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Heart disease and gender in mass print media
Maturitas 65 (2010) 215–218
Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Review
Heart disease and gender in mass print media Juanne Clarke ∗ Wilrid Laurier University, 75 University Ave. W, Waterloo, Ontario, N2K4G8 Canada
a r t i c l e
i n f o
Article history: Received 10 November 2009 Accepted 19 November 2009
Keywords: Media portrayal Gender Heart disease
a b s t r a c t Heart disease is a major cause of death, disease and disability in the developed world for both men and women. Women appear to be under-diagnosed and treated both because they fail to visit the doctor or hospital with relevant symptoms and because doctors tend to dismiss the seriousness of women’s symptoms of heart disease. This review examined the way that popular mass print media present the possible association between gender and heart disease. It found that there was: [1] an under-representation of heart disease as a possible concern to women, [2] a dismissing or sensationalization of women’s heart disease, [3] a tendency to blame women’s complex menopausal bodies for the causes of heart disease, [4] an association of women with the heart disease of their husbands, [5] a linking of heart disease with masculinity and [6] a promotion of the idea of the need for women to fear of heart disease and the necessity of taking cholesterol-lowering drugs. The review concluded with suggestions for further research and for practice. © 2009 Elsevier Ireland Ltd. All rights reserved.
Contents 1.
2.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1. Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2. Mass media and health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3. Heart disease and gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4. Heart disease and gender: knowledge and perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5. Mass media and gender differences in disease portrayal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion: clinical implications and suggestions for further research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
215 215 215 216 216 216 217 217 217
1. Introduction
1.2. Mass media and health
1.1. Purpose
People take action to prevent illness and to seek early help in the face of symptoms based on their beliefs about their own vulnerability and the severity of various disease conditions [7]. One of the most important sources of information for beliefs about health and illness in modern societies is mass media. People live their lives immersed in a context of mass media such as magazines, newspapers, movies, popular music and, increasingly internet sites. The Internet itself has been characterized as an “everyday helper” for information regarding health concerns [8]. According to the Pew Internet and American Life Project 8 in 10 Americans have looked on-line for health information and many of these people say that this information has had a “significant impact on the way they care for themselves and others” [9]. 70% of the UK population had access to the Internet within their own households in 2009 [10]. Social and health policies and individual decision-making all occur within this media saturated or mediated social world [11]. Taking this idea a step further Kivits demonstrates how health
The purpose of this review article is to describe and explain what is known about the way that gender and heart disease are portrayed in the mass media. To do this it will first demonstrate the importance of the mass media in modern societies for information about health and illness. It will then describe the morbidity and mortality rates of heart disease in women as compared to men. Reasons for the gender differences will be discussed. The literature on the media portrayal of women with heart disease will be reviewed along with the possible links between media portrayal and women’s heart disease issues. Finally clinical consequences, practice suggestions and areas for future research will be noted.
∗ Tel.: +1 5198868440. E-mail address: [email protected]. 0378-5122/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.maturitas.2009.11.019
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and media are now so tied together in personal understandings of health that they are virtually inseparable. He calls this phenomenon “mediated” health [8]. Media are available around-the-clock, accessible in private or publicly to the vast majority of people in the developed world and circulated across widespread socioeconomic, ethnic, age, geographic and other differences. Media are known to both set the agenda for topics of thought, discussion and policymaking and to frame those topics in certain ways [12]. Many people rely more on the media for health information than on health care providers [13–15]. While the majority of the population relies on mass media for all sorts of health-related information [16] magazines are seen as the most important source of information for heart disease by 43% of the population, followed by 24% who view television as most important and 18% who say their health care providers are most significant [17]. Women, in particular, are known to rely on magazines for information about health [18]. Now, several years later than these studies were published, it is likely that the Internet competes with magazines for information about heart health because, aside from email, search for health information is among the most popular reasons for Internet use [19]. 1.3. Heart disease and gender Heart disease is one of the most significant causes of disability and death for both men and women in industrialized nations [1,2]. According to the World Health Association (WHO) cardiovascular disease (CVD) causes an estimated 29% of death worldwide for a total of about 17.1 million people [20]. Diseases of the heart and circulatory system are the chief cause of mortality in the UK [3]. More women (102,780) than men (94,987) in the UK die from diseases of the circulatory system [3]. According to the American Heart Association close to 37% of all female deaths in the United States are the result of (CVD) including coronary heart disease (CHD), stroke and other cardiovascular diseases [21]. In the United States alone, CVD results in direct and indirect health care costs and loss of productivity amounting to $274 billion dollars annually [22]. CVD has a particularly high incidence among ethnic and racialized women (and men) lower in the socio-economic hierarchy [23]. The incidence of CVD is higher among men than women in the earlier years of life although the risk for CVD increases with age for both women and men. Moreover, women tend to be underdiagnosed, particularly in the early stages of the disease and in their younger years [6]. Women and the elderly tend to delay seeking treatment for cardiac symptoms [24]. Women are more likely to die within the first year of a heart attack, between about 23% of women as compared to 18% of men [25] or 38% of women and 25% of men [7]. There are a number of reasons that women give for being less likely to seek immediate help when they experience symptoms of an acute myocardial infarction (MI) including linking symptoms with non-cardiac causes, making light of symptoms, experiencing non-classical symptoms and relying on mass media and male family members symptoms for information [26].
