BACR & IACR Welcomes you

Annual Conference Belfast 2006

GENDER AND CHD: A SOCIAL SCIENCE PERSPECTIVE

David G. Shawdshaw02@bcuc.ac.uk

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