SINCE Framingham, 1,2 there has been compelling epidemiologic evidence that certain physiologic and behavioral factors place people at risk for developing heart disease. Even more important has been the publication of clinical trial evidence showing that when physiologic factors are treated and people make adjustments to particular behaviors, coronary heart disease (CHD) morbidity and mortality can be reduced. Many costly technological and pharmaceutical advances have occurred over the last few decades that have enhanced treatment options and improved outcomes for people who develop CHD. However, CHD remains a predominant public health problem, 3,4 perhaps in part because less attention has been paid to a potentially more economical treatment option, behavior modification.
Prevention initiatives can be enacted before (primary prevention) or after (secondary prevention) CHD has been diagnosed. Whether pharmaceutical or behavioral interventions are employed, it is intuitively understood and empirically demonstrated that primary prevention efforts show greater benefits and are more economical. 5 It should follow that once a coronary event has occurred, people would be more motivated to enact (secondary) prevention behaviors. However, this is yet to be concluded in the health care literature. 6,7
If people could attend to their known CHD risk factors by making changes in their behavior (whether dietary, lifestyle, smoking), much of the need for costly interventions and pharmaceuticals would be reduced. Although appearing to be a simple prescription, it is one that is very difficult to enact. The mechanisms underlying health behavior are complex and encompass the patient, healthcare provider, healthcare system, and sociocultural factors. 8 In this article, we will focus on a fundamental sociocultural factor that influences both primary and secondary CHD prevention behavior—gender.
Although related and often used interchangeably, the terms gender and sex need to be distinguished. The term sex conveys distinctions between males and females of a species, particularly in biophysical characteristics. These characteristics may be biochemical, gonadal, as well as physical and for the most part are universal. As Miles argues, “women and men inhabit the same world but the world of women is different from that of men.” 9(p1) The term gender conveys distinctions between men and women of a society, particularly as they undertake their social roles. People's gender, though not independent of their sex, develops predominantly on the basis of sociocultural norms and experiences and is expressed through the values they hold, their psychosocial characteristics, and ultimately their behaviors. The definition of gender implies that any exploration of a major health issue such as CHD, including its etiology, treatment, and recovery, is incomplete if the implications of gender-based values, beliefs, experiences, and skills are not considered.
COMPLIANCE WITH DISEASE PREVENTION BEHAVIORS
The empirical literature is abundant with evidence that modifying particular behaviors to prevent CHD, or its sequelae, works. We know that behaviors such as smoking, eating a high-fat and low-fibre diet, engaging in a sedentary and stressful lifestyle, and consuming large volumes of alcohol place people at risk for CHD. Further, once a diagnosis or event has occurred, it is clear that attending to CHD risk reduces the risk of future coronary events and mortality. 10–12 Studies conclusively show that when people with CHD actively engage in risk factor reduction efforts (eg, regular exercise, appropriate diet, smoking cessation, stress reduction), overall survival is extended, the need for procedures such as percutaneous coronary interventions and coronary artery bypass graft (CABG) surgery is decreased, and the incidence of subsequent myocardial infarction is reduced. 10,13 There is also suggestive evidence that secondary prevention efforts may also have a positive impact on health-related quality of life. Yet, the American Heart Association Task Force on Compliance maintains that people's reluctance to engage in risk reduction and disease prevention behaviors “is far more prevalent and varied than previously thought, [and argue that] more effective interventions are needed to reduce risk and improve patient outcomes.” 14(p1085) Despite strong epidemiological and clinical trial evidence of the link between particular lifestyle behaviors and their impact on CHD risk, the highest rates of noncompliance are typically found among people for whom lifestyle change or modification (as opposed to pharmaceutical therapy) is prescribed. Rates of noncompliance are estimated at up to and greater than 90%. 14–16
Evidence also suggests that despite widespread availability of clinical practice guidelines for identification and management of CHD risk, healthcare practitioner behavior in implementing these guidelines is suboptimal. 17 Although healthcare providers acknowledge that preventive efforts are important in helping people manage their CHD risk, they often lack confidence in people's desire and/or ability to make necessary changes and may be overwhelmed by the perceived enormous investment of time and resources needed to assist people with behavior change. Consequently they often do not include disease prevention counseling as a priority in planning care for patients. 18–22
