China is experiencing tremendous economic growth. Accompanying this change is a dramatic shift in social and epidemiological circumstances. Globally, coronary heart disease (CHD) is a leading cause of morbidity and mortality.1 Coronary heart disease is expected to contribute to 82% of the future increase in mortality in developing countries.2 With the ageing population, rapid economic development, and urbanization, China has experienced a transition from infectious to chronic diseases.3 These changes are accompanied by rapid social, political, and economic shifts that inevitably impact on the healthcare system.
The health of women in China extends beyond reproductive and infectious diseases.4,5 Heart disease and cerebrovascular disease are the first and second most common causes of death in Chinese women and the second and third causes of death for men.6 A study among Beijing residents illustrates that women's knowledge of myocardial infarction symptoms was comparable or lower than that described in the western regions more than a decade ago.7 Similar to international findings describing inferior outcomes experienced by women after an acute cardiac event,8,9 Jiang and colleagues10 found that the short- and long-term prognoses in women are far worse than in men after acute myocardial infarction. Not surprisingly, CHD places a heavy economic burden on families and the society. The direct medical cost of CHD in people aged 35 to 74 years is approximately ¥17.5 billion (around $2.6 billion) annually.11 Furthermore, there is a positive relationship between CHD and socioeconomic deprivation,12 which is likely exacerbated by the fee-for-service model.
Nursing in China
Nursing in modern China has evolved because of the influence of Western missionaries who began arriving in China in the 1880s.13 China established Asia's first 5-year bachelor of science in nursing degree in 1920. However, the abolishment of post-secondary nursing education 32 years later, along with the nationwide restructuring of the higher education system, meant that the progression of this program ceased.13,14 Since the recommencement of the higher education system in 1984, 5 levels of nursing education have been available in China. These levels are secondary, associate's, bachelor's, master's, and doctoral degrees. Nurses in China are predominately women and work full-time in hospital settings. Post-secondary degree holders account for only 1% of the entire nursing workforce.15 The doctoral degree was established recently through the cooperation of the nursing schools of Peking Union Medical College and Johns Hopkins University.16
Nurses play a crucial role in developing innovative models of care.17,18 There is a traditional Chinese saying that just 30% of healing depends on the treatment received, whereas the remainder depends on the nursing care. The Chinese nursing ethos reflects the underlying beliefs of Chinese people and their cultural understanding of health.19 Their receptivity to change is dependent on their knowledge, attitudes, and beliefs as well as their perception of need.20 A study undertaken by Guo21 showed that cardiology nurses were receptive to innovation and collaboration. To date, there has been minimal discussion and debate concerning women and heart disease in China.22 This is in contrast to the emerging literature in countries such as the United States, Australia, and the United Kingdom.23-25 To develop nursing strategies to improve the heart health of women in China, we considered it important to source the views of nurses working in a range of clinical settings.
Ethical approval was obtained before undertaking this study. Focus groups were used to capture the shared views of study participants regarding the risks of heart disease in women and how nurses individually and collectively can intervene to improve health outcomes. Focus groups consist of 5 to 15 participants who discuss and share their views, opinions, and experiences with the facilitation of a moderator.26 Focus groups are particularly useful as they facilitate interaction and assist in eliciting a range of views and perspectives that may not always be anticipated by the researcher.27-29
Hospitals have been classified as level 1, 2, or 3 since the Chinese hospital management system reform was implemented in the late 1980s. Level 1 hospitals are community hospitals with limited inpatient capacity; level 2 hospitals have at least 100 inpatient beds and provide acute medical care and preventive care services to populations of at least 100,000; and level 3 hospitals are major tertiary referral centers in provincial capitals and major cities.30 Patients can choose to visit any hospital. The higher classified hospitals charge more for the same service than lower level ones do. In China, most people self-fund their own medical treatment and others have some kind of health insurance, such as basic health insurance, labor health insurance, private health insurance, and so on.31
This study was undertaken in a capital city, and participants were from either level 2 or 3 hospitals. Participants were approached in various ways. Initially, colleagues of a researcher (Y.C.) were invited to participate. They were asked to invite any of their colleagues who they considered would be interested in participating. The initial focus groups were held in the early evening after work, where refreshments were provided. Upon arrival, the procedures and processes were explained to participants and informed consent was obtained. The focus groups were conducted in Chinese with Chinese-speaking moderators. The question route for the focus groups was generated to elicit participant's views and perspectives. These questions were informed by a literature review22 and a preliminary series of discussions undertaken with Chinese-born nurses in Australia. The question route is shown in Table 1. With participants' permission, the focus group discussions were audiotaped. The method of Halcomb and Davidson32 was used to manage the study data given the need for both the student and supervisor to have access to the data. Furthermore, it was considered that verbatim translation of the transcripts may distort nuances of Chinese conversation. Two bilingual Chinese nurses with cardiovascular nursing research experience (Y.C. and H.D.) facilitated the group discussions. The following steps depict the data collection and management process:
- Step 1. Interviews were audiotaped in conjunction with concurrent note taking.
