BACR & IACR Welcomes you
Annual Conference Belfast 2006
TERMINOLOGY
SEX: a biological term used by physical scientists…• genetic constitution, hormones, secondary sexual
characteristics• essentially immutable• femaleness and maleness
GENDER: a psycho-social term used by social scientists…• expression of biological sex• behaviour, emotions, communication, etc• learned and therefore culture-bound • masculinity and femininity
GENDER DIFFERENCES IN HEALTH
WOMEN MEN
more sick leave/days in bed
more health/medical consultations
more self-medication
more reproductive problems
more chronic illness serious chronic diseases
more acute non-fatal illnesses acute fatal illnesses
neurotic disorders pathological grief, PTSD
depression burnout
higher levels of physical symptoms better self-rated health
old age infirmity higher all-cause mortality
SUMMARY
differences in morbidity(women are sicker than men)
differences in mortality(men die earlier than women)
applies broadly to industrialised societiesbut almost all this is changing
CHD MORTALITY BY SEX(BHF 2005, ICD codes 120-125)
number of CHD deaths
percentage of all CHD deaths
females 51 495 45.2%
males 62 400 54.8%
total 113 895 100%
percentage of all deaths
female 16%
male 22%
CHD: A MAN’S DISEASE
Images of CHD:-
"....not the delicate, neurotic person......but the vigorous in mind and body, the keen and ambitious man, the indicator ofwhose engine is always at full speed ahead.“ (Osler, 1892)
Type A Personality/Behaviour Pattern (Rosenman & Freidman, 1974)• competitive, hard-driving, impatient, aggressive etc • a metaphor for masculinity
The persistent stereotype of a coronary candidate is likely to be amiddle aged, middle class man, red-faced, overweight, excitable,overworked, and in a high powered job.
Women were ignored in cardiac research for many years leading to avery weak evidence base for practice.Some awakening through the 1990’s but a number of studies havemixed findings…why?
SEX (biological characteristi
GENDER (gendered roles, social norms, attitudes etc)
THE RELATIONSHIP BETWEEN SEX AND GENDER
EXPLAINING GENDER DIFFERENCES
BIOLOGICAL• genetics• hormones• immune response• stress reaction
BEHAVIOURAL• health knowledge• health behaviour: eg smoking; food choices; exercise• illness behaviour• service uptake• communication
PSYCHO-SOCIAL(good reviews by Brezinka & Kittel, 1996; Jacobs & Stone, 1999)
Socio-Economic Status (Wilkinson, Marmot)• usually defined as poverty and low educational attainment• a stronger determinant of CHD mortality in women than men• difference persists when health behaviours are factored out• single status• we need to ask why?
Emotions & Support• anxiety and depression are more common among women• sources of stress likely to be different for many women
eg marital stress is more important to women than work stress (Ortho-Gomer et al 2000)
• social relationships are not a proxy for social support (Chesney & Darbes 1998)social support needs to be reconceptualised to take into account the obligations and care-giving aspects
EMPLOYMENT (good chapter in Orth-Gomer et al, 1998)
In general, having a job is associated with good health in both sexes.
However…• in men the impact of work on health is likely to be a function of the
work demands only• in women it is likely to be the work demands combined with other
areas of demand • the stress threshold above which work strain might have a
detrimental effect is lower for women• work is more cardio-protective for managerial/professional women• women in paid work tend to occupy different jobs to men
Karasek & Theorell’s Demand-Control Model: • high job demands; low autonomy/decision latitude; and low social
support• pathogenic job profile associated with CHD and other illnesses
DEMAND-CONTROL MODEL(Morrison & Bennett 2006, after Karasek & Theorell)
high decision control
low decision control
low demand high demand
dentistsales personarchitectscientist
police officerbank managerphysicianschool teacher
night watchmanjanitorlorry drivercarpenter
telephonistcookwaitersecretary
STEREOTYPICAL FEMALE CORONARY CANDIDATE (after Jacobs & Stone, 1999)
• post-menopausal and with co-morbidities• low SES with little formal education• high perceived stress• homemaker with no outside job• or has high demand-low control and still does most of the
home tasks• low social support in and out of the home• widow, also impacted by other bereavements• negative health behaviours (smoker, high fat diet, lack of
exercise)• of South Asian origin• lay care-giver
But do such women see themselves as coronarycandidates?
