Why do women with cardiac symptoms delay seeking medical help? Insights from a qualitative study among Jewish Israeli women

Abstract

Background:

The delay time from onset of symptoms of a myocardial infarction to seeking medical assistance can have life-threatening consequences. Women delay significantly more often than men do in calling for medical help, once symptoms of a myocardial infarction occur.

Objectives:

The current qualitative study’s main aim was to explore psychosocial factors that contribute to Israeli women’s delaying calls for medical assistance and, by contrast, the motivational factors that encourage them to do so.

Design:

A qualitative study.

Method:

In total, 12 women were interviewed shortly after experiencing a myocardial infarction. Qualitative data were subjected to thematic analysis.

Results:

Two major themes emerged describing barriers to seeking help: (1) the use of denial as a defense mechanism and (2) the need for control. The motivational factor which enhanced help-seeking was “fear of death.”

Conclusion:

These findings may help in designing gender-sensitive interventions with the aim of minimizing the symptom onset to call time and thus preventing irreversible and life-threatening health damage.

Keywords

denial delay gender help-seeking behavior medical care myocardial infarction symptoms onset to call women

Introduction

Cardiovascular diseases are the global leading cause of death in women and men.¹ The acute blockage of a coronary artery mediated by rupture or erosion of an atherosclerotic plaque within the artery is termed acute coronary syndrome and can lead myocardial infarction (MI), cardiogenic shock, chronic disability, and even death.² In recent years, the implementation of urgent revascularization in the setting of an acute blockage of the artery has led to a significant decrease in morbidity and mortality, yet patient delays in seeking medical help significantly impair the provision of timely and effective care.³ Despite improvements in patient awareness of the signs and symptoms of heart attacks, only a minority of patients receive optimally timed treatment for their symptoms.³

In westernized societies, the most significant period of delay along the treatment timeline is the time spent between the initial onset of symptoms and the person’s help-seeking actions, a delay referred to as “symptom onset to call.”⁴ Such a delay is in itself a critical risk factor for extensive cardiac damage and increases the risk of mortality.⁴ Older individuals, people of low socioeconomic statuses, and women have been consistently found to delay for a significantly longer period of time than have younger, more affluent individuals, and men.^5
–7

In the current qualitative study, we focused on reasons for the delay in seeking medical help among Israeli women with cardiac symptoms, and on the factors that might facilitate their help-seeking behavior. This kind of study has never been conducted in Israel before. Moreover, Israel provides a unique context in which to explore psychological reasons for delay in seeking emergency medical health due to its progressive National Health Insurance Law which reduces the crucial effect of economic factors—a factor which was found to explain delay in seeking medical help.⁸ According to this law, every resident is entitled to receive medical services from one of the four health plans regardless of age, pre-existing conditions, or health status.⁹ Thus, every Israeli resident, who has been transported to the hospital via ambulance and eventually hospitalized, is entitled to a full coverage of the ambulance fee, and those who were not hospitalized are entitled to 50% coverage.¹⁰

The Israeli context is, therefore, an opportune context to observe and pinpoint the psychological factors which contribute to women delaying, and the factors that promote seeking help. This information may enhance our ability to design targeted interventions to overcome detrimental delays, which can be of crucial clinical significance for patients from other countries who share similar health services.

Longer symptom onset to call time: gender differences

Heart disease has been perceived by society as a “male” disease, and the vast majority of research on the subject focused on men.¹¹ However, beginning in the late 1980s, heart disease was also found to be the leading cause of mortality among women.¹² Although the risk of heart disease is indeed higher in men, the literature suggests that women are less likely to survive a heart attack, with more women dying during hospitalization and within the 30-day timeframe following the cardiac event.^13
–16

There are several possible explanations for these differences, and one key issue is the gender gap in symptom onset to call time. There is consistent evidence that women delay longer than men in seeking medical help when feeling cardiac symptoms.^5,6 For example, according to the Acute Coronary Syndrome Israeli Survey (ACSIS) conducted in Israel in 2018, the median time until seeking medical help was approximately 35 min longer among women compared to men.¹³ Given the life-threatening aspects of an untreated MI, the question that arises is why women delay so much in seeking medical help.