- Step 2. Reflective journaling by moderators immediately followed the interviews.
- Step 3. Researchers listened to audiotapes to verify and clarify field notes and observations.
- Step 4. Preliminary content analysis was conducted. Soon after the 2 moderators agreed that their field notes accurately represented the interactions that occurred in each interview, analysis elicited common themes between interactions.
- Step 5. Secondary content analysis was conducted by an additional research team member who was not involved in the data collection. This researcher reviewed the analysis to validate the themes from the data.
- Step 6. Thematic review was conducted. In this process, the researchers reviewed secondary content analysis by relistening to audiotapes and making necessary changes. The process was repeated until researchers were confident that the themes illustrated the participants' perspectives.
Qualitative Data Analysis
A reflective and iterative process was used to maximize the validity of data interpretation and minimize external bias of the data.33 Data collection and analysis of the focus groups were carried out simultaneously to maximize the capacity to document group dynamics. Data analysis was conducted on recordings taken during the focus groups, handwritten field notes, and the researcher's own thoughts after each focus group discussion that were recorded in a reflective journal. The researchers who conducted the focus groups repeatedly listened to the audiotapes of the focus group discussions to immerse themselves in the data. Qualitative thematic analysis was applied to elicit common themes. This involved classifying words into categories based on their conceptual significance.34 This type of data coding and categorizing assisted in retrieving and reviewing emerging data. Attention was also placed on the range and diversity of experiences and perceptions within group and across groups.33 The initial themes were validated through subsequent probing of these topics during ensuing focus groups. Data from field notes and personal notes helped the researcher to interpret and understand the emerging themes.
The 5 focus groups consisted of 28 female Chinese hospital-based registered nurses. The characteristics of the participants are detailed in Table 2. Four themes emerged from the focus group data: (1) mixed perceptions of disease burden in women, (2) the impact of modern life on women's health, (3) need for focus on prevention and coordination, and (4) education and support are keys to driving healthcare improvements.
Mixed Perceptions of Disease Burden in Women
The health issues reported by participants to be the most significant health concerns in women were gynecological and breast conditions, cancer, depression, and musculoskeletal diseases. Heart disease was rarely identified and was attributed to older women. Participants' views about health issues for women were reflective of their personal and professional experiences.
At least 80% or 90% women have a kind of gynecology disease, including pelvic inflammatory disease, uterus prolapse, uterine myoma, or cancer. Last year, I had an operation and was told I had 37 uterine myoma. It was shocking…look the women around you, nearly almost suffer from this or that gynecology disease. (P7)
I've seen so many women with breast cancer, or fibroadenoma. I think breast cancer may be no. 1 killer for women. They talk about a lot about breast cancer on TV, newspaper, and radio. (P15)
I thought heart disease was a big health threat when I worked in cardiology ward…. Now I'm working in oncology ward and I find cancer may be the no. 1 killer for women. (P11)
Participants also noted the lifestyle changes that have accompanied the rapid social-economic development in China.
Have you noticed this phenomenon?… In the supermarket, it is often crowded with so many obese people instead of skeleton as before. Nowadays, people have sufficient "good" food, not much physical labor work. They eat as much as they want and won't walk stairs if there is a lift. They enjoy things they could not get before and not think it may impact on their health at all…(P11)
Heart disease is often seen in men or women after 50s or 60s. People should be aware there are more victims of so-called fashionable diseases such as hypertension, hyperlipidemia, diabetes, and coronary heart disease. (P10)
Modern-Life Impacts Upon Women's Health
Participants discussed the health consequences of increased pressure placed on women from both society and family.
