The European Journal of Public Health Advance Access originally published online on July 28, 2005
The European Journal of Public Health 2005 15(6):634-639; doi:10.1093/eurpub/cki050
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Health Inequalities |
Exploring gender and socioeconomic differences in treatment of coronary heart disease
Kristiina Manderbacka** Outcomes and Equity Research Group, National Research and Development Centre for Welfare and Health (STAKES), Helsinki, Finland
Correspondence: K. Manderbacka, DSocSc, Senior Researcher, Outcomes and Equity Research Group, National Research and Development Centre for Welfare and Health (STAKES), PO Box 220, 00531 Helsinki, Finland, tel: +358 9 3967 2078, fax: +358 9 3967 2485, e-mail: kristiina.manderbacka{at}stakes.fi
Received February 10, 2004, accepted August 31, 2004
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Abstract |
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Background: Earlier studies on gender and socioeconomic differences in the treatment of coronary heart disease have focused mainly on structural features of the health-care system on the one hand and on coronary patients' psychosocial characteristics on the other. The aim of this exploratory qualitative study was to trace key points in the pathways of treatment where patients' experience varies and which can contribute to gender and socioeconomic differences in treatment. Methods: The data consist of 30 interviews among persons diagnosed with or suspected to have coronary heart disease in the Health 2000, a representative cross-sectional interview and health examination survey. Purposive sampling was used to ensure variation in gender, socioeconomic status and disease severity. The data were analysed using qualitative content analysis. Results: Gender and socioeconomic differences were found in two key points in the pathways of treatment: doctor–patient interaction and the organization of primary care. The three features commonly distinguished in doctor–patient interaction, i.e. treatment decision-making, information exchange and interpersonal relationship, were all found to be relevant. A second key point was organization of primary care in terms of both access to examinations and care, and continuity of care. Conclusions: These results should sensitize us to gender and socioeconomic differences in coronary patients' problems in access to and continuity of care, as well as to potential problem areas in doctor–patient interaction.
Keywords: coronary heart disease, equity, health services research, patient perspective
Coronary heart disease (CHD) is a major cause of death in Western countries. Systematic gender and socioeconomic mortality differences have been reported in many of these countries, including Finland.1,2 Although the disease has relatively clear diagnostic criteria and well-established principles of treatment, studies have persistently reported differences between genders3,4 and socioeconomic groups5,6 in both access and quality of care. This is also the case in Finland, where men and individuals from higher socioeconomic groups have been reported to more often receive thrombolytic treatment, angiographies and revascularization operations after myocardial infarction than women and individuals from lower socioeconomic groups.7,8 Corresponding differences have been reported in revascularizations among coronary patients in general.9,10 These differences have persisted even though the number of coronary operations more than doubled from the 1980s to the 1990s.10
Finnish studies have suggested that these differences may be related to structural features of the health-care system (e.g. see the work by Keskimäki and colleagues9,11). Generally, the Finnish health-care system supports equity. Finland has a comprehensive primary and specialized health-care system with universal coverage, and a universal mandatory health insurance scheme partly compensates for earnings losses during illness, spending in medicines and private health services. Additionally, the services are mainly funded from tax revenues.12 There are, however, some features in the system that may compromise equity. Private provision has a major impact on ambulatory physician services, and private doctors account for a considerable proportion of referrals to public hospitals. There are also a few private hospitals in the country that account for less than 5% of all hospital days, but for a large share of certain surgical procedures. Public hospitals have a ‘special payment category’ where patients who pay extra charges as supplementary remuneration for senior doctors may choose their doctor and have shorter waiting times for treatments.11,12
Nevertheless, it is unlikely that these inequitable features of the health-care system fully explain the differences. Recently, several qualitative studies have been conducted in Britain and the US that have tried to uncover the barriers in access to care for CHD. These studies have been concerned with response to exertional chest pain,13,14 delay in seeking care during a cardiac event15–17 and barriers to the use of health services among coronary patients.18,19 The focus in these studies has mainly been on the cardiac patient and his or her psychosocial characteristics, e.g. attitudes, perceived risk and vulnerability, as well as cultural knowledge and interpretation of coronary symptoms. They have, however, also identified factors that are connected to patients' encounters with the health-care system, including past experience of difficulties in doctor–patient relationship14,17,19 and information exchange,13,14,16–18 as well as in access14,15,17,19 and continuity of care.19 Two of these studies have also examined gender and socioeconomic differences in access to care, and report differences in past experience of health care.13,14 In Finland, Lukkarinen20 interviewed coronary patients who had undergone a revascularization operation 1 year earlier. Although mainly focused on life course and illness experiences, the study also found that patients had difficulties in their encounters with the health-care system in terms of continuity of care.20
This exploratory study focuses on coronary patients' encounters with the health-care system. The aim is to trace key points in the pathways of treatment where patients' experience varies and which can contribute to gender and socioeconomic differences in treatment. This study examines how coronary patients present making the diagnosis, the treatment of CHD and those involved in these processes in an interview context.