Heart disease tends to be considered a man’s disease [29,30]. A bit more than ten years ago, people in general and women in particular were likely to believe that women were not especially vulnerable to heart disease [31]. According to the American Heart Association only 13% of a sample of 1000 women surveyed knew that heart disease and stroke were the greatest threat to women’s health [32]. Another survey found that even among women who claimed they were well informed about health issues; only 44% believed they could have a heart attack [31]. A more recent survey of a nationally representative sample of women found that by 2006, 57% of US women knew that heart disease was the leading cause of death among women [33]. Men have been believed to be the usual candidates for heart attacks, while women have been relatively invisible in everyday heart disease discourse [13]. Indeed, particular types of men were viewed as the most likely to be diagnosed with coronary disease. The commonplace picture of the person with a heart attack has been of a powerful and successful man in a stressful and high paying job [13]. Lefler calls this public image of the heart attack, the Hollywood heart attack, and argues that it is “characterized by a “middle-aged white male, clutching his chest in acute severe pain and subsequently dropping to the floor” [7]. Now, although the data is contradictory, it does appear that there is increasing awareness of the possibility of heart disease in women. Cancer is widely believed to be more prevalent and more fearsome than heart disease and receives a great deal more attention in public spheres such as the mass media [34]. A 2006 study based on a five-year scan of Canadian mass media noted that “CVD did not occupy a prominent place on the public agenda, despite being the leading cause of morbidity, mortality and health care expenditures” [35]. In fact, heart disease received only 0.8% of the overall media coverage across all health issues (with the exception of incidental mentions of CVD in the context of life style issues) [35]. A number of different studies have confirmed that women are more attuned to the threat of breast cancer than heart disease [17]. In Mosca’s research, 7% of women considered heart disease to be the greatest health problem facing women, 34% felt breast cancer was the greatest threat and 27% considered all other cancers as most significant [17]. Breast cancer receives considerably more media attention (and philanthropic dollars) than heart disease for women. In one example, the Star (a daily newspaper in Canada) was found to run three times the number of stories on breast cancer as heart disease [36]. Nevertheless, heart disease is a more significant cause of death and disability for women than cancer in general and breast cancer in particular in both the UK and the US [3,21]. For example, in the UK in 2005 108,615 women died as a result of coronary heart disease and, by contrast, 12,417 women died from breast cancer [3]. In the United States, CHD resulted in 213,572 deaths among women as compared to 41,446 from breast cancer [21]. The perceived risk for breast cancer may also be amplified for the reasons suggested in the following quotation. “Breast cancer is more dreaded, its causes are less understood, and its risk factors as less under personal control than heart disease or lung cancer” [22].
1.4. Heart disease and gender: knowledge and perception 1.5. Mass media and gender differences in disease portrayal Gender differences in the rates of diagnosis by age appear to result from both lack of knowledge and under-recognition of symptoms among women, as well as, under-diagnosis of women with symptoms among doctors [1,7]. There is comparatively little known about the early symptoms and signs of heart disease in women [1]. Historically women have tended to be overlooked in CVD research [27]. Recently, however, there has been a significant increase in the inclusion of women in clinical trials 2 [28]. Still, however, research on heart disease is under-represented in major medical journal publications such as the Journal of the American Medical Association and the New England Journal of Medicine [18].
