Illness attributions and myocardial infarction: the influence of gender and socio-economic circumstances on illness beliefs

ISSUES AND INNOVATIONS IN NURSING PRACTICE

Illness attributions and myocardial infarction: the in¯uence of gender

and socio-economic circumstances on illness beliefs

Rosemary King BA MA RN RM

Project Of®cer, Department of Human Services, Ballarat University, Victoria, Australia, and Clinical Nurse Specialist,

Women's Health Unit, St John of God Hospital, Ballarat, Victoria, Australia

Submitted for publication 17 April 2001

Accepted for publication 28 November 2001

Introduction

Chronic diseases such as cardiovascular disease and neo-

plasms now account for a signi®cant proportion of premature

mortality and morbidity in industrialized countries. Research

into myocardial infarction has yielded valuable insights into

its biomedical and psychosocial aspects. However, both in

Australia and elsewhere there has been little research on the

experiential dimension of suffering a heart attack, probably

one of the most dramatic and abrupt threats to life and

livelihood.

Patterns of disease are changing and infectious epidemics,

which previously in¯icted high mortality rates are now

replaced by long-term degenerative disease. Most people

now live longer, with a rising proportion of the disease

experienced as ongoing chronic illness. An appreciation of

the lived experiences and priorities of victims of coronary

artery disease and myocardial infarction will facilitate the

provision of appropriate information and interventions

targeted towards those most at risk.

In Australia, cardiovascular disease accounts for 42% of all

deaths and contributes to much additional illness and

disability. Myocardial infarction accounted for 55% of all

of these cardiovascular deaths [Commonwealth Department

of Health and Australian Institute of Health and Welfare

(CDH & AIHW 1999)]. The annual incidence of coronary

Ó 2002 Blackwell Science Ltd 431

Correspondence:

Rosemary King,

313 Neil St,

Ballarat,

Victoria 3350,

Australia.

E-mail: [email protected]

K I N GK I N G R . ( 2 0 0 2 )R . ( 20 0 2 ) Journal of Advanced Nursing 37(5), 431±438

Illness attributions and myocardial infarction: the in¯uence of gender and

socio-economic circumstances on illness beliefs

Aim. To present ®ndings from a study conducted between 1996 and 1998 to

investigate participants' perceptions of illness causation following a myocardial

infarction.

Rationale. The underlying assumption of many practitioners is that perceptions of

illness causation will in¯uence emotions and adjustment to illness.

Design. Phenomenology was the research methodology used to examine percep-

tions of illness causation. A convenience sample was taken of 24 men and women

who were admitted to a regional hospital in Victoria, Australia, with a provisional

diagnosis of myocardial infarction. Participants were interviewed shortly after

hospitalization, and interviews were taped, transcribed and thematically analysed.

Findings. Stress was the most commonly cited cause of illness. Men and women

demonstrated distinct differences in illness attribution. Participants who verbalized

concerns about their loss of autonomy and their subsequent ability for self-

management were predominantly female and uniformly members of the lowest

socio-economic group.

Conclusion. The article concludes with a discussion of implications of the ®ndings

for practice.

Keywords: myocardial infarction, illness attributions, stress, self-ef®cacy, gender,

socio-economic status

events in Australia is estimated at 421 per 100 000 among

males aged 35±69 women of the same age. In about one in

four the ®rst clinical presentation is fatal (CDH & AIHW

1999). Those groups most at risk are indigenous Australians

and people belonging to the most socio-economically disad-

vantaged group. Both these groups die at twice the rate of

other Australians (CDH & AIHW 1999).

Patterns of presentation, treatment and outcomes vary

between men and women (Jackson 1994, Bloom 1995,

Mckinlay 1995). Women with coronary artery disease can

present with different symptoms to men, and sometimes these

symptoms are atypical, particularly in younger women

(Jackson 1994). Myocardial infarction is managed less

aggressively in women (Bloom 1995, Mckinlay 1995).

Women are more likely to have a severe heart attack and

have a higher mortality rate from myocardial infarctions

(Clarke et al. 1994). Generally, both women and medical

practitioners demonstrate a lack of awareness of the risk of

myocardial infarction among women (Jackson 1994).

Literature review

The biomedical model operates with an ontological dualism

between the mind and the physical body, which separates the

disease processes from both the experiential or phenomeno-

logical processes of illness and its social context. These social

and phenomenological processes are a fundamental in¯uence

in the experience of and adjustment to illness and are

particularly relevant in the context of the changing patterns

of illness in western societies.