Nowadays, so many women have insomnia or depression. This is because of high pressure on them. (P2)
Being women, we have obligation by nature to rear our children, help them on their study to get them into a good university, and find a job later on; do the housework; look after the elders; and we also have to work hard and keep studying to maintain the current employment. (P6)
We could say, too much pressure on women is the first of all culprits for health problems in women. I feel myself like a machine, start busily running from waking up in the early morning. (P4)
Nearly all diseases have some kind relationship with high pressure, such as insomnia, depression, breast disease, heart disease, hypertension, thyroid disease. (P19)
Need for Focus on Prevention and Coordination
Participants discussed the lack of awareness of heart disease, a lack of health knowledge, health insurance coverage, and the view that individuals have less control over their health.
Generally speaking, health knowledge is far less than enough among Chinese population…it's understandable as we Chinese just get rid of starvation and poverty. I heard of health campaign a few times, but not once about heart disease. (P16)
People don't have the awareness to maintain or improve health in daily life…focus on health only when diagnosed with a disease. (P20)
Even though some people know prevention is important, but not able to afford regular screening, which plays an important role for early diagnosis and treatment…, it's so sad to see so many patients with curable disease give up treatment because not able to pay… (P25)
Participants readily described their view that there is a need for nurses to undertake interventions, to improve clinical outcomes for women with heart disease. They explained that increasing public awareness is a crucial step in this process.
Concept is the most important thing, sometimes attitude decides everything. First to do is to wake up the public that heart disease is a big health threat for women. Prevention is better than treatment. (P23)
I only know a few health campaign done in the past…never heard any about heart disease in women…we may do it… (P8)
Second, participants discussed a need to reform the contemporary nursing care model. They described streamlined processes between the communities to hospitals that can provide high-risk populations with improved care.
The patients will not be cared after discharge as no one I hand over to…we should have communication with the community nurses. (P24)
For nurses in community, they are at good position and could do more in terms of prevention, screen…than us hospital-based nurses. (P4)
Hospitalization is a critical time for people to focus more on their health. For hospital-based nurses, the delivery of holistic nursing care from admission to discharge, instead of functional nursing care, was perceived as important.
…on admission, from collection of history of disease, nurses should find out patients' risk factors of heart disease…decide caring plan accordingly, nursing intervene to decreasing high risks, followed by regular check up… (P22)
Third, there is an opportunity for nursing roles to extend into the area of health education. A range of methods in accordance with individual circumstances were mentioned by participants, including media such as radio, television, and Internet, distribution of health information booklets, and organization of health education campaigns, especially in remote areas.
…we could provide the information booklet or advertise health information on TV or at public places…radio is preferred media for women in country as it does not disrupt women from doing housework and it's cheap.(P8)
At the outpatient department, especially at medical clinic, is an ideal place for nurses to convey the health information to public. We could put the information on screen, talk to the people, edit some booklets displayed at the waiting area… (P1)
Education and Support Are Key to Driving Healthcare Improvements
Participants perceived barriers to improve the nursing role to address women's heart health. The barriers discussed included the limited education opportunities with nurses, the need for increasing the professional profile of nursing, and support for advanced practice and the limitations associated with limited health insurance coverage available in China.
Honestly,…some nurses do not have adequate professional knowledge and skills…some only got the information about heart disease in classroom many years ago… (P28)
…nursing, like medicine, is a profession needs the staff keep studying, otherwise you left yourself behind… (P8)
…the extreme busy clinical nurses are also occupied by lots of workload those not belong to nursing such as cleaning, safeguard the stuff. (P14)
…the most headache and saddest things is to persuade patients to pay when they owe the hospital money and monitor them not escaping from the hospital…(P11)
I have the knowledge and ability to write a booklet about health education on diet, exercise, etc. It's convenient for people to get it when they visit hospital, but nobody gave me the money to do it. (P4)
Furthermore, participants expressed a desire for more education and training, particularly in research, improved professional networking opportunities, and support from their organizations.
