A systematic review of healthcare experiences of women and men living with coronary heart disease
In total, 266 studies were screened, of which 43 studies were included (Fig. 2). Eleven studies were conducted in the United States of America21,22,23,24,25,26,27,28,29,30,31, nine were from the United Kingdom32,33,34,35,36,37,38,39,40, seven were from Canada41,42,43,44,45,46,47, five were from Sweden48,49,50,51,52, three were from Australia53,54,55, two were from Finland56,57, and one study each from Austria, Brazil, Denmark, Italy, New Zealand, and Spain (Supplementary Table 1)58,59,60,61,62,63.
Of the included studies, a total of 1522 people (62% women; people with CHD or CHD health professionals) were included. Twenty studies focused on the experiences of women with CHD22,24,28,29,34,36,37,38,39,40,41,47,48,49,50,53,55,63, three studies focused on the experiences of men with CHD46,60,62, 19 studies included a combination of women and men21,23,25,26,27,32,33,35,42,43,44,52,54,56,57,59,61, and two studies did not report gender breakdown31,51. There were no studies that reported non-binary, gender diverse, or transgender people. Three studies included healthcare professionals only31,51,58, one study included people with CHD and healthcare professionals30, and one study included people with CHD and carers45.
A variety of qualitative data collection methods were utilised, including interviews, interview following presentation of vignettes, content analysis, and focus groups. Few studies provided summary statistics on socioeconomic status (n = 6) and education (n = 14), respectively. The heterogeneity and limited data inhibited our ability to combine the data for meta-analysis.
Quality assessment
Among the included studies, 8 (18.6%) were rated as high quality, 29 (67.4%) as medium quality and 6 (13.9%) as low quality (Supplementary Table 1). The six low quality studies differed from the high-quality studies as they lacked a coherent explanation of theoretical underpinnings of their study design and did not adequately consider the relationship between participants and researchers. Low quality studies were sporadically spread across this study’s thematic outcomes, therefore minimising risk of bias.
Study themes
Four major themes were identified: assumptions about CHD (interpretation of signs and symptoms, help seeking); gender assigned roles; interactions with health care; and return to ‘normal’ life.
Assumptions about CHD: Interpretation of signs and symptoms
Studies reported that women and men held assumptions regarding CHD, particularly around their perception of who was a ‘typical’ heart attack candidate.
The assumption of CHD as a ‘man’s disease’ was cited frequently and led many women to question their own signs and symptoms. Women reported a high level of uncertainty about their symptoms (n = 12 studies), often attributing any signs or symptoms to non-cardiac causes such as old age, arthritis, or fatigue and often trying to persuade themselves that the symptoms would disappear with rest22,23,24,28,30,35,36,37,41,48,49,60. This was often linked to symptoms not aligning with what women thought as a ‘typical heart attack’, as there was no acute crushing chest pain as often described, instead, often reporting a gradual onset of symptoms such as feelings of nausea and breathlessness, causing a level of confusion and delays in seeking help28,31,32,53,58. In contrast, men were more explicit in their symptom descriptions and more commonly recognised them as cardiac symptoms, that warranted medical attention23,60,63 Riegel et al.23 suggested this was due to men being more confident in their decision-making, having greater social support and symptoms being more aligned with the public perception of CHD as a man’s disease.
Similarly, identifying CHD signs and symptoms were also more difficult due to assumptions of the typical ‘heart attack’ patient – often described in studies as male, overweight, smokers, who did little exercise. Participants were therefore confused as to what was happening if their own self-image differed, especially women who thought they were not at risk unless they had adopted ‘a man’s way of life’23,38,39.
Assumptions about CHD: help seeking
Women often delayed seeking medical help, preferring to ‘wait and see’. Studies reported the delays were often due to confusion over signs and symptoms not aligning with prior perceptions of CHD, with women self-medicating or resting to see if the signs would pass before ‘bothering’ others23,27,30,33,37,58. Studies described women not wanting to be seen by others as a ‘nuisance’, ‘ignorant’ or a ‘hypochondriac’ and as such, they were more likely to wait until they were incapacitated to seek medical help.