Theories of the embodiment of illness explore meaning and

the phenomenological dimensions of perception and identity.

Personal meanings of illness are a re¯ection of individual,

social and political circumstances. Turner (1992) suggests

that there are three senses in which we speak of a phenom-

enology of the body.

In the ®rst sense, we have a body which becomes the

subject of scrutiny by ourselves and others. Secondly, we are

also embodied in that our daily lives and spontaneous

behaviour are involuntary and unconscious. In this sense,

we are our body and we possess an embodied intelligence. In

the third sense our body is a product, a collection of practices,

bodily techniques over which we have mastery. The body in

this sense is a re¯ection of cultivated disciplines learned from

our culture, and in¯uenced by our gender, age and social

status (Turner 1992). Phenomenological perspectives on the

body confer legitimacy on embodiment as a unique form of

knowing or intuition (DiGiacomo 1992).

Kleinman a psychiatrist and anthropologist was the ®rst to

introduce the notion of narratives of illness (Kleinman 1988).

As Kleinman noted, the biomedical dualism between the

body and mind and the emphasis on elimination of symptoms

and disease (as opposed to management of symptoms)

restricts and inhibits the potential for psychosocial thera-

peutic interventions that can facilitate adjustment to chronic

disease (Kleinman 1988). These theoretical models of

phenomenology and narratives of meaning inform the

research approach.

A number of studies of illness beliefs and myocardial

infarction have been published in the United Kingdom (UK),

New Zealand and United States of America (USA). Two

studies in the UK were largely undertaken in order to

ascertain the level of public awareness of acknowledged risk

factors such as elevated serum cholesterol and smoking. Both

found that the majority of respondents nominated stress or

worry as the most important cause of myocardial infarction

(Murray 1989, Greenwood et al. 1994).

A further study in the UK involved 137 patients (105 male

and 32 female) recently admitted to hospital with myocardial

infarction (Cooper et al. 1999). This aimed to determine if

illness beliefs were predictive of attendance at rehabilitation.

It found that, in addition to being older, less aware of

cholesterol values and more likely to be unemployed, non-

attenders were less likely to believe that their condition was

controllable and that their lifestyle may have contributed to

the illness. Gender and socio-economic status were not

variables used to differentiate beliefs or behaviours (Cooper

et al. 1999).

A small study in New Zealand looked at the role of

patients' views of their illness with respect to predicting

return to work and other social roles (Petrie & Weinman

1996). The results showed that attendance at rehabilitation

was signi®cantly related to a stronger belief on admission that

the disease could be controlled or cured. In addition, those

who believed a myocardial infarction to have grave conse-

quences for their health reported more disability on follow-up

(Petrie & Weinman 1996). The authors conclude that illness

beliefs or perceptions are important determinants of recovery

from myocardial infarction.

People studying illness beliefs about myocardial infarction

in the USA have also been interested in the connection

between meanings of illness, perceptions of personal control

and ongoing adjustment to that illness. While Koslowsky

et al. (1978) did not establish any correlation between

personal illness attributions and behavioural change, two

other studies identi®ed stress as the most commonly cited

cause of myocardial infarction.

Af¯eck et al. (1987) conducted an 8-year study of causal

attribution, perceived bene®ts and morbidity, involving 287

men interviewed 8 weeks after their ®rst heart attack.

R. King

432 Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(5), 431±438

Participants who nominated stress were implicated in higher

morbidity following a heart attack. Another American study,

conducted by Low et al. (1992), examined women's illness

beliefs and ongoing morbidity and mortality. Women in the

study cited stress as the most common factor, while personal

behaviours such as smoking were infrequently mentioned.

The authors concluded that perceptions of control over the

disease affected compliance with treatment.

Two main differences between male and female attribution

patterns were noted over the three North American studies.

Women nominated personal behaviours infrequently and

were less likely to modify their lifestyle behaviours. In

addition, women commonly blamed marital problems or

personal relationships for their illness (Low et al. 1992). Men

were more likely to blame work and personal behaviours

(Koslowsky et al. 1978, Af¯eck et al. 1987). The most

commonly cited cause of illness in all the studies was stress,

but none reported on variations between socio-economic

groups. Therefore, it was decided to carry out a study to

explore illness beliefs and attribution following myocardial

infarction which included the variables of gender and socio-

economic status.

