Introduction
Cardiovascular illness is the main explanation for demise in girls all through the world.1 Despite important enhancements over the previous twenty years, cardiovascular mortality is considerably larger in girls than males after a coronary heart assault and ladies are much less prone to endure cardiovascular screening exams, obtain interventional remedy, or cardiac rehabilitation referrals.2–5 Risk components particular to girls have additionally been described, together with gestational diabetes,6 polycystic ovary syndrome,7 and pre-eclampsia.8
In Israel, girls have larger mortality charges than males from acute coronary syndrome (i.e coronary heart assault and unstable angina), with 30-day mortality charges of 6.5% versus 3.6%.9
Critics of Israel’s medical system have indicated that it doesn’t adequately tackle girls’s gender-related well being care wants, calling for nationwide funding and coverage modifications that promote gender-sensitive medical care.10,11 Additionally, girls in Israel are much less prone to be recommended by their doctor on points akin to diet, smoking, alcohol, or weight than girls within the US, even when recognized as excessive danger.12
Heart facilities for ladies (HCW) had been created to handle these disparities, offering intercourse and gender-specific cardiovascular care.13,14 Despite the growing prevalence of HCWs, there’s little knowledge assessing the affected person’s perspective on this gender-specific methodology of well being care supply.15 Given that randomization is much less possible in well being care supply and complicated scientific care settings, qualitative strategies could present the perfect method to understanding and evaluating these questions. Investigating sufferers’ views of a women-centered HCW can inform the design of different HCWs in addition to medical facilities concentrating on varied girls’s well being points. The present paper goals to determine sufferers’ preferences and perceived profit to cardiovascular gender medication and an all-female workers in a HCW by qualitative interviews.
Methods
Setting
Heart Center for Women
The Linda Joy Pollin Cardiovascular Wellness Center for Women is a coronary heart middle for ladies in Jerusalem, Israel, primarily targeted on illness prevention. On first go to, sufferers had been evaluated by a feminine nurse, nutritionist, physiotherapist, psychologist and heart specialist. Patient circumstances had been reviewed in a multidisciplinary assembly, offering sufferers with a abstract and proposals. Follow-up appointments had been scheduled in accordance with scientific indications. Inclusion standards consisted of experiencing a cardiovascular occasion (eg, myocardial infarction, percutaneous coronary intervention, or stroke), having an energetic cardiac symptom (eg, chest ache or arrhythmia) or three or extra danger components (eg, diabetes, hypertension, hyperlipidemia, peripheral artery illness, smoking, household historical past of coronary illness, gestational diabetes, pregnancy-induced hypertension/pre-eclampsia, or weight problems). Exclusion standards consisted of being pregnant, having kind 1 diabetes with insulin adjustment, a psychiatric prognosis that precluded participation, dementia, or receiving care from one other multidisciplinary clinic.
Sample
At the time of information assortment, 363 sufferers had been seen on the clinic, aged 21–91, 93.5% of whom had been self-referred. Qualitative knowledge had been collected in two waves: (1) Patients who attended the clinic between January 2016-December 2017 had been referred to as in a random sequence to acquire consent till saturation was reached within the qualitative interviews. Thirty-one girls consented and 25 finally had been interviewed. (2) In order to deepen insights on the gender-focus of the clinic, extra interviews had been carried out with a modified interview information. Patients who attended the clinic between May 2019-January 2020 had been referred to as in a random sequence to acquire consent till saturation was reached. Of the 20 who consented, 17 finally had been interviewed.
Data Collection
This knowledge had been collected as half of a bigger clinic analysis; the present evaluation targeted on motivation to take part and perceived advantages of attendance solely. Data had been collected over two waves. The first wave included 25 semi-structured interviews carried out by telephone utilizing an interview information. Questions had been based mostly on earlier analysis,16 addressing affected person expertise reasonably than satisfaction, to keep away from optimistic bias.17 Wave 1 interviews didn’t ask immediately about gender with a purpose to receive unprompted perceptions relating to this facet of care. Questions in wave 1 and wave 2 had been similar aside from 3 objects, which had been added following the preliminary evaluation of wave 1 knowledge. These objects relate on to motivation for attending this HCW in addition to gener-related elements of care. See Supplement 1 for the total interview questions. The second wave included 17 interviews, bringing the full variety of interviews to 42. Interviews had been audio recorded and transcribed verbatim.