…we like to have opportunity to work with other academics…. (P2)
…it's very meaningful to do some research work to improve patients' outcome…we would like to, but we need support from the hospital and need to improve our knowledge and skills to do this. (P8)
The general education level has improved among Chinese nurses along with the reestablishment of higher education in nursing. Despite these initiatives, there is still a gap between nurses' perception of the issues and the actual burden facing Chinese women. To our knowledge, this is the first study to explore nurses' perceptions of women's heart health in China. Nurses' perceptions are associated with their personal and professional experiences and are influenced by the media and the people around them. For instance, these data suggest that exposure to health issues resulted in increased awareness. Those who realized the relevance of heart disease to women were currently or previously working in a cardiology setting. As evidenced in this study, nurses' knowledge, attitudes, and beliefs are associated with their behavioral intention and clinical practice.20,35 Further research is needed to describe Chinese nurses' knowledge, attitude, beliefs, and clinical behaviors to improve women's heart health.
Economic burden was perceived by participants as a significant factor influencing women's health. In China, only 55% of urban and 21% of rural populations have health insurance.36 The average cost of a single hospital admission is almost equivalent to China's annual per-capita income and is more than twice the average annual income of the lowest 2 deciles of the population.36 "Too difficult to see a doctor, too expensive to see a doctor!" became one of the top issues in China's opinion polls.37 In accordance with these findings, medical service cost and absence of funded regular screenings are factors that emerged and are associated with not focusing on prevention. Not surprisingly, nonadherence to medications and deferring treatments were not uncommon circumstances reported by nurses.
Heart disease is an emerging problem in Chinese women.6 Nurses are in a good position to improve patients' clinical outcomes and challenge health transitions.38 It is necessary to strengthen the confidence of nurses and the public regarding the importance of the nursing role in improving people's health. Until recent times, a number of factors, particularly limited access to ongoing education, have limited the development of nursing in China.13 Strategies to increase the professional profile of nursing through leadership roles are important in developing innovative nursing models.
Second, nurses need more support to undertake ongoing education to enable them to be equipped to deal with the issues facing contemporary China. Reform of nursing curricula at the undergraduate and postgraduate levels, as well as continuing education programs, is warranted. Increasing investment in forging international cooperative research programs and nurse-led models of nursing care and activities that support health promotion are also warranted. Furthermore, investment in social marketing campaigns such as the "Go Red for Women" campaign39,40 that are culturally appropriate is necessary to increase the awareness of the Chinese public of the burden of CHD.
Finally, the very limited health insurance coverage affects coping with the high prevalence of chronic disease such as CHD in China. As complaints regarding the cost of medical services increase, expanding health insurance coverage and enabling greater access to medical care should be priorities of healthcare reform in China.
Limitations and Strengths of the Study
This study used convenience sampling in a metropolitan area in China. Findings may not reflect the perception of other nurses, particularly in remote areas. A further limitation is that participants may not have expressed divergent views to save other's face owing to cultural pressures. Despite these limitations, focus groups are a useful method to obtain comprehensive and detailed descriptions about perceptions of CHD in women. The capacity to undertake the study in Chinese has elucidated the key issues that nurses face in improving the heart health of Chinese women.
Heart disease among women is a growing problem. Internationally, there are strategic initiatives to increase this awareness. In China, addressing this problem is hindered not only by a lack of public awareness but also within the nursing profession. Shifting the focus from treatment to prevention and reform will require leverage both internal and external to the nursing profession. This study has shown that the awareness of heart disease as a problem for women was not evident and this is consistent with other studies. Efforts to improve awareness should involve nurses at individual, administrative, and public health levels.
Summary and Implications
- Coronary heart disease is a an emerging and growing problem in China.
- There is a limited focus on heart disease in women in China.
- Improving education and increasing awareness are important to address the growing numbers of Chinese women with heart disease.
The authors would like to thank the participants for their contribution to the study. Thanks are also extended to Prof Min Yang, who supported organizing focus groups.
3. NCCD. Report on Cardiovascular Disease in China
. Beijing, China
: Encyclopedia of China
Publishing House; 2006.