The postponement of medical care among women is frequently attributed to a diminished awareness of their symptoms. This perspective posits that the gender-based contrast in help-seeking behavior originates from the varied interpretation of cardiac symptoms experienced by women and men.¹⁷ Women’s delays in seeking medical care are often explained on the basis of physical differences between the genders. According to this view, the gender gap in seeking help derives from the differences in cardiac symptoms experienced by women and men. The most common MI symptoms for both genders are chest pain and discomfort. However, compared to men, women are less likely to report classic chest pain, and more likely to describe additional diverse symptoms, such as nausea, indigestion, shortness of breath, pain in the back, neck, and jaw, exhaustion, and general weakness.^18,19 Thus, whereas the classic “male” symptoms are well known and easily recognizable,²⁰ there is less awareness of and concern about symptoms in women, both among women themselves and among medical professionals.

Yet this explanation does not seem to hold up, given other studies showing that the most common presenting symptom for an MI in both men and women is chest discomfort, and it has been suggested that the similarities of the symptoms outweigh the differences.^21,22 Moreover, it has been found that the delay time among people who have already experienced MI in the past is not shortened.²³ Thus, even people with a significant risk of MI, who are well aware of the nature of the symptoms, do not necessarily call for help faster than do people who have no history of heart disease. In other words, recognizing the symptoms is not the only issue at hand. It is important to gain a deeper understanding of other possible factors that cause people, and especially women, to delay seeking help.

Delay in seeking medical help—psychological theories

A few psychological explanations have been offered to clarify why people delay seeking medical help during an MI, despite being able to identify the symptoms. The psychoanalytic perspective, for example, refers to the use of denial as a defense mechanism. A state of illness usually evokes anxiety and other strong emotional responses, and denial mechanism is activated to prevent an exaggerated emotional reaction and to regulate the levels of distress.^24
–26 It has been found that in the context of seeking medical help during an MI, denial acts as a barrier and increases the delay time.^27,28 Over the last two decades, considerable attention has been given to the effect of denial mechanism as a contributing factor to the prolonged delay in seeking medical assistance during an MI.^29,30 However, sufficient attention has not been given to the relationship between gender and the tendency to deny in the context of delays in seeking medical help.

From a social-learning theoretical perspective,³¹ the idea of “locus of control” (LOC) was conceptualized as a factor related to delays in seeking help. The concept of LOC includes two attribution styles: Internal LOC refers to the belief that a certain outcome is a consequence of one’s behavior, whereas external LOC views an outcome as contingent on different external factors, such as luck, fate, God, or significant others.^32,33 In the context of heart disease, internal LOC has been found to contribute to seeking help within the recommended time range.²³ Another study that measured a variety of psychological factors found that external LOC was a major predictor of delays in seeking help.²⁹ Yet these studies did not relate to the contribution of gender, vis a vis its effect on attributional style, and delays in seeking help.

Finally, theories of stress and coping³³ have emphasized the contribution of social support as a major factor in enhancing help-seeking.^34,35 Women tend to experience an MI approximately 7–10 years later than do men,³⁶ at a time when they are likely to have less extensive social support. Moreover, being married is associated with lower odds for delays in asking for medical assistance among men but not women.³⁷ Men are more likely than women to rely on spousal support during cardiac illness, possibly because by the time women have their own cardiac event, they may already be widowers. However, they may also wish not to burden their distal environment with their health condition, as they are accustomed to maintaining the caregiving role in the family.³⁸

Delay in seeking medical help—findings from previous qualitative studies

Table 1 presents the summary of findings of 17 qualitative studies published between 2003 and 2022.^39
–55 All these studies apply a qualitative approach to understanding women’s delay in seeking medical help in the context of emerging cardiac symptoms. Interestingly, most studies were executed in westernized countries, whereas only two collected data in other places as China and Jordan.

Table 1.

Literature review of qualitative studies focusing on reasons for delay in seeking treatment for acute MI symptoms.