Data Analysis
Qualitative knowledge had been analyzed manually utilizing the six phases of Braun and Clarke’s thematic evaluation18 and following Nowell et al’s standards19 to realize trustworthiness. Our full evaluation included three phases (See Table 1). Phase implementation for every stage are detailed as follows:
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Table 1 Three Stages of the Full Analysis |
Stage 1
During the first stage, the initial 25 interviews (wave 1) were analyzed following the first 4 phases of Braun and Clarke. Phase 1 and 2 were done by AF and research assistants and was reviewed by TR, who worked separately, sharing insights until consensus of a code book was reached. First, transcribed interviews were read several times to get familiar with the data and to search for possible meanings and patterns. Ideas were marked for coding in subsequent phases. The second phase involved the production of initial codes from the data. Phase 3 was led by AF and completed with TR and EL. Different codes were sorted into potential patterns (themes) and all relevant coded data extracts were coded within the identified themes and sub-themes. Phase 4 was done by AF and reviewed by DZ.
Stage 2
The second stage included both the initial 25 interviews (wave 1) and the additional 17 interviews (wave 2). During this stage, all 42 interviews were analyzed as one data set following Braun and Clarkes’ phase 1–6. Phase 1 and 2 were done by AF and reviewed independently by EL, sharing insights until consensus of a code book was reached. Transcribed interviews were initially read several times to establish familiarity with the data and then to search for possible meanings and patterns. During the second phase, initial codes were produced. Phase 3 was completed by AF. Codes were sorted into potential patterns (themes) and all relevant coded data extracts were coded within the identified themes and sub-themes. Phase 4 was completed by AF and reviewed by DZ. Phases 5 and 6 were completed by AF and EL, with the final report reviewed by DZ.
Stage 3
During stage 3, we looked exclusively at the themes of motivation to participate and perceived benefits of attendance and detailed all of the relevant coding (phases 5–6). These phases were done by AF and EL. Phase 5 entailed defining themes and sub-themes by detecting the story that each theme tells and considering how it fits into the broader context of our data. In the final phase, examples that best captured the essence of each of the themes were chosen. The final report (phase 6) was reviewed by DZ.
Ethical Considerations
Human subject approval was obtained from the hospital IRB, the Helsinki Committee of Hadassah Medical Organization (Hadassah University Medical Center, Study # HMO- 0094-15). This study complies with the Declaration of Helsinki. All participants provided informed consent, which included publication of anonymized responses. For anonymity, patients were encoded A1-A25 (first phase) and B1–B17 (second phase). Given the sensitive nature of the data collected, requests to access the dataset from qualified researchers trained in human subject confidentiality protocols may be sent to DZ.
Results
Demographic descriptors of the participants are presented in Table 2. Final thematic map of the interviews and detailed map of the stage 3 evaluation are offered in Figures 1 and 2, respectively. The themes recognized in stage 3 included: (1) motivators for attending a coronary heart middle for ladies and (2) perceived good thing about a coronary heart middle for ladies.
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Table 2 Clinic and sample Demographics, Presenting Complaints, and Risk Factors |
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Figure 1 Final thematic map of interviews. |
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Figure 2 Visual representation of stage 3 analysis. |
Motivators for Attending a Heart Center for Women
Participants did not identify the women-centered aspects of the HCW as motivating factors for attending the clinic. This was consistent in wave 1 and even in wave 2, where participants were directly asked if the gender aspects influenced their decision to attend the clinic.
No, no I did not [come to the clinic because it is for women specifically]. Even though I think … you probably also need to check women … I don’t like the differentiation of men and women, gender … [B17]
I didn’t even think about it [the fact that it is a clinic specifically for women] at all. [B14]
It [The fact that the clinic is specifically for women] was completely not a factor [in my decision to come]. [B4]
A few participants stated that they did not even realize that it was a women’s heart clinic.