4. Raymond S, Greenberg H, Leeder S. Beyond reproduction: women
's health in today's developing world. Int J Epidemiol
5. Hu Y. Disease burdens, structural challenges and policy options: rural Chinese women
's health under the landscape of globalization. Popul Dev
6. He J, Gu D, Wu X, et al. Major causes of death among men and women
. N Engl J Med
7. Zhang Q-T, Hu D-Y, Yang J-G, Zhang S-Y, Zhang X-Q, Liu S-S. Public knowledge of heart attack symptoms in Beijing residents (in Chinese). Chin Med J
8. Wiviott SDMD, Cannon CPMD, Morrow DAMDMPH, et al. differential expression of cardiac biomarkers by gender in patients with unstable angina/non-ST-elevation myocardial infarction: a TACTICS-TIMI 18 (Treat Angina With Aggrastat and Determine Cost of Therapy With an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction 18) Substudy. Circulation
9. Mikhail GW. Coronary heart disease
10. Jiang S, Ji X, Zhao Y, et al. Predictors of in-hospital mortality difference between male and female patients with acute myocardial infarction. Am J Cardiol
11. Zhai Y, Hu J-P, Kong L-Z, Zhao W-H, Chen C-M. Economic burden of coronary heart disease
and stroke attributable to hypertension in China
. Chin J Epidemiol
12. Yang L, Wu M, Cui B, Xu J. Economic burden of cardiovascular diseases in China
. Expert Rev Pharmacoeconomics Outcomes Res
13. Xu Y, Xu Z, Zhang J. The nursing education system in the People's Republic of China
: evolution, structure and reform. Int Nurs Rev
14. Hong Y-S, Yatsushiro R. Nursing education in China
in transition. J Oita Nurs Health Sci
15. Smith D, Tang S. Nursing in China
: historical development, current issues and future challenges. J Oita Nurs Health Sci
17. Dai R, Zhang C, Tian G. Causes of the Sleeping Obstacles in Elderly Inpatients Diabetes Mellitus and Nursing Intervention (in Chinese). J Nurs Sci
18. Liu B, Han J, Huang L, Peng Y. Nursing intervention to the elderly health improvement in community (in Chinese). Nanfang J Nurs
19. Wong TKS, Pang SMC, Wang CS, Zhang CJ. A Chinese definition of nursing. Nurs Enquiry
20. Chan S, Sarna L, Wong D, Lam T. Nurses' tobacco-related knowledge, attitudes, and practice in four major cities in China
. J Nurs Scholarsh
21. Guo H. A study of motivation factors concerning implicating cardiac rehabilitation program. Chin J Clin Rehabil
22. Cao Y, DiGiacomo M, Du HY, Ollerton E, Davidson P. Cardiovascular disease in Chinese women
: an emerging high-risk population and implications for nursing practice. J Cardiovasc Nurs
23. Davidson PM, Daly J, Hancock K, Jackson D. Australian women
and heart disease
: trends, epidemiological perspectives and the need for a culturally competent research agenda. Contemp Nurse
24. Lockyer L. Women
's interpretation of their coronary heart disease
symptoms. Eur J Cardiovasc Nurs
25. Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women
: 2007 update. J Am Coll Cardiol
26. Krueger RA, Casey MA. Focus Groups: A Practical Guide for Applied Research
. 3rd ed. Thousand Oaks, CA: Sage Publications Inc; 2000.
27. Betts NM, Baranowski T, Hoerr SL. Recommendations for planning and reporting focus group research. J Nutr Educ
28. Marshall C, Rossman G. Designing Qualitative Research
. 2nd ed. Thousand Oaks, CA: Sage; 1995.
29. Madriz E. Focus groups in feminist research. In: Labella P, ed. Handbook of Qualitative Research
. London, England: Sage Publications Ltd; 2000:835-839.
31. Rösner HJ. China
's health insurance system in transformation: preliminary assessment, and policy suggestions. Int Soc Secur Rev
32. Halcomb EJ, Davidson PM. Is verbatim transcription of interview data always necessary? Appl Nurs Res
33. Krueger RA. Focus Group Kit: Analyzing & Reporting Focus Group Results
. 6th ed. Thousand Oaks, CA: Sage Publications; 1998.
34. Sandelowski M. Focus on research methods, whatever happened to qualitative description? Res Nurs Health
35. He H-G, Polkki TP, Vehviläinen-Julkunen K, Pietilä A-M. Chinese nurses' use of non-pharmacological methods in children's postoperative pain relief. J Adv Nurs
36. Hu S, Tang S, Liu Y, Zhao Y, Escobar M-L, de Ferranti D. Reform of how health care is paid for in China
: challenges and opportunities. Lancet
37. Yip W, Hsiao W. The Chinese health system at a crossroads. Health Aff
38. Jones I, Johnson M. What is the role of the coronary care nurse
? A review of the literature. Eur J Cardiovasc Nurs