Coronary patients' accounts are examined not as factual descriptions of encounters, but rather as active reconstructions of events and occurrences that the interviewee chooses to make in the context of the interview,21,22 hence presenting medical encounters from the patient's point of view.
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The sample
Purposive sampling was used to select 30 interviewees from Health 2000, a representative, population-based, cross-sectional interview and health examination survey co-ordinated by the National Public Health Institute. The interviewees were selected from amongst Finnish-speaking persons involved in a supplementary part of the health examination between autumn 2001 and spring 2002 in Helsinki and Tampere University Hospital Districts and who, according to the information obtained at the baseline examination, had been diagnosed with or were suspected to have CHD. There were 89 such individuals in the Health 2000 sample in these areas. Purposive sampling was used to make sure that men and women from different socioeconomic groups, and more and less severe cases, were represented from both areas, and thereby to ensure a broad spectrum of experience of the encounters. The potential interviewees were contacted before the interview and all agreed to participate. The study protocol was approved by the Research Ethics Committee of STAKES.
Half of the interviewees came from each district. There were 17 men and 13 women, the mean age for men being 61 years (range 49–71) and for women 65 years (range 58–71). The mean duration of CHD was 8 years (range 1–22). Nine of the interviewees had had a myocardial infarction, five were totally symptomless and the rest had angina pectoris symptoms. Seventeen interviewees had undergone coronary angiography or a revascularization operation. Three interviewees were suspected to have CHD at the time of the Health 2000 baseline interviews. In the study year, two of them had undergone angiography showing no CHD. Nonetheless, they were included in the sample since they had experience of encounters with the health-care system due to suspected CHD. The interviewees came from both blue-collar and white-collar occupations. Seven of the interviewees were currently in gainful employment, 22 were retired and one was unemployed. The employed interviewees were followed up by occupational health-care services, and the retired and unemployed interviewees by a private specialist or at municipal health centres.
Data collection
The interviews were conducted in connection with the Health 2000 examinations, in a separate room. Once the basic sociodemographic data had been obtained, the interviewees were asked to tell the story of their coronary heart disease. In response, the interviewees provided a short sketch of their disease history. The rest of the interview was aimed at extracting further details about the diagnostic process and other encounters with the health-care system, personal experiences of the disease, the current situation and the underlying reasons for the disease. Two pilot interviews were carried out in August 2001 to test the interview schedule. The interviews proper took place between October 2001 and January 2002. They lasted between 40 and 120 min, were audiotaped with the interviewees' permission and transcribed verbatim.
Analysis
Data were analysed using qualitative content analysis.22,23 First, those involved in the treatment of CHD were identified from the accounts and compared along the pathways of treatment. Secondly, sections of the stories concerning encounters with the health-care system were categorized by the mode of narration.22 The modes examined were description, narration and argumentation. Description refers to reporting factual information and narration to stories told by the interviewee, while argumentation refers to the interviewee asserting a particular point of view to the interviewer. This categorization was used to unravel the meanings attached by the interviewees to their encounters with the health-care system in the context of the interview. The categorized sections were then analysed thematically and the themes cross-tabulated by gender, socioeconomic status and organization of health care to guarantee systematic analysis of the data.24
The data were analysed using ATLAS/ti software.25 In the database the interviewees were identified by a letter identifying the interviewer (KM or ET) and a number. The data were coded, and examined both thematically across interviews and in the context of each interview.