The study

Methodology

Phenomenology was the methodological approach used for

the study as it aims to enable understanding of the complex-

ities of individual experience and everyday lives, and places

intrinsic value upon the unique meanings of experience.

Phenomenology also proposes that individuals cannot be

understood unless we are aware of the context of their

environment; and that the manner in which people will

behave is based on their awareness and perception of the

phenomenon (Cluett & Bluff 2000).

Sample

Purposeful sampling permitted the selection of participants

whose experiences provided them with an understanding of

the phenomena of the experience of a myocardial infarction.

Twenty-four men and women (12 women and 12 men) were

recruited a few days after their admission to an Australian

rural public hospital with a provisional diagnosis of myocar-

dial infarction. The majority of participants were of low

socio-economic status, with 66% reporting an income of less

than $20 000 per annum. Women were generally poorer than

men, with only 20% reporting an income in excess of

$20 000 per annum. Fifty percent of respondents had

received an education to less than year 10, and women were

less educated than men. Women were generally older on

admission to hospital.

Selection included people who were admitted for the ®rst

or second time with a provisional diagnosis of myocardial

infarction.

Ethical issues

The Hospital Ethics Committee gave approval for the

research. Participants were approached personally by the

researcher while recovering on a medical ward following

transfer from Intensive Care. They were given a day to think

about participation; if they chose to participate then written

consent was requested for the study.

Interviews were conducted in a private room and were

usually tape recorded with the participant's consent. Parti-

cipants were informed that they could withdraw from the

study at any time. Tapes were transcribed and transcrip-

tions shown to participants for veri®cation of accuracy of

the data. Participants were given the opportunity to change

or clarify what they had said. Transcripts were kept in a

locked drawer and pseudonyms were used to protect

con®dentiality.

Study limitations

Limitations included the small size of the sample, and its

cultural homogeneity; all members are Australian citizens of

Anglo-Saxon descent. They came from a small regional city

with a population of 85 000 or from its hinterland farming

community. This sample is re¯ective of the cultural grouping

where the study took place but is representative of this region

only.

Data collection methods

A combination of qualitative and quantitative information

was gathered from each participant's medical records, plus a

demographic questionnaire and interview. The demographic

questionnaire was necessary to ascertain educational level,

income and occupation of participants. This information was

not available from medical records. Interviews were semi-

structured, conducted in a private room on the ward, and

lasted about half to three-quarters of an hour. The questions

were open ended but prompts were used to de®ne boundaries

around the issues discussed. Examples of prompt questions

used include:

· Why did you get sick?

· Tell me about getting sick?

Issues and innovations in nursing practice Illness attributions and myocardial infarction

Ó 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 37(5), 431±438 433

· What have you learnt about the disease since being here in

Hospital?

· Has what you learnt helped you?

Data analysis

Demographic information such as age, gender, income, educa-

tion level and risk factor status was quantitative information

gained from both questionnaire and medical records. Each

participant's education level and income was used to evaluate

socio-economic status. This information was linked with the

themes that developed from the interviews. The interviews

were analysed as texts from which certain themes were

extracted using Colaizzi's method (Cluett & Bluff 2000).

Transcripts were analysed through identi®cation of sep-

arate meaningful segments. Segments were the smallest

sentence, or sentences, which conveyed meaningful dialogue

as a separate entity. These segments were allocated into

themes. As the themes were identi®ed it became possible to

build selection criteria for inclusion into each theme, and then

cross-reference the segments with these criteria. The data

were organized into three themes titled; `Getting help',

`Taking stock' and `Helpers', each theme had a number of

categories (see Table 1).

Findings

Getting help

The ®rst theme `Getting help', developed from participants'

ideas about the cause of illness and their responses to the

symptoms that they experienced. Categories developed in this

theme included: Ìmplication of symptoms'. This category

centred on the fact that a minority of participants had not

understood the importance or implications of their symptoms

at the onset of the event. For example:

I thought it was the coughing that was making my chest so sore. I

®nally went to the doctor to get something to stop the coughing.