A gendered portrayal of disease in mass media has been documented [35–41]. Some work has studied diseases that are either exclusively diagnosed in men or women or are highly overrepresented in one or another gender (e.g. breast cancer). In these cases, the diseases themselves seem to take on the characteristics of masculinity or femininity [37–39,42]. Both prostate and testicular cancer, for example, were described as if they were ‘masculine’ and contextualized by stereotypically masculine contexts such as sports, competition, money and sexuality [40,41]. By contrast, breast cancer was described as a woman’s disease and related
J. Clarke / Maturitas 65 (2010) 215–218
to stereotypically female behaviours and attitudes such as emotionality and a preoccupation with appearance [39,43]. Little is known about the possible differences in the media portrayal of heart disease in men and women. Moreover, what is known is based on magazines only. One study focused on the portrayal of women and heart disease and cholesterol in seven US women’s magazines and two Canadian magazines and found that the magazine articles and advertisements served to reinforce fear about heart disease for women and to argue that women could not deal with the risk factors themselves through diet and exercise but ought to be taking cholesterol-lowering drugs [2]. Emphasis was placed on inequity in heart health services for women as compared to men. “A woman’s responsibility is no longer to maintain a healthy lifestyle but to remedy the discrimination of which women have been the object when it comes to preventing, diagnosing, and treating heart disease” [2]. Another article, published as commentary rather than research based investigation described the media sensationalization of a study in The Lancet wherein researchers had found that a personality trait labelled submissiveness was linked to myocardial infarction [46]. Following the publication of article in the medical journal newspapers across the UK published overstated and demeaning headlines such as the one in the Daily Telegraph “Put down that rolling pin darling, it’s bad for your heart” [46]. The purpose of this viewpoint story was to warn other researchers to be wary of publicity. Moyer and her colleagues examined the concordance between mass media stories about health topics in two US mass magazines Good Housekeeping and Woman’s Day as compared with two major medical journals the New England Journal of Medicine (NEJM) and the Journal of the American Medical Association (JAMA) [18]. They found that few mass media stories provided either citations or the names of the source journals for the studies discussed [18]. Moreover only seven percent of the articles discussed any of the major causes of death (cancer, heart disease and stroke) and health-related articles comprised only 1.2% of all articles. Interestingly neither JAMA nor NEJM covered heart disease to the extent they covered cancer or other less frequent causes of mortality and morbidity such as pregnancy or hormone replacement therapy. Another investigation based on all 75 articles that dealt with heart disease from the 20 highest circulating English language magazines published in Canada or the United States in 1991, 1996 and 2001 found that heart disease was portrayed in biased and gendered ways: more often as a disease of men; as almost foreseeable for men and even as an sign of successful manhood [15]. In addition heart disease was associated with men of renown and as the accepted prices of success, power and hard work. Even the doctors who treated men were described as celebrities. By contrast, women were described as ashamed of the diagnosis, as badly informed and emotionally labile, as caretakers of their husbands whom, the wives believed (before their own diagnosis), were more likely to suffer from heart disease. Moreover women’s bodies were described as inescapably symptomatic after menopause, bewildering and complex to treat and even to diagnose. Treatment for women was portrayed in contradictory ways and women were portrayed as victims of medical research. Beginning in 2001 there has been a concerted effort to market heart disease as a women’s disease through a campaign called The Heart Truth sponsored by the National Heart, Lung, and Blood Institute and Ogilvy Public Relations in the US [47]. Its intention has been to “dispel the myth that heart disease is a man’s disease”: “connect with women so they see the personal relevance of heart disease” and; “convey a sense of urgency and personal risk” [47]. There are indications that this campaign has met with some success. A survey done in March of 2008 found that 61% of American women could identify the Red Dress as the national symbol for women and heart disease, up from 25% in 2005. Furthermore, 45% of the women indi-
