ACCEL | A lot has been written regarding sex-based disparities in treatment and response to medical therapy. This is not that conversation. Don’t be disappointed; the topic here is at least as interesting, perhaps more so.

Sex differences in roles are ubiquitous in all societies. Rarely have these roles been examined, however, as they contribute to performance of self-care in adults with chronic illnesses. One of the few people who has conducted such research is Barbara J. Riegel, PhD, RN, a Professor of Nursing and Director of the Biobehavioral Research Center at the University of Pennsylvania School of Nursing in Philadelphia. She is also coauthor (with Debra K. Moser, DNSc, RN) of Cardiac Nursing: A Companion to Braunwald’s Heart Disease.

The Table below offers a few differences based on sex according to available data. It is interesting to consider how some of the differences between men and women might play out in terms of self-management of chronic disease. For example, could some of these sex-based differences in self-management contribute to the (often striking) difference in cardiovascular disease (CVD) mortality? For instance, except among the oldest population (85 years and up), more men are diagnosed with an MI or suffer coronary heart disease (CHD) mortality per 1,000 population. The biggest discrepancy is from age 55 to 64, where the rate among men is 185 versus 95 per 1,000 for women. At 85 and older, the rates turn: 75 for men compared to 110 of 1,000 for women.

Self-Care: Men vs. Women

According to Riegel, there are three broad aspects to self-care:

• Self-care maintenance: those behaviors used by patients with a chronic illness to maintain physical and emotional stability. (Think diet, exercise, sleep, medication taking, tobacco use, and stress management—or lack thereof.)
• Self-care monitoring: the process of observing oneself for changes in signs and symptoms. (This includes symptom monitoring, body listening [awareness], recognition of symptoms, and interpretation and labeling of symptoms.)
• Self-care management: the response to signs and symptoms when they occur. (Symptom management and behaviors aimed at the treatment of signs and symptoms.)

Of course, the first step is recognizing that one is at risk and, along those lines, progress has been made in convincing women—at least Caucasian women—that their #1 risk is CVD. For roughly the last decade, awareness of CVD as the leading cause of death in women has hovered between 60% and 70% in white women compared to just 33% in 1997. However, awareness is much lower among Black and Hispanic women (about 35%, as of the most recently available data [2012]).

What do women perceive as risky? That would include eating food high in saturated fat, a sedentary lifestyle, family history of heart disease, and high blood pressure. Not recognized: obesity, diabetes, and smoking.

Once the risk is perceived, studies have shown a correlation between sex and an ability to change lifestyle to reduce the risk of disease. Health behaviors are influenced by factors such as culture and environment. For men, the appraisal of projected harm or loss is very important (cognitive appraisal). Marital status is a factor, too, with married women less adequate in their own self-care. Confidence is important and women tend to be less confident, but they are more willing to take direction than men.

Women are significantly more likely to recognize ACS symptoms. For example, women were more likely than men to correctly identify these ACS symptoms: nausea/vomiting, back pain, heartburn/gastrointestinal symptoms, jaw pain, and neck pain (p=0.001 for each). Having said that, women consistently report more symptoms than men, although women may not recognize that their symptoms are important even when they know what to look for. Indeed, women are significantly more likely to attribute their symptoms to other illnesses. Men may (and here Riegel emphasizes ‘may’) be better at labeling their symptoms as meaningful. However, more than sex per se, she said that such differences as symptom labeling seem to be more associated with self-care confidence, social support, and mood.

Are differences in symptom recognition due to body awareness? Maybe. Riegel said women are more attentive to and more negative about their bodies than men. For women, she said, there is greater social pressure to meet attractiveness standards. However, not all men are attentive to their own body but body awareness may be greater in men who do care about their bodies.

Bottom line: men and women are motivated by different factors. Women want to avoid problems that affect family and friends, while men want to avoid physical and social problems that affect activities of daily living.

Whose Job Is It, Anyway?

In terms of the self-care education process, Riegel and colleagues conducted a secondary analysis of three small studies of adults with chronic HF, with data collected between 2006 and 2008.1 They identified two dominant perceived roles in self-care: active and passive. No surprise, but these were further categorized according to the degree of independence described by participants in self-care decision making: 27% expressed primary responsibility (‘It’s my job.’); 22% said such decisions were made in collaboration with friends, family, and/or their health care providers (‘We talk about what to do… decide together.’); and fully 51% expressed reliance upon direction from others (‘I just do what I’m told.’).

This latter group, who takes a passive role, comprises a majority of patients and they take a passive role in all aspects of self-care, relying on others to monitor and manage their symptoms. While the middle group describes self-care as a shared responsibility, there’s a downside: they are reluctant to act independently. Somebody had better be offering input or there is no collaboration and maybe nothing gets done.

As for sex differences, women were significantly better at self-care maintenance (p=0.04). While the trends favored women, too, for self-care management and confidence, the difference did not reach statistical significance.

Why does this matter? A passive role in self-care has been associated with poorer self-care outcomes among people with diabetes. In diabetes, self-care includes diet adherence, glucose monitoring, and symptom management—the very things viewed as a mediating factor in achieving the desired endpoint of glycosylated hemoglobin (HbA1c). Individuals who described having an active role in diabetes self-care had better HbA1c levels compared to those who assumed a passive role.

In patients with HF, the relationship of self-care and outcomes is more complex, according to Riegel. Her own work has shown that self-care maintenance and management are correlated with improved outcomes, including a decrease in HF admissions.2-4

Riegel and colleagues have also looked specifically at sex, CHD, and depression.5 Outcomes are worse in individuals with depressive symptoms and CHD, so, they wanted to identify characteristics that distinguish men from women with both conditions. They had 1,951 adults with CHD and elevated depressive symptoms complete questionnaires to measure anxiety, hostility, perceived control, and knowledge, attitudes, and beliefs about CHD.

Women were more likely to be single (OR: 3.61; p<0.001), unemployed (OR: 2.52; p<0.001), poorly educated (OR: 2.52; p<0.001), anxious (OR: 1.14; p<0.01), and to perceive lower control over their health (OR: 1.34; p<0.01) than men. It seems that women with CHD and depressive symptoms have fewer resources, greater anxiety, and lower perceived control than men. In women, they concluded, targeting modifiable factors, such as anxiety and perceived control, is warranted.

She encourages clinicians to assess the individual patient’s perceived role in self-care as part of the self-care education process, particularly in the setting of chronic diseases, such as heart failure. Understanding patient perceptions of their role may help guide education, which may be particularly useful for those patients most likely to defer to others for HF management advice.

References:

1. Dickson VV, Worrall-Carter L, Kuhn L, et al. J Nurs Healthc Chronic Illn. 2011;3:99-108.
2. Riegel B, Lee C, Vaughan Dickson V, et al. J Card Fail. 2009;15:508-16.
3. Riegel B, Driscoll A, Suwanno J, et al. J Card Fail. 2009;15:508-16.
4. Lee CS, Moser D, Lennie TA, et al. Heart Lung. 2011;40:12-20.
5. Doering LV, McKinley S, Riegel B, et al. Heart Lung. 2011;40:e4-14.

Keywords: CardioSource WorldNews, ACC Publications, Self Care, Sex Characteristics

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