Sex, gender & CHD:
a summary of recent evidence
Kate Hunt, Rani Elwy, Mark Petticrew
MRC Social & Public Health Sciences Unit Scotland, UK
Global Health Forum 6, Arusha, Tanzania, 11-13 November 2002
CHD - A problem of developed
countries?
• 44% of deaths from heart disease & stroke occur in the developing world • Leading cause of death for both sexes in:
– – – – The Americas (17.9% of all deaths), Eastern Mediterranean (13.6%) Europe (25.5%) South-East Asia (13.8%)
– Western Pacific (11.1%).
CHD - A male disease?
• Common but misconceived perception • Leading cause of deaths in both sexes
– c.14.6% of all deaths in women – c.12.8% of all deaths in men.
• Leading cause of morbidity in both sexes
– Rank of IHD in the causes of burden of disease
• 5th for men and 6th for women
Purpose of study
• To examine recent epidemiological papers on coronary heart disease (CHD) & assess extent to which they take account of sex and gender
Scope of review
STAGE 1 Review of abstracts of published papers on CHD - in English, 1996-2000
– electronic database search
STAGE 2 Detailed review of selection of eligible papers
– selected on the basis of country of study
Electronic database search: inclusion criteria
– published in 5 year period 1996-2000 – data on CHD with at least one of following: incidence, mortality, risk factors, treatment
– search terms
– includes data for both men and women
Electronic database search
Medline Embase HealthSTAR Popline Psychinfo CancerLit
Abstracts obtained from electronic database search assessed against inclusion criteria
Duplicates between databases excluded
Total number of studies considered for inclusion n = 3693
Ineligible studies: excluded n= 3380 (including 447 relevant studies on CHD which were limited to only one sex)
Studies which met inclusion criteria n = 313
Figure 2: Recent papers On Gender And Coronary Heart Disease
Papers 1-4 5 - 10 11 - 25 26 - 111 No Data
Selecting countries for more detailed review of papers
Studies which met inclusion criteria
N=313
Mapped and grouped by quintile of gender difference in life expectancy Countries from different quintiles to ensure geographic & socio-economic range Lowest 3 quintiles of gender difference in LE: 40/313 papers Selected country with most published papers
Selected countries
Q1 – India Q2 Nigeria Q3 –China Q4 – Japan, Sweden Q5 – Poland, Spain
Top two quintiles of gender difference in LE: 2 from each to get geog. And socio-ec. range
STAGE 2 - Salient conclusions
• Virtual absence of gender focus
– no focus on culture
• Few systematically address sex
– some ‘control’ for sex, – some present parallel models for men & women with little discussion
• Small minority explicitly examine whether same relationships seen in men & women
Limitations
• Sample rather than comprehensive systematic review
– no grey literature, hand-searching, contact with key authors etc.
• Selection bias?
– papers in other languages?
Conclusions (1)
• Evidence on epidemiology of sex and gender and CHD is dominated by studies from limited parts of globe notably USA
– Greater availability of large, long-established epidemiological studies, traditions, investments – Policy (reinforced in Public Law) to increase inclusion of women ?change in research culture
Conclusions (2)
• Lack of studies from developing world
– problems of collecting complete data on morbidity and mortality? – other health priorities ?
• Agenda and understanding of sex, gender and CHD is dominated by a western epidemiological view
Recommendations
• Funding
Research outputs
– challenge and change expectations about exclusion (of women) - follow NIH – explicit expectation of analysis of sex differences and similarities – explicit expectation of inclusion of issues relevant to gender
• Greater openness to studying cultural influences