217
cated that the campaign made them want to talk to their doctor and to get a check up for heart health [45]. In conclusion according to this brief review of the literature: 1. There is very little known about the portrayal of women and heart disease in the mass media. 2. That which is available is based on magazines and medical journals. 3. Therefore there are no studies of gender and heart disease portrayal on the Internet or television, although both of these are important to audiences. 4. What is available suggests [1] an under-representation of heart disease as a possible concern to women, [2] a dismissing or sensationalization of women’s heart disease, [3] a tendency to blame women’s complex menopausal bodies for the causes of heart disease, [4] an association of women with the heart disease of their husbands, [5] a linking of heart disease with masculinity and [6] a promotion of the idea of the need for women to fear of heart disease and the necessity of taking cholesterol-lowering drugs. 2. Conclusion: clinical implications and suggestions for further research The findings suggest the continuing need for medical researchers, practitioners and women to be attuned to the possibilities of heart disease in women and to continue to study possible differences in presentation, causation and treatment. Ongoing media advocacy by those organizations and professions especially concerned with heart disease is vital to expand the validity and frequency of the coverage of women’s risk for heart disease. There is a need for further research on the topic of women and heart disease in magazines as well as on television and on the Internet. The impact of media advocacy work such as the Red Dress campaign needs to be undertaken. Particularly as more information becomes available about association with relative poverty, racial/ethic and age differences in heart disease incidence, research on the differences in targeted media becomes crucial. Provenance Commissioned and externally peer reviewed. References [1] McKinlay JB. Some contributions from the social system to gender inequalities in heart disease. Journal of Health and Social Behavior 1996;37(1):1–26. [2] Savoie I, Kazanjian A, Brunger F. Women, the media, and heart disease. For better or worse? International Journal of Technology Assessment in Health Care 1999;15(4):729–37. [3] British Heart Foundation Statistics Database [www.heartstats.org]. [4] Heart and Stroke Foundation [http://www.heartandstroke.ca]. [5] U.S. Census Bureau: vital statistics. Statistical abstract of the United States; 2006 [http://wwwcensus.gov/prod/2005pubs/06statab/vitstat.pdf]. [6] Health Canada online. [http://www.hc-sc.gc.ca/english/disease/heart.htm]. [7] Lefler LL. Perceived risk of heart attack. A function of gender. Nursing Forum 2004;39(2):18–26. [8] Kivits J. Everyday health and the Internet: a mediated health perspective on health information seeking. Sociology of Health and Illness 2009;31(5):673–87. [9] Fox S. Pew Internet. Pew Internet & American Life Project; 2009 [http://www. pewinternet.org/topics/Health.aspx]. [10] Office for National Statistics. UK Internet Access; 2009 [www.statistics.gov. uk/cci/nugget.asp?ID=8]. [11] Altheide DL. Children and the discourse of fear. Symbolic Interaction 2002;25:229–50. [12] Weaver DH. Thoughts on agenda setting, framing, and priming. Journal of Communication 2007;57(1):142–7. [13] Emslie C, Hung K, Watt G. Invisible women? The importance of gender in lay beliefs about health problems. Sociology of Health and Illness 2001;23(2):203–33. [14] Barker K. Self-help literature and the making of an illness identity: the case of fibromyalgia syndrome (FMS). Social Problems 2002;49(3):279–300.