Authors	Year	Journal name	Article title	Country	Design	Number of participants (age)	Main findings and examples for reasons for delay:	Specificities and comments
Schoenberg et al.³⁹	2003	Social Science & Medicine	Unraveling the mysteries of timing: Women’s perceptions about time to treatment for cardiac symptoms	USA	Grounded theory	40 women (range 55–96 years)	Social and structural constraints. 1. Male norms that ultimately confuse symptom detection 2. Women’s negative encounters with healthcare providers 3. Competing social demands 4. Structural barriers delimiting women’s healthcare choices.
McSweeney et al.⁴⁰	2005	Progress in Cardiovascular Nursing	What’s Wrong With Me? Women’s Coronary Heart Disease Diagnostic Experiences	USA	Inductive thematic data analysis	40 women (range 27–79 years)	1. Denial
Moser et al.⁴¹	2005	Patient Education and Counseling	Gender differences in reasons patients delay in seeking treatment for acute myocardial infarction symptoms	USA	Trained study research assistants interviewed patients in their hospital rooms using the Modified Response to Symptoms Questionnaire	^a96 women (mean age: 64 ± 13) and 98 men (mean age 57 ± 13) years	Patients of both genders delayed due to the following reasons:1. Not attributing their symptoms to their heart2. Minimization of symptoms’ severity and relevancy3. Symptoms’ ambiguity (symptoms came and went)4. Lack of knowledge of cardiac symptoms	Factors that exerted a differential effect on delay between men and women were age, history of AMI, type of AMI (Q-wave and non-Q-wave), concerns about not wanting to trouble others (women), and lack of prior knowledge of thrombolytics (men).
Rosenfeld et al.⁴²	2005	American Journal of Critical Care	Understanding treatment-seeking delay in women with acute myocardial infarction: descriptions of decision-making patterns	USA	Narrative approach	52 women (aged 29–89 years)	Six common patterns of behavior during the decision time were identified:1. Knowing and going2. Knowing and letting someone take over3. Knowing and going on the patient’s own terms4. Knowing and waiting5. Managing an alternative hypothesis6. Minimizing.	The stories these women told suggested that they wanted to remain in control and were not willing to let others make decisions for them
Mac Innes⁴³	2006	European Journal of Cardiovascular Nursing	The illness perceptions of women following symptoms of acute myocardial infarction: a self-regulatory approach	UK	Thematic approach	10 women (Women were selected from a range of age groups: 30–59, 60–79, and 80 years and above)	Perceived lack of susceptibility to the disease and a belief that symptoms were benign.
Sjöström-Strand and Fridlund⁴⁴	2008	International Journal of Nursing Studies	Women’s descriptions of symptoms and delay reasons in seeking medical care at the time of a first myocardial infarction: A qualitative study	Sweden	Content analysis approach	19 women (aged 36–80 years)	1. Persuading to manage the symptoms2. Self-care handling3. Minimizing to manage the symptoms4. Caring responsibilities for the family5. Waiting for next of kin’s decision-making	Anxiety seemed to play an important role, both as defense mechanism resulting in delay in seeking medical care and a trigger to seek medical care.
Turris and Johnson⁴⁵	2008	Qualitative Health Research	Maintaining Integrity: Women and Treatment Seeking for the Symptoms of Potential Cardiac Illness	Canada	Grounded theory	16 women (aged 29–89 years)	1. Maintaining Integrity: Maintaining integrity refers to the process the women used to keep intact their sense of self and to keep going in the context of their daily lives, despite the threat represented by the symptoms of heart disease2. Fear of being embarrassed if false alarm3. Fear of a serious condition (to a lower degree)
Turris and Finamore⁴⁶	2008	Journal of Emergency Nursing	Reducing delay for women seeking treatment in the emergency department for symptoms of potential cardiac illness	Canada	Grounded theory	16 women (aged 29–89 years)
Galdas et al.⁴⁷	2010	Social Science & Medicine	Help-seeking for cardiac symptoms: Beyond the masculine feminine binary	Canada	Thematic approach	11 men and 9 women (aged 48–89 years)	1. Expressing stoicism, control, denial of weakness, and endurance.2. Ambiguity about the seriousness of their condition	Men’s and women’s experiences of seeking healthcare were not easily parsed into distinct binary gender patterns.