Some would argue that secondary prevention behaviors may be more readily adopted because a diagnosis or event has already occurred—making the perception of risk more real or immediate. However, this has not been borne out in the limited available literature. 6,7 Allen's study 6 examining risk factor management in women post-CABG surgery exemplified this problem when it demonstrated that 1 year later, 58% remained obese, 54% continued to be hypertensive, and 92% continued to have elevated low-density lipoprotein cholesterol levels. Despite having undergone such invasive treatment for their CHD, this cohort's risk management was sub-optimal and the members of this group remained at high risk for future CV events. When another cohort of men and women were interviewed following myocardial infarction, by Wiles, 7 they were highly impressed and influenced by the epidemiological information provided to them in the early phases of their recovery. However, over time and in the context of their own environments, the study participants developed varying explanations about the causes of the CHD and their potential risks. They then did not view lifestyle change as a rational action. How people frame or place their experiences into their everyday lives or sociocultural context will influence how they proceed with disease prevention activities. Individuals will employ disease prevention behaviors only if there is (a) an appreciation of a risk and/or benefit to adopting new behaviors and (b) the cost of enacting new behaviors is perceived as less than the risk and/or benefit. 23–27 There remains a gap between the evidence regarding the benefits associated with modifying CHD risk and people's action to engage in preventive behaviors.
GENDER, CHD, AND PREVENTION BEHAVIORS
Gender influences people's beliefs about health and their capacity to make lifestyle changes associated with disease prevention and risk reduction. 28–32 It is beyond the scope of this review to compare the scientific evidence on CHD prevention in women with that of men, and has been done by other authors. 33,34 On the whole, more studies have been done with male participants and where women have been included, their numbers are often small and separate analyses have not been done. 35,36 When analyses have been conducted, findings could typically be described as sex-based rather than gender-based, meaning the analysis has been based on biophysical outcomes such as improved lipid panels, amount of exercise, etc, rather than on the underlying mechanisms related to how the outcomes came about. Thus, we will focus not on the outcomes of disease prevention initiatives, but on the gender-based mechanisms and issues with which women in North American society are faced when integrating CHD prevention behaviors into their lives.
Fleury et al argued that understanding “the social context of women's experiences, is central to risk reduction efforts.” 33(p968) A number of social factors may influence women's understanding and appreciation of their health as well as their ability to engage in behaviors aimed at both the primary and secondary prevention of CHD. 34 These factors are linked primarily to women's typically lower socioeconomic status (eg, education, occupational status, marital status, parenthood, income) and the social roles that women hold. Women in North America have fewer years of formal education, hold lower status occupations (including homemaking), and, in all age groups, earn less money than their male counterparts—this is particularly dramatic for women who are single heads of families and who are of the nondominant racial/ethnic group. 37–39 The “otherness orientation” that women in our society hold also plays a pivotal role in the way that they prioritize and adopt actions aimed at enhancing their health. 28,30,33,40,41
Women's internal “other” orientation may limit their focus and capacity to access health information for themselves and then to act on it. Authors 28,30,40,41 and clinicians 42 have suggested that women may value the health and/or well-being of others in their families over themselves. Women have also admitted delaying symptom assessment and disease management to accommodate family needs. 30 In a study by King and Koop, 43 women entering hospital for cardiac surgery had significantly more care-giving responsibilities than did their male counterparts, despite being more functionally limited. They continued to provide continuous home-based care (eg, to ailing husbands or other family members) or intermittent care to grandchildren despite being patients themselves. Further, Arthur et al 44 and Benson et al 45 reported that even after diagnosis and/or treatment women either do not want to worry/disturb their families or find it more difficult to talk to family members than to talk with other women who have had a similar experience. There are clear implications for the discovery and acknowledgment of CHD risk as well as the success or failure of behavior change efforts when social influences such as these are formally considered.
