BACR & IACR
Welcomes you
Annual Conference
Belfast 2006
Belfast 2006
GENDER AND CHD: A SOCIAL
SCIENCE PERSPECTIVE
David G. Shaw
dshaw02@bcuc.ac.uk
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 societies
but almost all this is changing
CHD MORTALITY BY SEX
(BHF 2005, ICD codes 120-125)
number of
percentage of
CHD deaths 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 of
whose 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 a
middle 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 a
very weak evidence base for practice.
Some awakening through the 1990’s but a number of studies have
mixed findings…why?
THE RELATIONSHIP BETWEEN SEX
AND GENDER
GENDER
SEX
(biological characteristi
(gendered roles, social
norms, attitudes etc)
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 (OrthoGomer 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
dentist
sales person
architect
scientist
police officer
bank manager
physician
school teacher
low demand
high demand
night watchman
janitor
lorry driver
carpenter
low decision
control
telephonist
cook
waiter
secretary
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 coronary
candidates?
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
arrival in hospital to start
of treatment
hospital delay
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 comorbid 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)
REPRESENTATION
OF PROBLEM
ACTION
PLAN FOR
COPING
WITH
PROBLEM
APPRAISAL
EMOTIONAL
EXPERIENCE
ACTION
PLAN FOR
COPING
WITH
EMOTION
APPRAISAL
INTERNAL &
ENVIRONMENTAL
STIMULI
…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 are
less 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 attraction
Several 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 on
women (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 source
might 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