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[15] Clarke JN, van Amerom G, Binns J. Gender and heart disease in mass print media: 1991, 1996, 2001. Women and Health 2006;452:17–35. [16] Johnson T. Shattuck lecture—medicine and the media. Massachusetts Medical Society 1998;339(2):87–92. [17] Mosca L, Jones WK, King KB, Ouyang P, Redberg RF, Hill MN. Awareness, perception and knowledge of heart disease risk and prevention among women in the United States. Archives of Family Medicine 2000;9(6):506–15. [18] Moyer CA, Vishnu LO, Sonnad SS. Providing health information to women: the role of magazines. International Journal of Technology Assessment in Health Care 2001;17:137–45. [19] Statistics Canada. The Daily; 2008 [http://www.statcan.gc.ca/dailyquotidien/080612/dq080612b-eng.htm]. [20] World Health Organization. Cardiovascular diseases (CVDs); 2009 [http://www.who.int/mediacentre/factsheets/fs317/en/index.html]. [21] American Heart Association [http://www.americanheart.org/presenter.jhtml? identifier=4786]. [22] Covello VT, Peters RG. Women’s perceptions of the risks of age-related diseases, including breast cancer: reports from a 3-year research study. Health Communication 2002;14(3):377–95. [23] Warren-Findlow. Weathering: stress and heart disease in African American women living in Chicago. Qualitative Health Research 2006;16(2):221–37. [24] Gibler WB, Armstrong PW, Ohman EM, Weaver WD, Stebbins AL, Gore JM. Persistence of delays in presentation and treatment for patients with acute myocardial infarction. The GUSTO-I and GUSTO-III experience. Annals of Emergency Medicine 2000;39:123–30. [25] Persell S, Maviglia S, Bates D, Ayanian J. Ambulatory hypercholesterolemia management in patients with atherosclerosis. Journal of General Internal Medicine 2005;20(2):123–30. [26] Arslanian-Ergoren C. Treatment-seeking decisions of women with acute myocardial infarction. Women and Health 2005;42(2):53–70. [27] Grady D, Chaput L, Kristof M. Results of systematic review of research on diagnosis and treatment of coronary heart disease in women. Rockville, MD: Agency for Health care Research and Quality; 2003 [www.ahrq.gov/ research/wmwakeup.htm]. [28] Correa-de-Araujo. A wake-up call to advance women’s health. Women’s Health Issues 2004;14:31–4. [29] Rushton A, Clayton J. Coronary heart disease: women’s assessment of risk: a qualitative study. Health, Risk and Society 2002;42:125–33. [30] Curry P, O’Brien M. The male heart and the female mind: a study in the gendering of antidepressants and cardiovascular drugs in advertise-
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Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Review
Heart disease and gender in mass print media Juanne Clarke ∗ Wilrid Laurier University, 75 University Ave. W, Waterloo, Ontario, N2K4G8 Canada
a r t i c l e
i n f o
Article history: Received 10 November 2009 Accepted 19 November 2009
Keywords: Media portrayal Gender Heart disease
a b s t r a c t Heart disease is a major cause of death, disease and disability in the developed world for both men and women. Women appear to be under-diagnosed and treated both because they fail to visit the doctor or hospital with relevant symptoms and because doctors tend to dismiss the seriousness of women’s symptoms of heart disease. This review examined the way that popular mass print media present the possible association between gender and heart disease. It found that there was: [1] an under-representation of heart disease as a possible concern to women, [2] a dismissing or sensationalization of women’s heart disease, [3] a tendency to blame women’s complex menopausal bodies for the causes of heart disease, [4] an association of women with the heart disease of their husbands, [5] a linking of heart disease with masculinity and [6] a promotion of the idea of the need for women to fear of heart disease and the necessity of taking cholesterol-lowering drugs. The review concluded with suggestions for further research and for practice. © 2009 Elsevier Ireland Ltd. All rights reserved.
Contents 1.
2.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1. Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2. Mass media and health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3. Heart disease and gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.4. Heart disease and gender: knowledge and perception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5. Mass media and gender differences in disease portrayal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusion: clinical implications and suggestions for further research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
215 215 215 216 216 216 217 217 217
1. Introduction
1.2. Mass media and health
1.1. Purpose
People take action to prevent illness and to seek early help in the face of symptoms based on their beliefs about their own vulnerability and the severity of various disease conditions [7]. One of the most important sources of information for beliefs about health and illness in modern societies is mass media. People live their lives immersed in a context of mass media such as magazines, newspapers, movies, popular music and, increasingly internet sites. The Internet itself has been characterized as an “everyday helper” for information regarding health concerns [8]. According to the Pew Internet and American Life Project 8 in 10 Americans have looked on-line for health information and many of these people say that this information has had a “significant impact on the way they care for themselves and others” [9]. 70% of the UK population had access to the Internet within their own households in 2009 [10]. Social and health policies and individual decision-making all occur within this media saturated or mediated social world [11]. Taking this idea a step further Kivits demonstrates how health
The purpose of this review article is to describe and explain what is known about the way that gender and heart disease are portrayed in the mass media. To do this it will first demonstrate the importance of the mass media in modern societies for information about health and illness. It will then describe the morbidity and mortality rates of heart disease in women as compared to men. Reasons for the gender differences will be discussed. The literature on the media portrayal of women with heart disease will be reviewed along with the possible links between media portrayal and women’s heart disease issues. Finally clinical consequences, practice suggestions and areas for future research will be noted.
