practices in the established network. This has assisted the standards of cardiac rehabilita- tion throughout South Africa. For example, it is not possible to practice cardiac rehabilitation as part of this network if one does not have the nec- essary skilled staff, required emergency drugs, and an automated external defibrillator or similar device.
Shift of Emphasis in Cardiac Rehabilitation Programs in South Africa
Although the practice of cardiac rehabilitation in South Africa is conducted according to interna- tional guidelines and is considered successful,6,7 an observation from our Cardiac Rehabilitation Program is that patients attending the program for rehabilitation of a cardiac condition often also present with additional co-morbidities and mus- culoskeletal injuries. Thus we recently undertook a descriptive study to determine the profile of patients attending the Cardiac Rehabilitation Program at the Sports Science Institute of South Africa.8
This descriptive retrospective analysis evalu- ated the medical records of 313 patients who entered the program during the period of January 1996 to August 2000. Of the total population, 80% had documented coronary artery disease (CAD). The remaining 20% attended the program for rehabilitation of another chronic lifestyle disease. Of the group of patients presenting with CAD, only 31% presented with CAD as the sole disorder, 14% presented with CAD and
46 W.E. Derman
another chronic lifestyle disease, 26% with CAD and a chronic musculoskeletal injury, and a last group of 14% required rehabilitation for CAD plus another co-morbidity and a muscu- loskeletal injury. Furthermore, 11% presented with two or more risk factors, attending the program for primary prevention of CAD only, whilst 6% attended the program for primary prevention and the rehabilitation of another chronic disease.
Musculoskeletal rehabilitation was required in 57% of the total population. Of the total 286 mus- culoskeletal injuries noted, back injuries were the most common musculoskeletal condition (49%), with grade I motion segment abnormality the most common back injury (63% of back injuries).
Other common injuries included knee injuries (18%), shoulder injuries (13%), and hip injuries (7%).
These findings suggest that the focus of cardiac rehabilitation programs should be shifted to
“chronic disease” rehabilitation. Furthermore, as previous musculoskeletal injury is so common, staff who possess musculoskeletal rehabilitation skills should be employed in such programs.
Indeed, we suggest that lumbar “prehabilitation”
be taught to all patients enrolled in the program.
These factors may necessitate an evaluation of the current status of cardiac rehabilitation programs in general, including provisions for musculoskele- tal rehabilitation, variety in exercise forms, adequate supervision, the necessary testing and exercise equipment, and adequate reimbursement by medical aid schemes.
Challenges in South Africa
The economic diversity in South Africa makes the provision of cardiac rehabilitation services very challenging, particularly at the state or provincial hospitals where budget and staff shortages have made exercise rehabilitation programs seem a less important priority.
Initiating programs into the poorer community is also a significant challenge. One successful model used by the Community Health Interven- tion Programmes (CHIPs) Division of the Sports Science Institute of South Africa has been to ini- tiate low-cost, community-led rehabilitation and
primary prevention projects in the Western Cape and Gauteng regions in South Africa. Members of the community are encouraged to contact this division of the Institute and, once a core group of thirty community members, a safe venue (e.g. a church or school hall) and three to four community leaders volunteer, the Institute pro- vides leadership and training as well as supervi- sion for the initial 8 weeks of the program. A small amount of essential equipment (balls, rubber resistance bands, and blood pressure monitoring equipment) are donated to the group by a sponsor.
The four community leaders are then trained by our staff regarding low-intensity exercise training, safety issues during exercise, and patient monitoring. The initial 8 weeks of training is followed by a co-implementation period of 6 weeks, where community leaders and Institute staff together lead the program. Once the training is complete and our team are convinced the group is running smoothly and safely, the project is then handed over to the community at a cele- bratory function. The Institute provides ongoing back-up help for problem solving and guidance for the community leaders. This has proved to be a successful model and to date over 30 such programs have been created within the community.
References
1. Bradshaw D, Groenewald P, Laubscher R, et al.
Initial Burden of Disease Estimates for South Africa, 2000. Cape Town: South African Medical Research Council; 2003 (http://www.mrc.ac.za/bod/
bod.htm).
2. Bradshaw D. What do we know about the burden of cardiovascular disease in South Africa. Cardiovasc J S Afr 2005;16(3):140–141.
3. Bourne LT, Langenhoven ML, Steyn K, Jooste PL, Laubscher JA, van der Vyver E. Nutrient intake in the urban African population of the Cape Peninsula, South Africa. The Brisk study. Cent Afr J Med 1993;39(12):238–247.
4. Yach D, Townshend G. Smoking and Health in South Africa: the need for Action. Cape Town: South African Medical Research Council; 1988.
5. Reddy SP, Panday S, Swart D, et al. The South African Youth Risk Behaviour Survey 2002. Cape Town: South African Medical Research Council;
2003.
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6. Joughin HM, Digenio AG, Daly L, Kqare E. Physio- logical benefits of a prolonged moderate-intensity endurance training programme in patients with coronary artery disease. S Afr Med J 1999;
89(5):545–550.
7. Digenio AG, Cantor A, Noakes TD, et al. Is severe left ventricular dysfunction a contraindication to parti-
cipation in an exercise rehabilitation programme?
S Afr Med J 1996;86(9):1106–1109.
8. Dreyer L, Schwellnus M, Noakes TD, Derman EW.
Physiological and medical considerations of patients attending cardiac rehab programmes: implications for staffing and equipment. Med Sci Sports Exerc 2001;33(5, Suppl);S320.