(Female, aged 67)

Well I had a test, I don't know what sort of a test. One lady who was

doing the ultrasound said Òoooh you have already had a heart

attack.' I said `Not to my knowledge.' Then the doctor came in and

said Òoooh you have already had a heart attack.' I said `Not to my

knowledge.' I realized that something had happened that I had no

knowledge of. (Male, aged 73)

A second category was titled `Predisposing illness or event', a

third of participants believing that a predisposing event or

illness had caused the illness. These previous illnesses

included for one participant a prior diagnosis of arterioscler-

osis in the carotid arteries. For another participant it meant

previous surgery that he suspected may have thrown off a

clot, causing this present myocardial infarction. Predisposing

events cited by participants included being out in the cold

weather on a tractor all day in one case, and a fall with

possible loss of consciousness 2 weeks prior to the heart

attack, in another:

I really felt that it was the cold wind that played up with me, because

I've been on the tractor and the cold wind on my chest is what started

it off. (Male, aged 73)

Participants usually recognized more than one cause of

illness, and many cited some lifestyle factors such as exercise

and diet but stress was nominated by 17 participants. The

term `stress' was used in many contexts to suggest rigorous

physical work, worry, emotional and physical hardship. Both

men and women used the term stress, sometimes in similar

contexts, but there was a pattern of difference between male

and female attributions. Men tended to focus on work as the

main area of stress in their lives. Women were more inclined

to speak about stress in the context of personal relationships

and their own personality, describing themselves as being

prone to worry:

I have been so ®t, so healthy and active. and I have no idea; there is

no one in the family with this complaint, I really put a lot of it down

to stress¼I am a stressed sort of person so this is what I put it down

to. I am a worrier. (Female aged 64)

`Dissatisfaction with previous treatment' and `Family history'

were other categories identi®ed under the ®rst theme.

Taking stock

The second theme, `Taking stock' incorporated categories

relating to the potential signi®cance and adaption to the

Table 1 Themes and categories from qualitative analysis

Getting help Taking stock Helpers

Implications of symptoms Change through self management Perceptions of care given

Predisposing illness or event Threat of mortality/changing priorities Lack of care

Dissatisfaction with previous treatment Loss of autonomy and changes in body image The therapeutic relationship

Lifestyle factors/family history Connecting with others

R. King


illness. The second category of themes related to how

participants had adjusted to the diagnosis of a myocardial

infarction. One of the categories in this theme was `Change

through self management'.

Many of the participants, two-thirds of the men and half of

the women, identi®ed changes they would make to their

lifestyle:

Certainly a better diet, a more cholesterol-free diet. and I will be

taking medication to help me live a normal life without feeling too

much pain¼I've learnt I'm too young to be having this problem, and

I want to reach my goal of 80. (Male, aged 51)

For many the threat to their life had resulted in a renewed

appreciation of life. This theme was titled `Changing prior-

ities':

You wake up in the morning now and you don't care whether it's hot

or cold, wet or dry, you just say, Thank you Lord, it's another new

day. (Male, aged 73)

You should never look forward to holidays, rather you should live

each day as it comes, because when you get near to the end of it, it

isn't that long and you wonder where it has all gone. There's a lot of

pleasure in every day, reading a book, sitting on your bum. You don't

know what's going to happen, the ambulance arrives, the men are

working on you. You are unsure if this is it; in fact you are frightened

to ask if this is it. Because you don't want to know. (Male, aged 72)

Diminished autonomy and a lack of self-ef®cacy was another

category identi®ed by the researcher. This group was mainly

female and uniformly from the lowest socio-economic group:

I know that I can only have one life. I ®gure I have 5 or 6 years

and I reckon that I have to ®t in as much as I can. It's not a cure, it's

only a bypass, it won't last forever. I'm trying to ®t more in but it's

hard to change old routines. I know I should go out more, do more

things. (Female, aged 65)

Helpers

The third theme, titled `Helpers' encompassed categories

relating to participants' perceptions of the care and help given

to them while they were ill. The ®rst category included the

care given by health professionals, paramedical, medical and

nursing staff. This category encompassed participants'

experiences of the initial contact and treatment by ambulance

through to admission to Coronary Care and then subsequent

transfer to the medical wards; it was titled `Perceptions of

care given'.

Relationships with the medical, nursing and paramedical

staff were both positive and negative. Generally, staff were

cited by half the participants as being very important to them.

Those staff members who gave care during the acute and

volatile episode of illness were cited most frequently.