∗ Tel.: +1 5198868440. E-mail address: [email protected]. 0378-5122/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.maturitas.2009.11.019
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and media are now so tied together in personal understandings of health that they are virtually inseparable. He calls this phenomenon “mediated” health [8]. Media are available around-the-clock, accessible in private or publicly to the vast majority of people in the developed world and circulated across widespread socioeconomic, ethnic, age, geographic and other differences. Media are known to both set the agenda for topics of thought, discussion and policymaking and to frame those topics in certain ways [12]. Many people rely more on the media for health information than on health care providers [13–15]. While the majority of the population relies on mass media for all sorts of health-related information [16] magazines are seen as the most important source of information for heart disease by 43% of the population, followed by 24% who view television as most important and 18% who say their health care providers are most significant [17]. Women, in particular, are known to rely on magazines for information about health [18]. Now, several years later than these studies were published, it is likely that the Internet competes with magazines for information about heart health because, aside from email, search for health information is among the most popular reasons for Internet use [19]. 1.3. Heart disease and gender Heart disease is one of the most significant causes of disability and death for both men and women in industrialized nations [1,2]. According to the World Health Association (WHO) cardiovascular disease (CVD) causes an estimated 29% of death worldwide for a total of about 17.1 million people [20]. Diseases of the heart and circulatory system are the chief cause of mortality in the UK [3]. More women (102,780) than men (94,987) in the UK die from diseases of the circulatory system [3]. According to the American Heart Association close to 37% of all female deaths in the United States are the result of (CVD) including coronary heart disease (CHD), stroke and other cardiovascular diseases [21]. In the United States alone, CVD results in direct and indirect health care costs and loss of productivity amounting to $274 billion dollars annually [22]. CVD has a particularly high incidence among ethnic and racialized women (and men) lower in the socio-economic hierarchy [23]. The incidence of CVD is higher among men than women in the earlier years of life although the risk for CVD increases with age for both women and men. Moreover, women tend to be underdiagnosed, particularly in the early stages of the disease and in their younger years [6]. Women and the elderly tend to delay seeking treatment for cardiac symptoms [24]. Women are more likely to die within the first year of a heart attack, between about 23% of women as compared to 18% of men [25] or 38% of women and 25% of men [7]. There are a number of reasons that women give for being less likely to seek immediate help when they experience symptoms of an acute myocardial infarction (MI) including linking symptoms with non-cardiac causes, making light of symptoms, experiencing non-classical symptoms and relying on mass media and male family members symptoms for information [26].
Heart disease tends to be considered a man’s disease [29,30]. A bit more than ten years ago, people in general and women in particular were likely to believe that women were not especially vulnerable to heart disease [31]. According to the American Heart Association only 13% of a sample of 1000 women surveyed knew that heart disease and stroke were the greatest threat to women’s health [32]. Another survey found that even among women who claimed they were well informed about health issues; only 44% believed they could have a heart attack [31]. A more recent survey of a nationally representative sample of women found that by 2006, 57% of US women knew that heart disease was the leading cause of death among women [33]. Men have been believed to be the usual candidates for heart attacks, while women have been relatively invisible in everyday heart disease discourse [13]. Indeed, particular types of men were viewed as the most likely to be diagnosed with coronary disease. The commonplace picture of the person with a heart attack has been of a powerful and successful man in a stressful and high paying job [13]. Lefler calls this public image of the heart attack, the Hollywood heart attack, and argues that it is “characterized by a “middle-aged white male, clutching his chest in acute severe pain and subsequently dropping to the floor” [7]. Now, although the data is contradictory, it does appear that there is increasing awareness of the possibility of heart disease in women. Cancer is widely believed to be more prevalent and more fearsome than heart disease and receives a great deal more attention in public spheres such as the mass media [34]. A 2006 study based on a five-year scan of Canadian mass media noted that “CVD did not occupy a prominent place on the public agenda, despite being the leading cause of morbidity, mortality and health care expenditures” [35]. In fact, heart disease received only 0.8% of the overall media coverage across all health issues (with the exception of incidental mentions of CVD in the context of life style issues) [35]. A number of different studies have confirmed that women are more attuned to the threat of breast cancer than heart disease [17]. In Mosca’s research, 7% of women considered heart disease to be the greatest health problem facing women, 34% felt breast cancer was the greatest threat and 27% considered all other cancers as most significant [17]. Breast cancer receives considerably more media attention (and philanthropic dollars) than heart disease for women. In one example, the Star (a daily newspaper in Canada) was found to run three times the number of stories on breast cancer as heart disease [36]. Nevertheless, heart disease is a more significant cause of death and disability for women than cancer in general and breast cancer in particular in both the UK and the US [3,21]. For example, in the UK in 2005 108,615 women died as a result of coronary heart disease and, by contrast, 12,417 women died from breast cancer [3]. In the United States, CHD resulted in 213,572 deaths among women as compared to 41,446 from breast cancer [21]. The perceived risk for breast cancer may also be amplified for the reasons suggested in the following quotation. “Breast cancer is more dreaded, its causes are less understood, and its risk factors as less under personal control than heart disease or lung cancer” [22].
