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Background
Coronary heart disease (CHD) is the leading cause of death in the
UK. While death rates from CHD are declining, sharp class differences
in mortality remain. The reasons for the slower decline in lower
socio-economic groups are poorly understood. However, class differences
in the lifestyle factors associated with CHD, including diet, cigarette
smoking and leisure-time exercise, are known to play an important
role.
Decisions about
health-related behaviours like smoking are shaped by a wide range
of influences. Among these are our beliefs about inherited risks
and about whether or not CHD 'runs in the family'. Lifestyle decisions
are known to be closely linked to perceptions about the inheritance
of body shape, physical weaknesses and susceptibility to chronic
illnesses, like CHD.
At present,
little is known about people's knowledge and beliefs about their
inherited predisposition to CHD. A better understanding of people's
beliefs about inherited risk is not only important for health promotion
policy and practice, it is also important for the development of
screening and genetic counselling programmes and for effective interventions
in clinical practice.
Aims and
Objectives
The study aims to investigate the role of perceived 'inheritance'
in perpetuating class inequalities in health-related lifestyles.
Its objectives are:
- to compare
the experience of family history of heart disease amongst men
and women of different social classes;
- to investigate
how individual perceptions of inherited susceptibility to major
chronic illness or premature mortality enhance or attenuate the
effectiveness of health promotion;
- to contribute
to the development of two important theoretical areas: perception
of risk and the role of family in shaping one's identity and sense
of self.
Study Design
This study offers a unique opportunity to research these issues.
It is based on in-depth interviews with adults where information
is already available not only about their coronary risk factors
but about the coronary risk status of their parents. Interviewees
will be selected from the 'FASTCARD' (Family Study of Cardiovascular
Disease) study: a clinical epidemiological study of offspring of
participants in the Paisley-Renfrew Study which was conducted in
1972-76. The Paisely-Renfrew Study involved 80% of the general population
of men and women in this part of the west of Scotland.
Together, the
FASTCARD study and the Paisley-Renfrew study provide a wealth of
information both on parents and on their offspring (who are now
in middle age). There are data on behavioural and biochemical CHD
risk factors, coronary events, parental occupation and mortality
rates as well as information on perceptions and 'objective' measurements
of family history of CHD. The in-depth interviews can thus examine
in detail the relationship between perceptions of low and high family
risk and the adoption of more and less healthy lifestyles. They
can explore explanations for 'discordant' family histories (where
'objective' information on parental risk contrasts with perceptions
of family history) and explore the various meanings of 'inheritance'.
Policy Implications
for those who are at greatest risk of major morbidity and premature
death. In this way, it will aid the development of policies to tackle
the behavioural factors that contribute to socio-economic variations
in health. With the advent of more widespread genetic testing in
coming years, the study will also provide invaluable material to
help predict the likely impact on people's lifestyles of knowing
that they are at increased risk of disease.
Project Summary
Coronary heart disease accounts for over a quarter of deaths in
the UK, yet few studies have explored beliefs about 'heart problems'
in the general population. The project filled this important gap
through a qualitative study of middle-aged men and women. The sample
included roughly equal numbers of men and women from middle class
groups (both the respondent and their father had a non-manual job)
and working class groups (both had manual jobs). The 61 respondents
were drawn from a larger quantitative survey of cardiorespiratory
disease (MIDSPAN Family Study) conducted in 1996 in the West of
Scotland. This baseline survey included information on whether respondents
believed that coronary heart disease (CHD) 'ran' their family. In
this larger study, 16% thought that they had a family history of
heart disease.
Key findings
- Women talked
with greater ease about family health in the interviews, but systematic
analysis of the accounts suggested that men's knowledge was not
substantially less. Most respondents knew something about their
grandparents' health or cause of death, but few knew about earlier
generations.
- In accord
with clinical definitions of family history, more weight was given
to deaths in first degree relatives at young ages than to CHD
deaths among other and older relatives. In general, men, particularly
working class men, required a larger number of relatives to be
affected by CHD before being convinced they had a family history
of the disease. Coronary deaths among the over 60s were more likely
to be attributed to 'old age' among the working class respondents
than among the middle class respondents, where further explanation
of the cause of death was seen to be required.
- A distinction
was commonly made between inherited risk within the family generally
and personally. Thus, one could believe that heart disease ran
in one's family without feeling personally at risk. A perception
of enhanced personal risk attributable to family history was reduced
if one did not 'take after' the particular family members who
had heart disease (with respect to build, temperament, etc).
- CHD is perceived
to be a male disease. Respondents' accounts of who was vulnerable
to heart problems all centred on men - as did their accounts of
unlikely 'candidates'. Only when asked about specific relatives
did respondents discuss women with heart problems. While accounts
of male sufferers focused on sudden, fatal heart attacks, accounts
of women usually concentrated on long-term CHD morbidity.
- An important
influence on attitudes to behavioural change (in diet, smoking
etc.) is the perception that the legacy of family history and
accumulated life experiences could not be 'undone'. A further
influence was the perception that CHD was 'a good way to go':
most narratives of CHD discussed fatal heart attacks and emphasised
a sudden, quick and painless death.
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