In the Coronary Care Unit (CCU), one girl was pretty good. Pretty

dedicated, she was very good and there all the time. It relaxed you,

made you feel, if you think in your mind: they are good, you feel

secure. Couldn't speak highly enough of the nursing staff and the way

they gave you care. If you were sick in the night they were there to

help you. (Male, aged 58)

The paramedics were terri®c. A young doctor in CCU was excellent

from an emotional point of view. It was very encouraging. Its hard to

rationalizebutyouneedsomeoneto inspirecon®dence inanemergency.

He looked after my wife too. Others can scare you. (Male, aged 68)

These transcripts identify the vulnerability that participants'

experienced in the acute phase of illness, their desire to

relinquish control to the hands of experts, and their appreci-

ation when this occurred in such a way as to instill con®dence.

Not all participants were happy with the care they

received. A ®fth of participants' commented on lack of care

or complacency from staff:

The staff are too complacent. The younger ones aren't as committed

as they used to be. Doctors and nurses bury their own mistakes.

(Female, aged 64)

A quarter of participants' commented on what was important

to them in a relationship with health professionals. Trust was

important, some participants' discussed aspects that helped

create trust. Respondents noted that they felt more con®dence

in the treatment they were getting, and in their own self-

management if health care workers took more of an interest

in them:

I have a family doctor, she is very kind and listens to you, and that is

very important from a patient's point of view. That the doctor listens

to what you say. And of course we are not always right in our way of

thinking, but if we can become a little more con®dent in what we are

thinking we would do a lot better. (Female, aged 62)

Its very important in nursing interactions that they call you by the

name you want, and that you can call them a name. Means that there

is something personal, that you are not just a thing in a bed. It's nice

when nurses take a little bit of time to chat, share part of what they

are as a person. (Female, aged 40)

Trust was expressed in terms of the quality of communication

and the importance of personalized care.

Discussion

Participants cited stress as the most common cause of their

illness. This corresponds with previous research on illness



attributions and myocardial infarction (Koslowsky et al.

1978, Af¯eck et al. 1987, Murray 1989, Low et al. 1992,

Greenwood et al. 1994). Stress has many meanings, which

include the scienti®cally quanti®able physiological `stress

response' that is measured by cardiopulmonary and endocrine

activity (Selye 1975). Stress and cardiac disease have a long

historical association. Corvisart, a physician, is reported to

have ®rst described the relationship between physiological

stress and myocardial infarction in 1812. He noted that

cardiac disease depended upon `the passions of man', and that

extreme physical exertion and powerful emotions such as fear,

anger and despair could injure the heart (Selye 1975, p. 776).

More recently, personality type has been linked with the

incidence of myocardial infarction. In the 1950s two cardi-

ologists, Friedman and Rosenman (1957) described the

coronary prone `Type A' personality. High levels of compet-

itiveness, aggression, time urgency and a preoccupation with

deadlines characterize this personality.

Stress was described by participants' in a number of

contexts that included a speci®c troubling or dif®cult event,

grief and loss, hard work and worry.

The present study suggested that men and women displayed

distinctly different patterns of beliefs about illness attribution.

While both men and women cited stress as a common factor,

men emphasized stressors at work while women focused on

dif®cult relationships. Men were also more likely to nominate

behavioural or lifestyle factors as important factors in the

illness onset. Women were less likely to nominate smoking or

other factors such as diet and exercise as in¯uential. These

different patterns of illness attribution have also been noted in

other studies of illness attribution and myocardial infarction

(Koslowsky et al. 1978, Low et al. 1992).

Links with educational levels, income, and gender were

made with all the themes identi®ed. Participants from the

lowest socio-economic group, who were also predominantly

female, were those who identi®ed diminished autonomy and

self-ef®cacy as being a concern following the myocardial

infarction. Both gender and socio-economic status indicate

distinct patterns of perception and understanding following

this illness episode.

Gender differences in anxiety levels, perceptions of self-

ef®cacy, activity tolerance and adherence to medical advice

were noted in a North American study of gender behaviour

and cardiac rehabilitation. Men were considerably more able

to tolerate exercise and other activities of living, whilst

women were more anxious and perceived themselves as

having considerable less self-ef®cacy in enduring exercise and

other daily living skills (McHugh Schuster & Waldron 1990).