1.4. Heart disease and gender: knowledge and perception 1.5. Mass media and gender differences in disease portrayal Gender differences in the rates of diagnosis by age appear to result from both lack of knowledge and under-recognition of symptoms among women, as well as, under-diagnosis of women with symptoms among doctors [1,7]. There is comparatively little known about the early symptoms and signs of heart disease in women [1]. Historically women have tended to be overlooked in CVD research [27]. Recently, however, there has been a significant increase in the inclusion of women in clinical trials 2 [28]. Still, however, research on heart disease is under-represented in major medical journal publications such as the Journal of the American Medical Association and the New England Journal of Medicine [18].
A gendered portrayal of disease in mass media has been documented [35–41]. Some work has studied diseases that are either exclusively diagnosed in men or women or are highly overrepresented in one or another gender (e.g. breast cancer). In these cases, the diseases themselves seem to take on the characteristics of masculinity or femininity [37–39,42]. Both prostate and testicular cancer, for example, were described as if they were ‘masculine’ and contextualized by stereotypically masculine contexts such as sports, competition, money and sexuality [40,41]. By contrast, breast cancer was described as a woman’s disease and related
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to stereotypically female behaviours and attitudes such as emotionality and a preoccupation with appearance [39,43]. Little is known about the possible differences in the media portrayal of heart disease in men and women. Moreover, what is known is based on magazines only. One study focused on the portrayal of women and heart disease and cholesterol in seven US women’s magazines and two Canadian magazines and found that the magazine articles and advertisements served to reinforce fear about heart disease for women and to argue that women could not deal with the risk factors themselves through diet and exercise but ought to be taking cholesterol-lowering drugs [2]. Emphasis was placed on inequity in heart health services for women as compared to men. “A woman’s responsibility is no longer to maintain a healthy lifestyle but to remedy the discrimination of which women have been the object when it comes to preventing, diagnosing, and treating heart disease” [2]. Another article, published as commentary rather than research based investigation described the media sensationalization of a study in The Lancet wherein researchers had found that a personality trait labelled submissiveness was linked to myocardial infarction [46]. Following the publication of article in the medical journal newspapers across the UK published overstated and demeaning headlines such as the one in the Daily Telegraph “Put down that rolling pin darling, it’s bad for your heart” [46]. The purpose of this viewpoint story was to warn other researchers to be wary of publicity. Moyer and her colleagues examined the concordance between mass media stories about health topics in two US mass magazines Good Housekeeping and Woman’s Day as compared with two major medical journals the New England Journal of Medicine (NEJM) and the Journal of the American Medical Association (JAMA) [18]. They found that few mass media stories provided either citations or the names of the source journals for the studies discussed [18]. Moreover only seven percent of the articles discussed any of the major causes of death (cancer, heart disease and stroke) and health-related articles comprised only 1.2% of all articles. Interestingly neither JAMA nor NEJM covered heart disease to the extent they covered cancer or other less frequent causes of mortality and morbidity such as pregnancy or hormone replacement therapy. Another investigation based on all 75 articles that dealt with heart disease from the 20 highest circulating English language magazines published in Canada or the United States in 1991, 1996 and 2001 found that heart disease was portrayed in biased and gendered ways: more often as a disease of men; as almost foreseeable for men and even as an sign of successful manhood [15]. In addition heart disease was associated with men of renown and as the accepted prices of success, power and hard work. Even the doctors who treated men were described as celebrities. By contrast, women were described as ashamed of the diagnosis, as badly informed and emotionally labile, as caretakers of their husbands whom, the wives believed (before their own diagnosis), were more likely to suffer from heart disease. Moreover women’s bodies were described as inescapably