I did not notice if it was for men or women … [B1]
While the gender aspects of the HCW were not motivating factors to their attendance, participants did state that they came to the HCW out of fear for their own health or following a personal cardiovascular problem.
I got scared one night. I had very strong chest pains. I immediately thought of the heart, but the doctor told me it was reflux. I was not satisfied with that [answer]. I wanted to stop it right away. [B9]
I want to see if the risk of heart disease at the moment is really high for me. It’s very important to me. I need to see what else can help to prevent another attack. [A17]
Participants also reported making an appointment at the HCW after a family member or friend experienced a concerning cardiovascular event.
I have a good friend that had … a heart attack at a relatively young age. And she goes to this clinic. [B2]
Participants stated that they were looking for a place that would address their concerns related to heart health.
Really, I wanted to have an immediate address … here I found an address for the heart issues. [B4]
I came voluntarily … following a workshop that gave a lecture … it was important for me to check my heart. [A25]
Perceived Benefit of a Heart Center for Women
Participants stated that, as a gender medicine clinic, the HCW addressed the differences between men and women related to symptoms and treatment, which many first learned about during their visit.
I was told that a woman’s symptoms are not the same as a man’s … They told me the risks that exist. [A25]
… when I heard about it [that the clinic focuses on a woman’s heart], then I said: ‘why a woman’s heart, and not a heart in general?’ So they [the staff] told me that many times the symptoms of heart disease for women are a little different from men, and a lot of doctors have a tendency to think that if you do not have these symptoms of men, then you probably have no heart problem. [B12]
Participants indicated that the all-female aspect of the HCW was a valuable part of their experience at the HCW.
But it was nice when I came … It was nicer for me that they were all women, yes. [B4]
Yes, I think it’s an advantage that everyone is a woman … [B9]
Participants said that the all-female staff made them feel more comfortable; it created a pleasant atmosphere, they had a common language with the staff, and they felt cared for and understood.
Women understand women better- not just the disease but the experience. Going through menopause, she understands what it means, what it does to the body, to mood – to the entire woman. [B9])
Women, their heads work differently, its more comfortable, more pleasant … It’s easier for them to understand, easier to understand lifestyle, there is much more shared … no matter the age, religious or not religious, these things are easier to bridge the moment that there is a shared foundation [of being a woman]. [B3]
It was more pleasant; the whole approach is different with men. It’s a different world … the fact that everyone is a woman and professional and kind and they all truly make you feel like they care about you, giving personal attention … very different. [B6]
Some participants reported benefits that were not directly related to attending a women-centered clinic specifically, but that may not be addressed in a standard clinic. This included personalized treatment, holistic care, and multi-disciplinary treatment all under one roof, in one day.
The treatment is personal, you get the full attention, which does not happen in other clinics that … you are one of many and here you feel really … like the only child. [B14]
I felt that someone was really looking at all the parameters, and all the things, to understand my condition … [B2]
The approach there is holistic. They don’t just look at the symptom … they look at the person as a whole and not as a specific point problem. [B8]
I met with a series of experts, a nurse, a doctor, a nutritionist, with a physical therapist. It was [a] long [day], but it was worth it. [A18]
And every field was … another area of the whole topic … nutrition … exercise … even psychological. And then the doctor who took all the data and analyzed it along with me. [A5]
A few participants mentioned that their visit at the HCW had a positive impact on their knowledge, health, and health behaviors.