It is well-recognized that low socio-economic status is a

considerable risk factor in illness morbidity and mortality. In

Australia, premature death is twice as common among those

categorized as belonging to low socio-economic groups

(Germov 1998). Powles and Salzberg (1989) suggest that job

autonomy is an important determinant in promoting general

capacities for self-management. They found that ìn all cases

job affects man more than man affects job' (Powles &

Salzberg 1989, p. 154). The present ®ndings are consistent

with other job socialization theories that suggest that

working life shapes beliefs, values and a sense of compet-

ence:

If we grant that work experience can induce such long-term effects or

adaptations, it is a small step to conclude that the differential

development of a capacity for self management at work will carry

over to a differential capacity for managing one's own health.

(Powles & Salzberg 1989, p. 155)

People in low socio-economic groups experience more

premature mortality or earlier morbidity, and there are many

structural and behavioural factors that may in¯uence this

situation. These include educational levels, consumption

patterns, failure to intervene earlier in the disease process,

hazardous work conditions and perceptions of self-ef®cacy

and self-management. Perceptions of autonomy and self-

ef®cacy may well be internalizations that are closely related

to income, gender and occupation. The author suggests that

perceptions of self-ef®cacy are important factors in ongoing

behavioural and personal adaptation to the adversity of

chronic illness.

The study of illness attribution and recovery from myocar-

dial infarction conducted in New Zealand (Petrie &

Weinman 1996) also demonstrated a strong link between

patients' perceptions of the illness, participation in rehabil-

itation, return to work and long-term disability. The authors

found that illness perceptions were strongly in¯uential in

predicting recovery and rehabilitation, and conclude that in

order to optimize cardiac rehabilitation it is important to

identify illness perceptions in the early stages of the disease.

Thus perceptions of illness and self-ef®cacy may be predictive

of long-term recovery.

In the earlier theoretical discussion of perception and

identity, Turner's (1992) model of phenomenology was

described as having three dimensions of embodiment. One

of these is the collection of practices, bodily techniques and

cultivated disciplines that re¯ect the in¯uence of culture,

gender and socio-economic status. Perceptions and meanings

of embodiment confer a uniquely individual, intuitive

knowing directly related to cultural, social and gender

af®liations. Meaning culture, gender and socio-economic

status are factors that in¯uence an individual's perceptions

and understandings of disease processes.

R. King


Implications for nursing practice

It is important to establish an understanding of the beliefs

that surround an individual's illness experience. This enables

the patient to tell their story and in doing so they begin to

contribute to and become involved in the management of

their illness. For many this will form the basis of a trusting

relationship between patient and nurse. The illness story will

identify key issues of concern for the patient.

Kleinman (1988) has noted the value of illness narratives as

a mechanism that provides a window of opportunity for the

implementation of psychosocial interventions aimed at faci-

litating adjustment to chronic disease. Participants have

noted that listening and treating the person as an individual

begins the process of building a trusting relationship between

health professional and patient. Nursing interventions may

be as simple as dispelling myths about the illness and

identifying and ®lling speci®c knowledge gaps. For example,

many people in this study were unaware of the signi®cance of

a family history of myocardial infarction and cardiovascular

disease. Evidence from the interviews suggested that other

family members were more willing to adopt lifestyle

changes when they were aware of the familial risk of the

disease.

Developing illness narratives provides an opportunity for

nurses to identify areas where people are feeling more or less

disempowered. These areas can be targeted and developed

with an emphasis on education and creative strategies for

empowerment. The research con®rms that factors such as

gender and socio-economic status do in¯uence perceptions

and understandings of the illness. Cultural and family

factors will also be important in moulding attitudes and

beliefs.

People have different beliefs and needs and will respond to

different strategies of health promotion and rehabilitation.

Nurses who are working with cardiac patients need to foster

trust and empathy in order to develop an understanding of

their illness beliefs. The illness story may become the

underlying structure from which nurses and patients can

work together to identify mutually acceptable goals, and

which can meet both the patient's personal needs and the

nurse's objectives of health promotion.

Future research

It would be useful to explore further aspects of gender and

socio-economic circumstance with regard to illness attribu-

tions, rehabilitation and self-management following myocar-

dial infarction. An assessment of early psychological

intervention and its in¯uence on beliefs, attitudes to self-

ef®cacy and behavioural adaptations would also help to

promote a greater awareness of the importance of these issues

in recovery.

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Documents

Illness attributions and myocardial infarction: the influence of gender and socio-economic circumstances on illness beliefs