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Treatment decision-making
Coronary patients' stories of their disease featured several actors playing different parts, but in most cases only doctors and the interviewees themselves were presented as being actively involved in making decisions about treatment. Eleven interviewees mentioned nurses and other health-care personnel, but they were presented as being involved in treatment decisions only indirectly, as providers of information and support and as performers of tests and treatment. Family members were mentioned in some interviews, mainly as being involved in making the decision to seek care and on no more than two occasions as being directly involved in treatment decisions after the first contact. Fellow CHD sufferers were mainly presented as sources of information and support. Four different models of decision-making were identified: a doctor-centred model, shared decision-making, a combination of these two models and a care-demanding model.
Nine interviewees presented the doctor as the sole decision-maker, with the interviewee remaining a passive object. In these interviews the actors involved in treatment decisions were referred to as ‘they’, ‘he’, ‘the doctors’; the interviewees also spoke in the passive voice and sometimes used the name of the doctor who made the decisions. In extract 1, K13 tells the story of his acute myocardial infarction, describing himself as an object of others' actions.
Extract 1
KM: So how did it happen?
K13: Well it was nothing really, I was working and then just all of a sudden I felt this pain in my heart and then they took me away, no first I went down to the occupational health centre and then from there to the hospital.
KM: Yes and then when you got to the hospital, what happened next?
K13: Well they referred me to Tampere for angiography and then they sent me off for an urgent operation (male, 56 years, factory worker).
Later on in the interview, when specifically asked about decision-making, this interviewee makes it quite clear that no discussions took place by saying ‘[n]o there was nothing else apart from this that I have to have this operation’.
A doctor-centred model was presented by interviewees who were treated both operatively and non-operatively. In non-operative cases the interviewees said the medication was quite simply prescribed to them. The passive object status was also expressed in three accounts where the interviewees said that coronary angiography had been planned at some point of time, but had never been conducted, and that they had not raised the subject with the doctor.
Twelve interviewees presented themselves as having been actively involved in making treatment decisions together with their doctor. They either referred explicitly to having discussions about their treatment options, or told their story as a dialogue between ‘I’ and ‘the doctor(s)’. E13 (extract 2) tells a story in which she and her family are actively involved in deciding together with the doctor whether or not an operation is needed after myocardial infarction. She presents the discussions as concrete occurrences: a conversation and a meeting with a doctor. Interviewees receiving non-operative treatment also presented shared decision-making; in these cases the discussions had concerned examinations and medication options.
Extract 2
E13: [...] when the treatment [was started] it was there at the [name of the central hospital] and this [doctor] who was on the emergency ward at the time, or in the cardiac unit, the doctor, he recommended to my daughter that without any question he would recommend having the operation that we should start the paperwork. As I said because I'm retired that if it doesn't, I mean, I mean at this point it was [name of the doctor] who said that that's no obstacle, and then there was this other doctor who just said that since you're fit enough and since we can really help with this, help us, so he [said that he] felt that it's really worthwhile to file the papers, and so that's what we did then, with my daughter so we went to see this doctor because he'd asked me to go over and see him to talk this all over and, so what we [want to do] (female, 65 years, retired financial administrator).
Four interviewees presented separate models of decision-making at different levels of health care. At the primary care level, they described shared decision-making with their doctor; and at district or university hospital level, the doctor-centred model with a cardiologist or a cardiac surgeon.
A care-demanding model of decision-making was identified in five interviews. In these cases the interviewees presented themselves as the main actor in the decision-making process, indicating that diagnostic tests would not have been conducted, or that treatment would not have been started, had they not demanded it. This is exemplified by extract 3. When asked to describe the onset of her coronary heart disease, K04 talks about difficulties in making the diagnosis.
Extract 3
K04: I noticed that there was this hill I always climbed on my bicycle and then once I didn't really manage all the way and I thought something's not quite right now. But I was just fifty and it was awkward trying to explain this to the doctor that when a woman's fifty she's always in that [menopausal] age. So they don't take it seriously or anything and then during the week the situation got worse and I had to get back to the doctor again and he referred me straight to the hospital. So there I was lying half a day and they were all interviewing me and then they wanted me to go to the gynaecologist again because I'd been there five times already [for these symptoms] and they thought it was the menopause but I kept telling them that this time, I'm not going away that this is not what this is about. It's something else. And so it was the very same day I got to ride that bicycle [an exercise ECG] and so then they saw it ... (female, 58 years, factory worker).