Women also spoke of important activities and responsibilities that prevented or forestalled seeking medical attention22,49,52. Concern for the family often led to ignoring symptoms, because responsibilities, such as housework or caring for other family members, could not be delegated to others, and treating symptoms failed to ‘fit’ into their lives22.
Seeking advice from friends or family before seeking medical attention was commonly reported by both women and men, with many only seeking healthcare due to the friend or family member’s insistence. Immediate family members, usually daughters, were instrumental in organising medical attention37. Wives were commonly the impetus for men to seek help, insisting on them acting on symptoms and seeking care37,40,52 and this was reported by Brink et al.52 as being one of the reasons why men sought medical attention faster than women. However, it was not reported that husbands were the impetus for women to seek help.
Women delaying seeking professional medical care was also often due to logistical concerns such as inadequate transportation, workforce shortages at medical centres, and waiting times, especially in regional or rural areas22,29,54.
Rosenfeld et al.29 reported that women preferred to visit a general practitioner rather than engaging with emergency services as they often felt that their symptoms were not severe enough to waste emergency services time.
Gender-assigned roles
As previously described, women commonly spoke of their sense of responsibility for family and home and prioritising their duty to others over their own health needs. The interruption to normality in everyday routines for the women reportedly caused anxiety and many attempted to hide their feelings to shield family members from concern22,49. Studies reported that women were keen to be discharged from hospital following treatment, although many women reported fears of the future and fear of implication of the illness on their roles as family carers40,47,55.
This sense of responsibility for family and home was less often noted by men. Studies observed that men were often more concerned about their social position and concerned with how their recovery period might impact the way they were seen by others or how they would reconcile with their role as the ‘breadwinner’ of the family if they were forced to decrease their workload44,45.
Cewers et al.51 reported that health professionals tended to have specific gendered role perceptions, influencing advice regarding recovery at home. Men were seen as the ‘workers’ and were more likely to do sport than women, whereas women were seen as the carers and housekeepers and were more likely to participate in yoga and walking in their recovery.
Interactions with healthcare
Four studies specifically focused on patient experiences with health care professionals, with gender differences apparent in these interactions22,30,56.
Women described not being ‘listened to’ by health professionals and often reported being dismissed due to the lack of specificity of their symptom descriptions22,40,55. Women also voiced frustration with the lack of information provided regarding their initial diagnoses and discharge40,55. This finding was related to their need to organise their domestic duties and for their ‘forward planning’.
In contrast, health professionals identified that they often saw women as emotional and ‘in distress’, unable to articulate their symptoms clearly, which made it difficult to reconstruct pain development51,58. These studies concluded that women were more difficult to diagnose as they were often presenting older, had more complex conditions and were in later stages of illness due to delayed help seeking.
Women tended to have stronger emotional responses to their diagnosis than men, with most women reporting sadness and resignation26,40,59. Checa et al.59 described women’s concern about the future and how their disease could affect their roles within the family, whereas men tended to be more relaxed and even optimistic about being ‘cured’. However, this contrasted with Evangelista et al.26 who reported women used more optimistic coping strategies than men, who tended to use more emotion-focused and fatalistic coping strategies.
One study, focused on men’s psychological reactions and experiences following a cardiac event, reported participants had difficulties in adapting to their new postcardiac identity and accepting their new ‘roles’46.
Return to new normal
A desire to return to a familiar lifestyle was reported by both women and men40,44,47,55. However, women were more often concerned about the practical support they would need on returning home (e.g., shopping, cleaning) than men, and it was reported that women became avid planners in their recovery to ensure returning to their ‘normal’ lives as soon as possible47. Men reported being fearful of being discharged home as they were unsure of what life would look like in terms of employability, sexual virility, and other’s perceptions of them44,45.
On returning home, women often spoke of loss of control of their home situation and appeared to equate this loss of role functioning with a diminution in their value as a person34,45,47. Women reported being happy to talk and discuss their illness and hear from other patients, whereas men were less likely to want to share any thoughts and feelings and often self-isolated44,52.
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