ABSTRACTIntroduction

In the developing phase of the complex health intervention: Physical Activity to reduce Vascular Erectile Dysfunction (PAVED), it is crucial to explore whether men can accept the communicative component regarding information that regular aerobe Physical Activity can reduce Erectile Dysfunction (i-PAVED). This information is provided by health professionals (HPs) in cardiac rehabilitation, where sexuality issues such as erectile dysfunction (ED) are otherwise rarely addressed.

Aim

To explore how acceptance of cardiac HPs’ address of sexuality, ED, and i-PAVED can be identified in men's narratives.

Methods

In this descriptive qualitative study, we conducted semi-structured individual interviews with 20 men (range 48-78 years of age) attending municipal cardiac secondary prevention and rehabilitation programmes on their acceptance of HPs’ address of sexuality, ED, and i-PAVED. The Theoretical Framework of Acceptability components (affective attitude, burden, ethicality, intervention coherence, perceived effectiveness, opportunity costs and self-efficacy) and three temporal perspectives (retrospective, concurrent and prospective) were used in the concept-driven first step of a content analysis, which was followed by a thematically data-driven second step.

Main Outcome Measures

Men anticipated and experiential acceptance was identified in six out of seven components of Theoretical Framework of Acceptability.

Results

Men acceptance was identified as “expression of interest,” “addressing sexuality,” “attitudes and values,” “understandable and meaningful,” “insights” and “motivation,” whereas no narratives were identified in relation to the component of opportunity costs.

Conclusion

As an aspect of the development of the complex cardiovascular health care intervention PAVED, this qualitative study showed that men attending cardiac secondary prevention and rehabilitation seemed to prospectively accept the communicative component of PAVED being HPs’ address of sexuality, ED, and i-PAVED, if the HPs are professional, educated and competent in the field of sexual health. Gerbild H, Areskoug-Josefsson K, Larsen CM, et al. Acceptability of Health Professionals’ Address of Sexuality and Erectile Dysfunction - A Qualitative Interview Study with Men in Cardiac Rehabilitation. Sex Med 2021;9:100369.

INTRODUCTIONAcceptability has become a key consideration in the development phase of complex interventions in health care.1

Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework 2017;17:1-13

,2Bleijenberg N de Man-van Ginkel J.M. Trappenburg JCA et al.Increasing value and reducing waste by optimizing the development of complex interventions: Enriching the development phase of the medical research council (MRC) framework. Complex interventions are defined as interventions with several interacting components1

Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework 2017;17:1-13

,2Bleijenberg N de Man-van Ginkel J.M. Trappenburg JCA et al.Increasing value and reducing waste by optimizing the development of complex interventions: Enriching the development phase of the medical research council (MRC) framework. and has proven to be effective in developing person-centered care.3

Olesen ML, Duun-Henriksen A, Hansson H, et al. A person-centered intervention targeting the psychosocial needs of gynecological cancer survivors: a randomized clinical trial 2016;10:832-841

Furthermore, careful development of complex interventions improve their adoption in health care.4

O'Cathain A, Croot L, Duncan E, et al. Guidance on how to develop complex interventions to improve health and healthcare 2019;9:e029954

Acceptability is a multi-faceted construct that reflects to which extent people receiving a health care intervention consider the intervention to be appropriate.1

Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework 2017;17:1-13

This study is part of a project developing the complex intervention: Regular aerobe Physical Activity to reduce Vascular Erectile Dysfunction (PAVED),5

Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. physical activity to improve erectile function: a systematic review of intervention studies 2018;6:75-89

, 6Gonzáles A Carvalho Td Andreato L et al.Physical exercise in the management of erectile dysfunction in patients with heart failure., 7Physical activity as an adjunct treatment for erectile dysfunction. which implies that health professionals (HPs) address sensitive issues such as sexuality and erectile dysfunction (ED).5

Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. physical activity to improve erectile function: a systematic review of intervention studies 2018;6:75-89

,7Physical activity as an adjunct treatment for erectile dysfunction.,8Discussing a sensitive topic: nurse practitioners' and physician assistants' communication strategies in managing patients with erectile dysfunction. The intervention PAVED consists of two main interacting components (Figure 1).

Figure 1Components of PAVED (i-PAVED is explored in this study).