I felt it contributed to my awareness of heart health … and to pay attention to the signs of … [when] something is wrong …. They gave [me] guidance. [B10]
As for the physical activity … I was given all sorts of tips … They told me the risks that exist … Fats or physical inactivity … that can cause all kinds of problems in the future. It was important to me. [A25]
I did change my lifestyle with a lower carbohydrate diet, I do more sports … Let’s say I’m a happier woman … I feel it both in body and mind. [B4]
I don’t think it’s an exaggeration to say that you really saved my life because until I visited the clinic, I didn’t know that I had any problem with high blood pressure. [A2]
Discussion
HCWs have been proposed as part of a comprehensive policy for addressing gender equity in women’s cardiovascular care.14,20 The present examine used qualitative strategies to discover the affected person perspective at an all-female HCW with a purpose to perceive the perceived good thing about women-centered care, together with cardiovascular gender medication and a single-sex well being care supply setting. The girls in our examine didn’t search care at this HCW with a purpose to receive women-centered care; they had been motivated solely by worry and concern for his or her well being. While these elements of care didn’t encourage attendance, the ladies did report added advantages of elevated consciousness of coronary heart illness in girls, improved well being, and habits modifications, in addition to the optimistic interpersonal and emotional good thing about an all-female workers. Women didn’t spontaneously determine these advantages, nevertheless; they had been solely recognized upon subsequent focused inquiry, on reflection. To our data, that is the primary report of a qualitative evaluation of sufferers who search care in a HCW setting.
Single-Sex Aspect
Our findings point out that ladies didn’t particularly search an all-female facility. This was obvious by each oblique and direct questioning about motivation for attending the clinic. It is feasible that ladies favor same-sex medical look after extra intimate and uniquely feminine care, akin to gynecology or breast well being,21,22 reasonably than cardiology. While girls in our examine didn’t search women-centered care, they did respect elements of care that they attributed to the female-to-female interplay: feeling comfy, being understood and cared for, personalised care, and consideration of their expertise and life-style. Women additionally said that they benefitted from the clinic’s whole-person remedy.
It has been argued that women-specific companies necessitate going past the all-female atmosphere, offering care that’s considerably completely different than conventional care.23,24 The care attributes talked about by the ladies on this examine fall underneath “person-centered care”, an method to medication that includes 5 dimensions, particularly: holistic care, attendance to sufferers’ beliefs and values, genuine engagement, shared choice making, and sympathetic presence.25 Providing person-directed care, nevertheless, shouldn’t be restricted to feminine suppliers. As mirrored in our examine, girls report that skilled and private components are extra vital than gender of their medical supplier choice.22,26 Similarly, a examine of an all-female cardiac rehabilitation program discovered that workers members’ consideration to sufferers’ private well being issues (and peer help) facilitated participation.27 Research finds that patient-centered communication expertise reasonably than doctor’s gender influences affected person satisfaction and compliance.28 While not solely female-provided, analysis means that feminine physicians usually tend to interact on this patient-oriented type of communication, significantly with feminine sufferers.29–31
Gender Medicine Aspects
Participants reported receiving sex-specific cardiovascular data, which they might not have obtained in an ordinary multidisciplinary clinic. Women, specifically younger girls, cite the shortage of perceived private danger as a barrier to performing cardiovascular health-promoting behaviors.32,33 Education and elevated consciousness of each the medical and non-medical intercourse and gender-based cardiovascular danger components, akin to socioeconomic and caregiver standing, the long-term impression of abuse in addition to polycystic ovary syndrome, gestational diabetes, and so on., could facilitate extra correct evaluation of private danger and subsequent well being behaviors.34
Limitations of this examine embrace its use of a single HCW; nevertheless, saturation was reached within the interviews. Additionally, on condition that examine individuals proceed to obtain clinic service, this will scale back their probability to offer crucial responses. Similarly, these with detrimental opinions could also be extra prone to refuse participation. The majority of individuals had been self-referred; findings could not generalize to sufferers who’re referred to a HCW by a medical skilled. This, nevertheless, will increase the probability of figuring out affected person motivators.
Conclusion
While they didn’t actively search women-centered care, the ladies on this examine subsequently reported academic, well being, and care provision advantages to their HCW attendance. They significantly appreciated elements of person-centered care, particularly holistic remedy, feeling understood, consideration of their expertise and life-style, in addition to receiving private consideration and concern. These findings could inform each the design and analysis of medical care services that purpose to handle the gender disparities in cardiovascular well being and different medical specialties.
Acknowledgments
We wish to thank the analysis assistants who had been nursing college students on the Jerusalem College of Technology for his or her important assist. We additionally want to thank the ladies individuals for his or her time and insights. The examine was funded by a personal grant from the Pollin Family Foundation.
Disclosure
The authors report no conflicts of curiosity on this work.
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