COMPONENTS OF TREATMENT DELAY INTERVAL
patient delay onset of symptoms to point of contact with EMS
EMS delay contact with EMS to arrival in hospital
hospital delay arrival in hospital to start of treatment
total delay period onset of symptoms to start of treatment
ILLNESS BEHAVIOUR…
The ‘gender paradox’ - women delay even longer than men.• possibly different presentation, context of background of
co-morbid symptoms, low somatic awareness• competing time and role demands, role adherence• concerns about troubling others• structural barriers, eg transport, health insurance (US)
Cardiac illness prototypes are culturally shared beliefs about
CHD.• social construction of ‘standard’ cardiac symptoms based
on male norms • low public perception of risk compared with carcinoma of
breast• applies to HPs as well as members of the public
SELF-REGULATORY MODEL(Leventhal & Cameron, 1987)
INTERNAL & ENVIRONMENTAL
STIMULI
REPRESENTATION OF PROBLEM
EMOTIONAL EXPERIENCE
ACTION PLAN FOR COPING
WITH PROBLEM
ACTION PLAN FOR COPING
WITH EMOTION
APPRAISAL
APPRAISAL
…ILLNESS BEHAVIOUR
Self-Regulatory Model focuses on the individual:• cognitive representations – sets of beliefs about CHD
(risk, causes, presentation, seriousness etc)• pervasive fallacies about low susceptibility
(even in the face of multiple risk factors)• women are often indecisive in the face of symptoms• often make inappropriate lay or professional consultations• beliefs about symptoms might not match experience, which
correlates( with delays
Heuristics (decision-rules) correlate with delays:• one is that we tend to attribute symptoms to stress when they
occur in challenging circumstances• another is gender, which will influences attribution
(Martin & Suls, 2003)
DIAGNOSIS AND TREATMENT
Women more commonly misdiagnosed:• ECG changes less prominent in women• symptoms might be different• but HPs are no different to anyone else; their perceptions
are subject to error (eg McKinlay studies)• medical textbooks – disproportionate number of male
images Investigation and treatment:Numerous UK and US studies have shown that women areless likely:• to be admitted to CCU, and to be thrombolysed• to receive aspirin and ß blockers on discharge• to be offered angioplasty or CABG(much debate about the possible reasons for all this)
CR ATTENDANCE
Another paradox…• women are less likely to attend and complete CR• especially low those from low SES groups; MEG’s;
elders; & younger women less likely (Inverse Care Law)• women are less likely to be invited
Emery (1995) identifies three areas to consider in
encouraging women to attend:-
1. Programme characteristics
2. The CR environment
3. Patient characteristics
Other factors: women are less likely to be accompanied;
more likely to need social support from the group; role
adherence for both sexes, though roles might differ.
REHABILITATION AND THE SICK ROLE
Role Resumption:• many women resume activities too soon, sooner than men• and the activities are often inadvisable• additive effect of various roles• salience of place, those for whom the home is also the workplace• role attractionSeveral recent UK studies: Thornton, Radley, Shaw.
Work disability: • data on women are scarce but there are a couple of good studies• less likely to be encouraged to return to work by HPs • might have different motives for returning to work: men are more
likely to return to work if married and if high income; in women no relationship with income, singles more likely to return
• women see themselves as tougher and rate their MI as less severe, so they soldier on (Nau et al 2005)
EMOTIONALITY
• females more anxious and depressed than males• but this applies to trait anxiety and depression pre-CHD anyway • so correlational studies are of little help• some of the difference might result from reporting bias due to
social norms about emotional expression• and females generally prefer to use emotion-focussed coping
styles• in some studies depression emerged later in men (after a
month), which could be due to the resumption of roles and diminution of denial, which is more common in men
• women often have to face their problems earlier than men, and therefore become distressed earlier
• women are consistently more prone to vicarious distress• less likely to have the benefit of protective buffering from partner
SEXUAL MORBIDITY
• many studies on male coronary victims• a number of small studies and a couple of big
ones on post MI women – results are equivocal
• but there are significant problems in both sexes
• difficult to unpack, given the unknown dyadic dynamics
• women are older, more anxious and might have older husbands
• direction of causality yet to be established
CAUSAL ATTRIBUTIONS
Most studies have been on men, but some data onwomen (eg Lewin et al):• men tend to attribute their CHD to modifiable causes
(eg smoking, diet)• women tend to make external attributions
(ag luck, fate, heredity)• this external locus of control might help explain
women’s non-uptake of CR since the things on offer will do little to assist with their perceived cause
• might also explain why women are less likely to modify risky behaviour
Stress is an attribution common to both but the sourcemight be different:• in men it is often work stress• women often identify relationship/family problems (eg
bereavement) and care-giving roles
IMPLICATIONS
• explain about the nature of CR rather than just invite• need to be aware that women generally are at higher
risk of psycho-social impairment than men• women are not a homogeneous group• need to examine sub-components of gender and
other individual variables such as culture• assess and work with causal attributions• assess role occupancy and tailor CR accordingly• assess social support and maximise where possible• more research on women’s illness representations• government/public health policy needs to focus
superordinate social factors that lead to individual behaviour
BACR & IACR Welcomes you
Annual Conference Belfast 2006