The sociocultural construction of gender also influences women's access to and ability to process healthcare information (particularly related to assessment of risk or susceptibility), as well as their perceptions of personal control. 31,36 In turn, women's capacity to engage in preventive behaviors is affected. Whether there is a socialized or private system to administer healthcare, it is clear that people of lower socioeconomic (to which women are more likely than men to belong) and nondominant racial/ethnic groups (which adds another dimension of difficulty for women) have lesser access to health care resources than those of different groups. 33,39,46 Despite the widespread awareness that women are indeed at risk for developing CHD, women of particular social and cultural environments may either not concern themselves with health risk or believe that they are not at risk for CHD. Further, primary and secondary disease prevention efforts such as maintaining a low-fat diet or regular program of exercise will become a low priority when compared to more immediate needs such as safety, affording lodging/food, or caring for a family. Canadian statistics, for example, reveal that when women are the employed head of a lone-parent household, they earn 45% less than their male counterparts. 37 In and of itself, employment outside the home does not increase women's risk for CHD. 34 However, women holding low status positions will not have the benefits—particularly economic health-related benefits—that are available to people who hold higher status positions. Further, lower status employment leaves little room for women's autonomy in controlling or managing their time during the working day. This will have both psychological (eg, stress) and practical effects that may influence development of CHD and ability to engage in disease prevention activities. 36 Some have argued that multiple role responsibilities (eg, employee, wife, mother, caregiver) are stressful for women. 47–50 The key elements are more likely the social status and support that women have while holding their multiple roles. 51,52 Yet, continued active engagement in multiple roles can inhibit women's ability to actively engage in behaviors aimed at enhancing their own health. 28,53
Today, a variety of models exist to assist clinicians as they work to enhance the compliance of people who are facing behavioral change to reduce their CHD risk. The most commonly used health behavior frameworks 54 include the Health Belief Model, 55–57 Transtheoretical Model, 58,59 Theory of Reasoned Action/Planned Behavior, 60,61 and Social Cognitive Theory. 62,63 At the time of their conceptualization, these models offered new insight into human behavior as it related to health; however, the sociomedical context of the time was fundamentally different from that of today. Historically, the patient's role as a participant or decision-maker in his or her own care was much less valued than at present. Recommendations, typically made to patients by physicians, were offered and adherence was expected. The role of gender was generally not considered. Women were more likely to be (and possibly still are) influenced by sex-role, power, and status differences. Decisions about health behavior were physician- or health professional-centered rather than patient-centered. Unfortunately, though the involvement of patients as health care partners is seen as progress, this movement has occurred without careful assessment of patients'/women's readiness for partnership and self-management. Patient participation may require the ability to process vast and growing amounts of scientific evidence and engage in complex decision-making. Importantly, the influence of gender on all of these processes must be considered. Engaging in the “work” of self-management, which is focused on “self” rather than “other” is largely inconsistent with what is currently appreciated about the female gender.
In all of the dominant theoretical models mentioned above, the influence of gender has not been made explicit. Although theoretically appealing and indeed widely used, these health behavior models lack central consideration of gender, the fundamental element that creates context for and may drive people's behavior. 54–63 Each model has met with varying success and critique when used to guide clinical practice with people who need to make lifestyle modifications (particularly smoking cessation, engaging in exercise, improving diet). Although each offers a slightly different view of how the salient concepts interrelate, Redding et al argue that the available health behavior models “are not so different…[and that] most differences really amount to emphasis on one construct over another.” 64(p181) The above-mentioned theoretical models are sophisticated and well tested. In addition, they include constructs, such as readiness to participate, social support, social networks, and health values, that apply to both sexes. What has not been made explicit is how such constructs might be modified by gender-based interpretations. For example, how might the social role of women influence the point at which they are ready to make decisions or take action? How might women and men use their social networks differently or use them at all? How do gender-based health values influence health behavior and how are those values learned, applied, and changed? Theoretical models must, by definition, be derived from and represent generalizable observations; thus apply to both men and women. However, they must also provide general guidance or flexibility for modification around uniquely important male-female differences, that is, gender influences. To date, most theoretical models remain ambiguous in this regard.