Gallagher et al.⁴⁸	2010	Heart & Lung	Symptoms and treatment-seeking responses in women experiencing acute coronary syndrome for the first time	Australia	General inductive approach for analyzing qualitative data	10 women (aged 44–82 years)	1. Diversity of symptom experience2. Beliefs in low vulnerability to CHD3. Health professionals’ responses which did not match the women’s actual health circumstances4. Applying self-treatment and waiting it out.
Herning et al.⁴⁹	2011	European Journal of Cardiovascular Nursing	Women’s experiences and behavior at onset of symptoms of ST segment elevation acute myocardial infarction	Denmark	Phenomenological analysis	14 women (aged 50–84 years)	Reasons for delay:1. Not identifying the symptoms as being of cardiac origin2. Not having a prepared action plan in case of an emergency situation3. Not living with someone or contacting other persons.
Davis et al.⁵⁰	2013	Heart & Lung	Thoughts and behaviors of women with symptoms of acute coronary syndrome	USA	Grounded theory	Nine women(aged 49–74 years)	All participants went through a basic social-cognitive process of searching for the meaning of their symptoms which informed their decisions about seeking care. Stages in the process can be divided into two core categories:1. Symptom recognition and interpretation,2. the larger social context: managing relationships and social obligations.
Lichtman et al.⁵¹	2015	Circulation: Cardiovascular Qualitative Outcomes	Symptom Recognition and Healthcare Experiences of Young Women with Acute Myocardial Infarction	USA	Thematic approach	30 women (aged 30–55 years)	Five themes characterized the experiences of young women recently hospitalized with AMI in this study:1. Prodromal symptoms varied substantially in both nature and duration;2. Participants inaccurately assessed personal risk of heart disease and commonly attributed symptoms to noncardiac causes;3. Competing and conflicting priorities influenced decisions about seeking acute care as family and work responsibilities,4. Fear of being related to as hypochondriac, and relying on strategies for self-care to treat their symptoms until they reached a threshold they could no longer tolerate;5. The healthcare system was not consistently responsive to young women with AMI, resulting in delays in diagnosis;6. Participants did not routinely access primary care, including preventive care for heart disease
Gyberg et al.⁵²	2015	Scandinavian Journal of Caring Sciences	Women’s help-seeking behavior during a first acute myocardial infarction	Sweden	Grounded theory	17 women (aged 38–75 years)	1. Perceiving symptoms as non-intriguing and reinforcing harmless explanations.2. Struggling to keep one’s life in order and maintain independence
Berg Gundersen et al.⁵³	2017	Health Psychology and Behavioral Medicine	Women with coronary heart disease—making sense of their symptoms and their experiences from interacting with their general practitioners	Norway	Phenomenological analysis	Nine women (aged 47–78 years)	1. Not recognizing worrying symptoms2. Receiving a noncardiac formal diagnosis	All participants were scheduled for a coronary artery bypass graft
Hadid et al.⁵⁴	2020	Cardiology Research and Practice	Factors Associated with Prehospital Delay among Men and Women Newly Experiencing Acute Coronary Syndrome: A Inquiry	Jordan	Inductive content analysis	35 men and 33 women (aged 22–74 years)	Reasons for delay1. Lack of knowledge about ACS symptoms (no gender differences)2. Socioeconomic and healthcare barriers3. Family and caregiving concerns	Men were worried about family maintenance and financial competence, whereas women were more concerned about caregiving tasks
Yu et al.⁵⁵	2022	Journal of Advanced Nursing	“I’m still young. . . it doesn’t matter”—A qualitative study on the neglect of prodromal myocardial infarction symptoms among young- and middle-aged adults	China	Inductive thematic data analysis	7 women and 14 men (aged 32–55 years)	1. Young age2. Pursuit of personal values (to be somebody useful)3. Role pressure (to be a good family member, employee, and friend)	Young- and middle-aged adultsNo gender differences in delay reasons