Later on in the interview, when specifically asked about the interaction, K04 summarizes her experience saying ‘[i]t has really been un uphill battle for me to get the message across what I thought was wrong with me. I really had to try hard, to keep nagging away at them.’ Care-demanding was presented by these interviewees in several points of the treatment pathways, both in the making of the diagnosis and at different occasions during the follow-up.
A care-demanding model only appeared in women's accounts, whereas other models were presented by both genders. Shared decision-making was more common among white-collar employees, and doctor-centred decision-making among blue-collar workers. However, none of the models was socioeconomic group-specific. The interviewees treated by a private specialist consistently presented shared decision-making, while those treated in health centres or occupational health care showed more variation.
Experience of medical encounters
All interviewees presented a more or less detailed description when asked about making of the diagnosis or follow-up after it. The making of the diagnosis was usually presented as a chronological story of how the chest pain had started, the interviewee had sought primary care or was taken to hospital due to myocardial infarction, diagnostic tests were carried out and the diagnosis confirmed. These stories were mainly chronicles of a chain of events in time whereas follow-up was mainly described as a regularly repeated sequence of encounters. This is illustrated by extract 4 from the interview with E08. First, she simply confirms that follow-up has been taken care of. When probed, she goes on to describe the tests that have been taken.
Extract 4
ET: And uhm, are you, have you had regular check-ups for instance?
E08: Yes.
ET: Where?
E08: I go to our occupational health centre. Every now and then they do an ECG and, a few times a year, and then otherwise blood pressure measurements, my blood pressure's been quite normal for some time now so (female, 59 years, office manager).
When probed for more details, some interviewees simply elaborated upon their initial description, presenting further details of these encounters. Others would turn to presenting evidence of the quality of these encounters. This evidence could take the form of a direct argument or a story of an episode in health care indicating good or bad experience with health care.
Altogether nine interviewees presented further evidence to confirm that the follow-up was well organized. The interview with E08 continues by the interviewer presenting an additional probe about the adequacy of the follow-up (extract 5). To this, E08 responds by pointing out that she has good interaction with her doctor, and then moves on to present a story about her last check-up indicating easy access to health services. She then concludes the argument with presenting her opinion of her doctor.
Extract 5
ET: And these controls are quite adequate in that sense?
E08: Well yes, to me it is and I mean I can talk with the doctor at the occupational health services, and if there's anything then he'll always see me and I mean the last time I was there we were saying that now that everything's looking good I wouldn't have to go so often and then he really stressed to me that if there's anything at all then don't wait but get in touch straightaway. So I do think he really looks after me (female, 59 years, office manager).
Ten interviewees mentioned problems with follow-up, for instance in access to care or in doctor–patient interaction. E14 (extract 6) talks about these kinds of problems. When asked where she has been for her check-ups, she stresses that she personally has made sure the examinations have been conducted regularly. The story she tells about her latest episode in primary care points to problems with follow-up.
Extract 6
E14: [...] So the ECG is always, I've always had an ECG once a year.
ET: Yes so you've had that.
E14: Yes, ECG, that's right.
ET: And where have you been to have that?
E14: I've had it when we lived we were in the catchment area of [name of health centre], they took it there and now I've had it here at [name of health centre] and then at [name of health centre]. So I mean I have made sure about [having ECG regularly]. And now here they took one here [at Health 2000] when I had this [health examination] and they told me to bring the ECG up here to [name of health centre] and I showed it but I didn't really get any sort of response from the doctor.
ET: There was no feedback?
E14: Well no (laughter), it was strange because this [doctor] said I should show it because there was something there and so I did and I said I would want to [have a new test], and well, he sent me off to have another test. So I went in for new tests but I must have had three different doctors and they just told me to phone in whether there was anything in the results. So eventually when I got through they said there's no cause for anything. If you ask me the whole system was pretty much adrift [...] (female, 69 years, retired office worker).