symptomatic after menopause, bewildering and complex to treat and even to diagnose. Treatment for women was portrayed in contradictory ways and women were portrayed as victims of medical research. Beginning in 2001 there has been a concerted effort to market heart disease as a women’s disease through a campaign called The Heart Truth sponsored by the National Heart, Lung, and Blood Institute and Ogilvy Public Relations in the US [47]. Its intention has been to “dispel the myth that heart disease is a man’s disease”: “connect with women so they see the personal relevance of heart disease” and; “convey a sense of urgency and personal risk” [47]. There are indications that this campaign has met with some success. A survey done in March of 2008 found that 61% of American women could identify the Red Dress as the national symbol for women and heart disease, up from 25% in 2005. Furthermore, 45% of the women indi-
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cated that the campaign made them want to talk to their doctor and to get a check up for heart health [45]. In conclusion according to this brief review of the literature: 1. There is very little known about the portrayal of women and heart disease in the mass media. 2. That which is available is based on magazines and medical journals. 3. Therefore there are no studies of gender and heart disease portrayal on the Internet or television, although both of these are important to audiences. 4. What is available suggests [1] an under-representation of heart disease as a possible concern to women, [2] a dismissing or sensationalization of women’s heart disease, [3] a tendency to blame women’s complex menopausal bodies for the causes of heart disease, [4] an association of women with the heart disease of their husbands, [5] a linking of heart disease with masculinity and [6] a promotion of the idea of the need for women to fear of heart disease and the necessity of taking cholesterol-lowering drugs. 2. Conclusion: clinical implications and suggestions for further research The findings suggest the continuing need for medical researchers, practitioners and women to be attuned to the possibilities of heart disease in women and to continue to study possible differences in presentation, causation and treatment. Ongoing media advocacy by those organizations and professions especially concerned with heart disease is vital to expand the validity and frequency of the coverage of women’s risk for heart disease. There is a need for further research on the topic of women and heart disease in magazines as well as on television and on the Internet. The impact of media advocacy work such as the Red Dress campaign needs to be undertaken. Particularly as more information becomes available about association with relative poverty, racial/ethic and age differences in heart disease incidence, research on the differences in targeted media becomes crucial. Provenance Commissioned and externally peer reviewed. References [1] McKinlay JB. Some contributions from the social system to gender inequalities in heart disease. Journal of Health and Social Behavior 1996;37(1):1–26. [2] Savoie I, Kazanjian A, Brunger F. Women, the media, and heart disease. For better or worse? International Journal of Technology Assessment in Health Care 1999;15(4):729–37. [3] British Heart Foundation Statistics Database [www.heartstats.org]. [4] Heart and Stroke Foundation [http://www.heartandstroke.ca]. [5] U.S. Census Bureau: vital statistics. Statistical abstract of the United States; 2006 [http://wwwcensus.gov/prod/2005pubs/06statab/vitstat.pdf]. [6] Health Canada online. [http://www.hc-sc.gc.ca/english/disease/heart.htm]. [7] Lefler LL. Perceived risk of heart attack. A function of gender. Nursing Forum 2004;39(2):18–26. [8] Kivits J. Everyday health and the Internet: a mediated health perspective on health information seeking. Sociology of Health and Illness 2009;31(5):673–87. [9] Fox S. Pew Internet. Pew Internet & American Life Project; 2009 [http://www. pewinternet.org/topics/Health.aspx]. [10] Office for National Statistics. UK Internet Access; 2009 [www.statistics.gov. uk/cci/nugget.asp?ID=8]. [11] Altheide DL. Children and the discourse of fear. Symbolic Interaction 2002;25:229–50. [12] Weaver DH. Thoughts on agenda setting, framing, and priming. Journal of Communication 2007;57(1):142–7. [13] Emslie C, Hung K, Watt G. Invisible women? The importance of gender in lay beliefs about health problems. Sociology of Health and Illness 2001;23(2):203–33. [14] Barker K. Self-help literature and the making of an illness identity: the case of fibromyalgia syndrome (FMS). Social Problems 2002;49(3):279–300.
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