One component is HPs’ communication consisting of supervision and guidance for regular aerobe physical activity, and HP's information about the fact that regular aerobe Physical Activity can reduce Vascular Erectile Dysfunction (i-PAVED).5

Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. physical activity to improve erectile function: a systematic review of intervention studies 2018;6:75-89

,7Physical activity as an adjunct treatment for erectile dysfunction. The other is men's action being performance of aerobe physical activity to enable the desired physiological effect: reduced vascular ED.5

Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. physical activity to improve erectile function: a systematic review of intervention studies 2018;6:75-89

, 6Gonzáles A Carvalho Td Andreato L et al.Physical exercise in the management of erectile dysfunction in patients with heart failure., 7Physical activity as an adjunct treatment for erectile dysfunction. Regular aerobe physical activity is currently a core intervention in cardiovascular secondary prevention and rehabilitation.9Corrà U Piepoli MF Carré F et al.Secondary prevention through cardiac rehabilitation: physical activity counselling and exercise training: key components of the position paper from the cardiac rehabilitation section of the European Association of Cardiovascular Prevention and Rehabilitation. The focus of this pre-intervention study is the communicative component, i-PAVED, and not on adherence to the core intervention of regular physical activity. The communicative component i-PAVED is less practiced and less understood because ED often remains overlooked, under-recognised, under-screened, under-diagnosed, under-treated and unaddressed by HPs.7Physical activity as an adjunct treatment for erectile dysfunction.,10Understanding the needs and objectives of erectile dysfunction patients., 11Sexual function of patients with heart failure: facts and numbers., 12Hatzichristou D Tsimtsiou Z. Prevention and management of cardiovascular disease and erectile dysfunction: toward a common patient-centered, care model. Pre-intervention studies are rarely performed, and most interventions are solution-driven rather than need driven.1

Sekhon M, Cartwright M, Francis JJ. Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework 2017;17:1-13

However, a pre-intervention analysis of I-PAVED from the perspectives of potential receivers can improve the understanding, development and design of the challenging component, i-PAVED, and thereby increase effectiveness of the intervention.13

Slattery P, Saeri AK, Bragge P. Research co-design in health: a rapid overview of reviews 2020;18

Common barriers for HPs’ address of sexuality and sexual issues such as ED are due to lack of HP education, competences and professionalism in the field of sexuality, or HPs’ perception that addressing sexuality is embarrassing for patients, being too intimate, private and potentially offensive to discuss.14Wang P Ai J Davidson PM et al.Nurses' attitudes, beliefs and practices on sexuality for cardiovascular care: a cross-sectional study., 15Discussing sexuality in healthcare: a systematic review., 16

Ezhova I, Savidge L, Bonnett C, et al. Barriers to older adults seeking sexual health advice and treatment: a scoping review 2020;107:103566

, 17Engelen MM Knoll JL Rabsztyn PRI et al.Sexual health communication between healthcare professionals and adolescents with chronic conditions in Western countries., 18Byrne M Doherty S Murphy AW et al.Communicating about sexual concerns within cardiac health services: do service providers and service users agree?. Furthermore, HPs’ reason for not inquiring about sexual function and ED can be attributed to their impression of cardiac patients’ lack of readiness and reluctance to bring up the subject.14Wang P Ai J Davidson PM et al.Nurses' attitudes, beliefs and practices on sexuality for cardiovascular care: a cross-sectional study.,18Byrne M Doherty S Murphy AW et al.Communicating about sexual concerns within cardiac health services: do service providers and service users agree?.,19Salehian R Khodaeifar F Naserbakht M et al.Attitudes and performance of cardiologists toward sexual issues in cardiovascular patients.. A biopsychosocial approach is significant in providing cardiac rehabilitation and addressing sexuality.20Sexuality as a health-promoting factor - theoretical and clinical considerations.,21Kreikebaum S Guarneri E Talavera G et al.Evaluation of a holistic cardiac rehabilitation in the reduction of biopsychosocial risk factors among patients with coronary heart disease.ED is defined as the inability to attain or maintain a penile erection of sufficient quality to perform satisfactory sexual activity,,23Mulhall JP Giraldi A Hackett G et al.The 2018 revision to the process of care model for evaluation of erectile dysfunction. and is currently one of the most common sexual dysfunctions for men worldwide.5

Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. physical activity to improve erectile function: a systematic review of intervention studies 2018;6:75-89

,6Gonzáles A Carvalho Td Andreato L et al.Physical exercise in the management of erectile dysfunction in patients with heart failure. Studies show that ED negatively affects men's self-esteem, sex life and quality of life.5

Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. physical activity to improve erectile function: a systematic review of intervention studies 2018;6:75-89

, 6Gonzáles A Carvalho Td Andreato L et al.Physical exercise in the management of erectile dysfunction in patients with heart failure., 7Physical activity as an adjunct treatment for erectile dysfunction.,24Diaconu CC Manea M Marcu DR et al.The erectile dysfunction as a marker of cardiovascular disease: a review. ED is frequently symptomatic of underlying endothelia dysfunction and arteriosclerosis,5

Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. physical activity to improve erectile function: a systematic review of intervention studies 2018;6:75-89

,7Physical activity as an adjunct treatment for erectile dysfunction.,25Baumann F Hehli D Makaloski V et al.Erectile dysfunction - overview from a cardiovascular perspective. and among health-related lifestyle factors, a physically inactivity lifestyle is the most important risk factor for vascular ED.26Health-related lifestyle factors and sexual dysfunction: a meta-analysis of population-based research. Physical inactivity, obesity, hypertension, metabolic syndrome and cardiovascular diseases are recognised as independent risk factors for vascular ED.5

Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. physical activity to improve erectile function: a systematic review of intervention studies 2018;6:75-89

,7Physical activity as an adjunct treatment for erectile dysfunction. For patients with cardiovascular diseases, self-care includes self-care maintenance such as regular exercise.27Jaarsma T Strömberg A Ben Gal T et al.Comparison of self-care behaviors of heart failure patients in 15 countries worldwide. Physical activity is suggested to be the first-line prevention and treatment option of vascular ED.7Physical activity as an adjunct treatment for erectile dysfunction.,28What do most erectile dysfunction guidelines have in common? No evidence-based discussion or recommendation of heart-healthy lifestyle changes and/or Panax ginseng. Advising about lifestyle modification is a rational first step, because next to prevention of cardiovascular events, lifestyle changes may reduce vascular ED.28What do most erectile dysfunction guidelines have in common? No evidence-based discussion or recommendation of heart-healthy lifestyle changes and/or Panax ginseng.,29Nicolai MPJ van Bavel J Somsen GA et al.Erectile dysfunction in the cardiology practice - a patients' perspective. Men in cardiac secondary prevention and rehabilitation are at increased risk of vascular ED.5

Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. physical activity to improve erectile function: a systematic review of intervention studies 2018;6:75-89

,25Baumann F Hehli D Makaloski V et al.Erectile dysfunction - overview from a cardiovascular perspective.,29Nicolai MPJ van Bavel J Somsen GA et al.Erectile dysfunction in the cardiology practice - a patients' perspective. ED is reported in up to 81% of these men, compared with 50% of the older population in general.11Sexual function of patients with heart failure: facts and numbers. Good sexual functioning and performance is important to most men with cardiovascular diseases.30Kalka D Karpinski Ł Gebala J et al.Sexual health of male cardiac patients - present status and expectations of patients with coronary heart disease. Therefore, international HPs are recommended to address sexuality and ED in cardiovascular care and rehabilitation,31Burnett AL Nehra A Breau RH et al.Erectile dysfunction: AUA guideline., 32Lindstrom Egholm C Rossau HK Nilsen P et al.Implementation of a politically initiated national clinical guideline for cardiac rehabilitation in hospitals and municipalities in Denmark., 33

Hackett G, Kirby M, Wylie K, et al. British society for sexual medicine guidelines on the management of erectile dysfunction in men—2017 2018;15:430-457

but this rarely happens in daily cardiac practice.5

Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. physical activity to improve erectile function: a systematic review of intervention studies 2018;6:75-89

,34Palm P Missel M Zwisler A et al.A place of understanding: patients' lived experiences of participating in a sexual rehabilitation programme after heart disease. Sexuality and sexual problems are reported to be taboo subjects34Palm P Missel M Zwisler A et al.A place of understanding: patients' lived experiences of participating in a sexual rehabilitation programme after heart disease., 35Sexual counseling and cardiovascular disease: practical approaches., 36Traumer L Jacobsen MH Laursen BS. Patients' experiences of sexuality as a taboo subject in the Danish healthcare system: a qualitative interview study. and underreported by men.37Frost M Wraae K Gudex C et al.Chronic diseases in elderly men: underreporting and underdiagnosis. Men do not seek treatment or tell HPs about ED when they are not asked or invited to do so by HPs.10Understanding the needs and objectives of erectile dysfunction patients.,16

Ezhova I, Savidge L, Bonnett C, et al. Barriers to older adults seeking sexual health advice and treatment: a scoping review 2020;107:103566

,17Engelen MM Knoll JL Rabsztyn PRI et al.Sexual health communication between healthcare professionals and adolescents with chronic conditions in Western countries. Men with cardiovascular diseases lack knowledge and understanding of the links between cardiovascular diseases and ED.30Kalka D Karpinski Ł Gebala J et al.Sexual health of male cardiac patients - present status and expectations of patients with coronary heart disease.,38

Shabsigh R, Kaufman J, Magee M, et al. Lack of awareness of erectile dysfunction in many men with risk factors for erectile dysfunction 2010;10:18

Studies have indicated that patients with cardiovascular diseases feel that it would be helpful to discuss ED with HPs.29Nicolai MPJ van Bavel J Somsen GA et al.Erectile dysfunction in the cardiology practice - a patients' perspective.,30Kalka D Karpinski Ł Gebala J et al.Sexual health of male cardiac patients - present status and expectations of patients with coronary heart disease.,39Byrne M Doherty S Murphy A et al.The CHARMS Study: cardiac patients' experiences of sexual problems following cardiac rehabilitation. Men with ED may have different preferences depending on their perceptions of the illness and treatment.