A closer examination of arguments indicating bad or good experience of care (table 1) showed that the interviewees used similar elements in the argumentation for both. An important element of these arguments was doctor–patient interaction, especially in terms of information exchange. Whether the patients received information and had their views taken into account were both important. Another important element was connected to the organization of health care, namely access to tests and care and continuity or care, i.e. whether or not the patients had their own doctor. Furthermore, the doctor's perceived competence and approach towards patients seemed to play a role in how encounters were experienced.
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Problems were mentioned more often by women. Those with a shared decision-making model presented mainly neutral descriptions or argued for good experience, those presenting a care-demanding model presented mainly problems in follow-up, while those with a doctor-centred model showed more variation in the way they presented their experience. Both those interviewees who had their check-ups at occupational health-care services and those visiting health centres presented problems, whereas those using private specialist care did not.
Some interviewees described episodes of diagnostic confusion before the disease was detected and five of them took up problems in their first encounters. These problems included difficulties in access to examinations and lack of continuity of care. Difficulties were also mentioned in doctor–patient interaction. These patients felt that the doctors had ignored their views and that their complaints had not been taken seriously during their first contacts.
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Discussion |
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This small scale exploratory study examined coronary patients' accounts of their encounters with health care to trace different points in the pathways of treatment that can have an effect on gender and socioeconomic differences. Two key points emerged in the analysis: doctor–patient interaction and the organization of primary care. The three features commonly distinguished in doctor–patient interaction, i.e. treatment decision-making, information exchange and interpersonal relationship,26 were all found to be relevant to the way coronary patients experienced their encounters with health-care system. Two contrasting models of treatment decision-making were identified, coinciding with those often specified in doctor–patient interaction:26 shared and doctor-centred decision-making models. The doctor-centred model was in the present study more common among blue-collar workers and the shared decision-making model among those using private care. The utilization of private care is clearly concentrated in higher socioeconomic groups in Finland.27 There is also earlier evidence that social class differences between doctors and patients can have an effect on the choice of the treatment decision-making model.28 A third model was also found in which the interviewees presented themselves as care-demanding subjects. In the present study only women presented this model, whereas the other two models were presented by both genders. Women may, more often than men, experience disregard of their coronary symptoms in their encounters with the health-care system,13,17,29 which can prompt them to demand care.
A second key point that emerged in the present analysis was organization of primary care in terms of both access to and continuity of care. In the present study, women and persons from lower socioeconomic groups were more likely to have difficulties in gaining access to services and lack a permanent contact in primary care. Gender difference in access to examinations and care can be connected to CHD being perceived as a male disease. It may therefore be diagnosed in a later stage among women, and they may be less likely to be referred to investigations and treatment.29 Systematic gender bias favouring men has also been reported in secondary prevention of CHD in general practice,30 and respondents from a deprived area have been reported to be more likely to experience difficulties in access to health services.14 Similar results have also been reported in Finland among coronary patients in access to angiography and resvascularization operations.7,9,10
This qualitative study focused on gender and socioeconomic differences in coronary patients' encounters with health care. It was therefore important to ensure a broad spectrum of experience of these encounters. It follows that CHD severity varied from chance-found symptomless diseases to myocardial infarction, indicating obvious treatment differences. There was a large variation in the duration of the disease, which also contributes to treatment differences, since the treatment of CHD has changed with new treatment recommendations in the 1990s.31 Nevertheless, coronary patients' experience of doctor–patient interaction or of access to and continuity of care should not be affected by disease severity or content of care.
When examining gender and socioeconomic differences in CHD treatment, attention needs to be focused on primary care in terms of both doctor–patient interaction, and access to and continuity of care, along with patients' psychosocial characteristics, cultural knowledge and interpretation of coronary symptoms (cf.15–19). In the present study they emerged as key points in which coronary patients' experience of encounters with health care varied by gender and socioeconomic group. Whether there are systematic differences between population groups in access to primary care or in continuity of care remains to be ascertained by further studies using large, representative samples. Further research is also needed to increase our understanding of potential differences in doctor–patient interaction and, at a more general level, of the processes leading to treatment differences. Nevertheless, the results reported here should sensitize us to coronary patients' problems in access and continuity of care as well as to potential problems in doctor–patient interaction.
Key points
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Acknowledgments |
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The study was financially supported by Academy of Finland (grant Nos. 48773 and 53496).
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