Socioeconomic variations in responses to chest pain: qualitative study

Perceived vulnerability to heart disease

Respondents from the deprived area reported feeling more vulnerable to heart disease than those from the affluent area. This greater perceived vulnerability related to their strong family histories and greater sense of identification with high risk groups and stereotypes of cardiac patients; they were more likely to have vivid memories of witnessing angina and deaths from heart disease in young relatives. For example, R38 (male, 65, D) explained that two of his brothers and two nephews had angina; he communicated a sense of resignation to having heart disease by saying: “The whole lot of us have had angina.” R44 (male, 57, D) reported that his father had died of heart disease at the age of 48 and that six paternal uncles had died of heart disease before the age of 60. He felt sure that his strong family history meant that he would die of heart disease. When asked why he thought he was having a heart attack, he said: “Well, wi' this runnin' in the family, it's always on the mind, you know, that if I'm gonnae die—it's gonnae be a heart attack, know? I don't think of myself dyin' wi' anythin' else.”

The sense of vulnerability felt by the deprived respondents was often accentuated by their identification with the dominant “red and bloated” cardiac stereotype and with social groups and geographical areas associated with high risk: “I just know the research. The east end ae Glasgow is where the heart attacks are more prominent than any other part of the west of Scotland; the west side ae Scotland is most prominent in the heart attacks than any place else in the British Isles. If you are looking for a candidate for a heart attack, you've come tae the right area” (R34, male, 61, D).

In contrast, respondents from the affluent area were more likely to deny a family history of heart disease. Others presented their family histories as discrete and isolated events or reported a belief that their positive family history could be “cancelled out” by leading a healthy lifestyle. They also distanced themselves from cardiac stereotypes by speaking about them in the third person: “They'd probably be overweight. Smokes and drinks too much probably. Eats the wrong things or too well. Somebody who doesn't do an awful lot of exercise” (R30, female, 47, A).

Even though respondents from the deprived area expressed a greater sense of vulnerability than the affluent respondents, they were no more likely to report presenting with chest pain. Their illness behaviour was modified by their experience of illness and their expectations of health care.

Experience of illness

Forty four respondents made a clear general statement about their health. Of these, 21 stated that their health was good, 7 judged their health to be moderate, and 16 said that their health was poor. Of the 16 people with poor perceived health, 12 were from the deprived area; of the 21 people with good perceived health, 15 were from the affluent area. As well as often reporting poor health: “It [health] is knackered (laughs), really, in a nutshell” (R32, male, 60, D), people from the deprived area often reported that their health was in decline:

HMR: “How do you feel about your health at the moment?”

R44 (male, 57, D): “At the moment (laughs) I feel I'm going down hill rapidly, you know.”

Respondents from the deprived area were also more likely to report other significant medical conditions and to have low expectations about longevity and ageing. R28 (female, 65, D) reported having diabetes, stroke, hypertension, and high cholesterol, and said laughingly: “You name it, I've got it, you know what I mean?” Another respondent (R23, female, 65, D) said: “Well, I've got thyroid trouble, a couple of collapsed vertebraes in the spine, I've had incontinence for a long time—I've had a lot of operations for that—and I've had osteoporosis.”

Yet another respondent (R43, male, 58, D), when asked about his health, said: “I'm gettin' a lot of pain in my chest for some unknown reason.”

HMR: “Are you?”

R43 (laughs): “Aye, but I think it's auld age.”

HMR: “How old are you?”

R43: “I'm fifty nine on the seventh. I dunno. I've seen a few of my mates goin' away [dying], aye they never reached this one. So, the boys are all congratulatin' me, thinkin' ‘At least he made it to auld age pension’ you know, ‘cause a lot of them didnae get there.”

Respondents reported three reasons for not presenting with chest pain that were related to perceived poor health. Firstly, they normalised their chest pain: “I just thought ‘Och, you've had to work long hours,’ you know, so I thought it was just tiredness, that's all” (R54, female, 56, D). Secondly, they were unable to distinguish chest pain from symptoms of other physical conditions, such as chest infections and heartburn: “It's hard tae say if you've got angina attack or the chest pains, ‘cause I get a lot of chest pains through infections, you know, an’ it's hard to determine one fae the other” (R31, male, 60, D); or they attributed it to “stress”: “I put it [chest pain] down to because of the rushin’ about, you know, workin' and shoppin' and you know all the different things, ‘cause it's quite strenuous looking after two teenage boys” (R48, female, 51, D). Thirdly, respondents with multiple health problems expressed concerns about overusing medical services:

R57 (female, 53, D): “I actually thought then ‘Is this the start of a heart attack? No, Jesus God, no,’ but I don't know, I just left it.”