The literature is replete with descriptive studies aimed at examining differences (and similarities) between men's and women's risk-taking behavior (eg, smoking, sedentary lifestyle, dietary intake, and alcohol consumption), participation in cardiac rehabilitation, as well as adherence/compliance to medical recommendations. Description of the magnitude of the potential differences between men's and women's CHD prevention behaviors is necessary in order to fully appreciate, for example, risk of nonadherence to healthcare recommendations. However, the problem of gender-based differences in prevention behaviors will not be well managed or solved until the mechanisms that underlie these choices are identified.
WHAT DO WE NEED TO LEARN?
To appropriately address the influence of gender on CHD prevention initiatives, we need to develop a clearer understanding of (a) the mechanisms that underlie people's choices to manage their CHD risk, (b) whether mechanisms exist that are truly gender-specific, and if so, (c) the influence that these mechanisms have on management of CHD risk. Theoretical models need further examination and/or modification to include potentially important gender-based constructs such as social support, the role of social networks, the value of health, and other factors that are rooted in life experience. Yet this cannot happen until the different factors that influence women and men, or the factors that influence women and men differently, are well articulated. Thereafter, we need to learn how (and indeed if) gender influences the way that people make choices about managing their CHD risk, and to develop and empirically test practical, sustainable interventions at individual and community levels. Gender, a sociocultural determinant of health, has far-reaching implications for health care practice and health policy development. 33
SUGGESTIONS FOR FUTURE DIRECTIONS IN RESEARCH AND PRACTICE
The next generation of CHD prevention research in this area will need to be gender-based. It will require long-term commitment from funding agencies and the scientific community to assure well-designed work from a variety of perspectives. Descriptive and theory-generating work will need to be undertaken to identify if and how women and men are indeed distinct in their health management, health behavior decision-making, making change, as well as how and when women and men are most influenced in their lives. Rigorous multimethod studies (that include triangulation of qualitative and quantitative methods) 36 will be needed to uncover and then measure the factors that may differentially influence women and men as they make choices regarding their cardiac health. Once such factors are identified, studies will need to be undertaken to examine whether they are indeed amenable to change. In that regard, strong epidemiologic, theory testing (eg, clinical trial), as well as economic evidence will also need to be generated to inform policy and practice.
To facilitate the recognition and value, as well as adoption, of new behaviors aimed at enhancing women's heart health, clinicians will need to be increasingly conscious of and purposefully include gender-based issues in their everyday assessments and practice. Specifically, clinicians need to assess their women patients' readiness and desire to be active participants in healthcare decisions. Thereafter, clinicians need to identify, adopt, and utilize gender-appropriate strategies aimed at enhancing patient's involvement in their healthcare (eg, how to access, select, process information in the context of women's lives/social roles etc). As Sharonne Hayes suggested in an interview for the Journal of Women's Health & Gender-Based Medicine the question “Where in your day can you find time to do something physically active?” 42(p20) is an excellent point of departure for dialogue with women patients. This question engages women's assistance in solving the problem and will provide information to the healthcare practitioner that will assist in understanding the context in which the woman lives and must fit healthcare recommendations. Hayes also suggests building on women's connectedness to others and in particular their families. If women make heart healthy choices for themselves, then they are being good role models for their children and helping them to learn good health behaviors.
Mechanisms underlying the sociocultural phenomenon of gender and its effect on the development (and hence the prevention of CHD) are not well described in the literature. Despite a proliferation of research undertaken in the last few decades that examines the experience of having and recovering from cardiac events or procedures (with little focus on differentiation between men and women), and attempts to refine predictive models of prevention behaviors for CHD, the healthcare community is still without the necessary understanding of how gender influences peoples', and women's in particular, decision-making about the behavior that places them at risk for CHD.
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