Editorials

Tackling coronary heart disease

A gender sensitive approach is needed

Coronary heart disease is the commonest cause of death in the United Kingdom, with marked gender differences in incidence, presentation, referral, recovery, and rehabilitation.^1-6 Current policy on coronary heart disease is written in gender neutral language at a time when treatment has been moving towards a more behavioural model, where cardiac rehabilitation is a therapeutic option and changing cardiac health behaviour a major objective. Given the importance of this there is a need for health strategy that is gender sensitive.

The government views the national service framework for coronary heart disease as its "blueprint" for tackling heart disease.⁷ It lays out 12 standards and sets out services that should be available throughout England. Although the framework acknowledges gender differences, there is no clear recognition in the guidelines of how these are to be addressed.

In part this is due to the evidence on which the guidelines have been based. Relatively small numbers of women, older people (both men and women), and ethnic minorities have been included in biomedical research into coronary heart disease, which has largely ignored women and treated white low risk men presenting with their first acute episode as a convenient sample. This is possibly due to the difficulties associated with controlling for comorbidity in older men and women, and the ethical and legal problems associated with fertile women who may be pregnant.⁸ Therefore it has been customary to apply the conclusions of research to populations not studied, since it has been thought reasonable to assume there is no biologically plausible reason to expect findings to vary between the sexes. There is evidence, however, that women have not been well catered for by services underpinned by existing research. Studies that have included women appear to have had deficiencies in recognising and treating coronary heart disease.⁵

These difficulties for women are compounded by the existing consensus among both the public and health professionals that coronary heart disease is a disease of men. ^{9 10} In a recent study in which women with coronary heart disease were interviewed, one participant talked of men she knew being potential coronary candidates but she did not view herself as at risk as she was a woman and could not think of any famous women who had had a heart attack.¹¹

The current research focus therefore has meant that women's experience has not been captured and used in service deliverybut neither, it may be argued, has men's. Despite most research being undertaken on men we are not much closer to an understanding of how men experience coronary heart disease. This is due to the failure of much research to acknowledge the gender sensitive nature of coronary heart disease and thus to treat gender as a variable to be controlled. Gender effectively becomes invisible, resulting in research that does not consider the issue of masculinity and men's acknowledged difficulty in managing their health. ^{12 13} Despite coronary heart disease being stereotyped as a male disease, men display a high degree of ignorance and avoidance of both coronary heart disease and the risk factors associated with it. For instance, though women may avoid considering their risk of developing coronary heart disease by assuming it is a male disease, men too delay in seeking medical help when experiencing chest pain. ^{5 14} Thus coronary heart disease is the greatest cause of premature death in men, yet it is relatively unresearched from the perspective of men's health behaviour.

Though the aims as set out in the national service framework are laudable, the fact that the framework does not include male and female specific standards makes it harder to create the environment for research and health strategy development that addresses men and women's separate needs. This is already evident by the relative dearth of social research into gender and coronary heart disease. Both women's health groups and the Men's Health Forum (www.men'shealthforum.org.uk) have noted that only a few practitioners have set up gender sensitive initiatives.

Gender must be seen as an important factor in health care planning and delivery. Coronary heart disease is a prime example of where there are known gender differences. We need investment in research and inclusion of gender within educational programmes, without which health professionals will remain ignorant of the problems created by gender neutral health care.

Alan White, senior lecturer in nursing. 

School of Health and Community Care, Leeds Metropolitan University, Leeds LS1 3HE (a.white{at}lmu.ac.uk)

Lesley Lockyer, research fellow. 

School of Healthcare Studies, University of Leeds, Leeds LS2 9UT (l.j.lockyer{at}leeds.ac.uk)