HMR: “You didn't call your doctor then?”

R57: “No, because at that particular point I thought I was goin' tae the doctor far too much an' I don't know why, I think sometimes the doctor thinks you're playin' on it. And then I say, no I'll leave it just to see, ‘cause I'm not one for actually bothering the doctor.”

Past experience and future expectations of health care

In both geographical areas, perceived quality of interactions with the general practitioner and future expectations of health care shaped illness behaviour. Respondents from the deprived area were more likely to report negative experiences of health care and to have lower expectations of health care. The quality of interactions was determined by the degree of social alignment between the doctor and the respondent, the degree to which knowledge about health was shared in the consultation, and the extent to which respondents felt at fault for their health problems.

None of the respondents from the socially deprived area was personally connected with the medical profession, but 10 affluent respondents stated that they or their spouse worked in medical or allied professions. Affluent respondents were also more likely to report friendships with doctors and privileged access to health care. For example, R11 (male, 58, A), who was under pressure to get back to work, reported that his general practitioner arranged a cardiology appointment that afternoon by fax. He then said:

R11: “I went up [to the hospital]. They put me on the jogging machine etcetera, they did the ECG, they did an angiograph, and they told me there and then that it was all negative. Then they sent me for a head scan, negative, everything negative.”

HMR: “Why did you have a head scan?”

R11: “Just as a precautionary measure.”

In the deprived area, several respondents reported difficulty accessing health services. For example, R54 (female, 56, D), who has laryngeal carcinoma, had presented many times before being referred:

HMR: “How long had you had the sore throat before you went to your doctor?”

R54: “I'd been goin' to him on and off for about two years and complainin' an' just gettin' cough bottles and antibiotics and, of course, everything they blame on smoking.”

The extent to which knowledge was shared also varied with socioeconomic status. The more affluent respondents reported greater formal medical knowledge and more extensive sharing of knowledge with their general practitioner: “We [himself and the general practitioner] always sit and have a chat and he says ‘Oh I read this interesting paper in the Lancet the other day and it says ‘da-da-da’ “(R13, male, 47, A). In contrast, people from the deprived area often felt that they were not given adequate information: “They [doctors] just say ‘you have to do this, you have to do that’ and that's it. I'm a question asker, and they don't like me asking questions” (R53, female, 62, D).

The issue of blame was discussed by respondents from both areas. Heart disease was linked to risk behaviours and to negative personality traits such as selfishness: “not thinkin' ae other people before yourself” (R48, female, 51, D); weakness: “people that drink or weaklings” (R28, female, 65, D); and laziness: “I think if you were a sort of lazy layabout and suddenly got up and asked the heart to do all these things you might have problems” (R49, female, 51, D). However, deprived respondents were more likely to report being personally involved in risk behaviours and to feel at fault for their chest pain: “You only get what you deserve. The books tell you that, and the telly and the papers tell you that” (R34, male, 61, D). R56 (female, 64, D) said: “I have gave my body one leathering, you know, and it's reacted, I mean it, like everything else, they say the worm turns. My body's turning. It's just saying, you've abused me, now I'll abuse you.”

Many of the deprived respondents believed that their general practitioner would blame them for their health problems. For example, when asked whether he had consulted his general practitioner about his chest pain, R41 (male, 53, D) said: “No, they just tell you tae give up smokin', that's aw.”

Respondents who believed that they led a healthy lifestyle (mainly from the affluent area) rarely considered themselves to be to blame for their chest pain. Indeed, some reported feeling cheated that, despite believing that they had led a healthy life, they had heart disease: “It niggles me I have to admit—if you look at me I'm skinny and I don't smoke and I'm fairly active, and why the hell should I get a cardiac disorder?” (R15, male, 57, A).