No age range was provided.

The studies unfolded diverse reasons for delay. Most often it was detected that women tended to either minimize the symptoms or refrain to attribute them to a serious medical event. Consequently, many women acted on self-treatment behaviors instead of calling for professional help. In addition, women hesitate to call for help due to interpersonal factors, such as their caring responsibility for their families or their fear to be treated disrespectfully by the health systems. Women also expressed their need to maintain their integrity, an important motivation preventing them from easily asking for others’ help. Finally, economical barriers and denial were also detected yet to a lesser degree.

The current research

The literature points to an existing gap in understanding the different psychological barriers that lead to a greater delay in seeking medical help among women. Much data exist on the subject; however, most of the findings were generated from Westernized countries, such as Canada, the United States, the United Kingdom, or Sweden, and much less so from other parts of the world, such as the Middle East and specifically Israel. Moreover, none of these countries have the same healthcare benefits as the Israeli progressive National Health Insurance Law allows. The existence of this law diminishes to a great extent the possible economical barriers which uphold individuals from reaching out for medical help and thus enables the investigation of more nuanced psychological reasons.

Finally, most of the former studies highlighted reasons for delay but neglected to assess help-seeking motivations. As it is imperative to discover these motivations and to capitalize on them when developing interventions enhancing health-seeking behaviors, the current research focused on both the psychological factors that might serve as barriers to seeking help, and possible motivational factors that enhance help-seeking. As such, we investigated both women who delayed seeking medical help and those who came promptly. Given the fact that no such study has ever been carried out in Israel, this study saw fit to explore women’s phenomenological experience using a qualitative method based on the narrative approach.

Method

We used the COREQ criteria (Consolidated Criteria for Reporting Qualitative Research) to detail the analysis process of our qualitative data (see Supplemental Appendix no. 1).

Study design and sample

Research participants were women (N = 12) in the age range of 34–86 (M = 61.5, SD = 15.8) years who recently experienced an MI (both types of MI, ST elevation and non-ST elevation), in accordance with the criteria of the American College of Cardiology (ACC/AHA).^56,57 These women were hospitalized in a central hospital in Israel. The participants were recruited from individuals who were hospitalized in the coronary care unit (CCU) or the Cardiology Department, during the research period, and who met the above MI criteria. Women who did not speak fluent Hebrew or who could not be interviewed for other reasons were excluded from the study (see Figure 1).

Figure 1.

Flowchart of the study recruitment process.

Procedure

The recruitment of participants was carried out over a period of 10 months, from March to December 2019. The research team scanned the list of patients hospitalized during this period and approached all women with an MI diagnosis for recruitment. An explanation of the research and its clinical value was provided, and the women who agreed to participate in the study signed a consent form. Interviews were carried out in one session per patient (M _time = 60 min, range in minutes = 40–90, SD = 12.5 min), within a maximum of 1 week from hospitalization (M = 2.8 days; SD = 1.8). Interviews took place in a private room in the hospital or at the patient’s home, depending on the participant’s preference. Psychosocial data, health behaviors, and medical background were collected. The participants were interviewed using a semi-structured interview, and special consideration was given to the participants’ needs during the interviews (e.g. breaks, abbreviating the interview). See Supplemental Appendix no. 2 for the full Interview protocol.

Data collection

Semi-structured interview: The current study, and the interview that was conducted, stems from the narrative approach, which holds that human experience is best represented through stories and narratives.⁵⁸ Specifically, the narrative methodology as used in this study, focuses on the story as the person chooses to tell it,⁵⁹ regarding the research questions. The first part of the interview was unstructured, and the participants were asked to talk openly about their MI experience. This part of the interview was carried out with the purpose to approximate to each participant’s unique experience in terms of the feelings, behaviors, and thoughts that accompanied their MI event, dating from the time when it started. The second part of the interview consisted of specific questions that focused on psychosocial factors and encouraged the participants to chronologically reflect on and detail their decision-making process, from the time of the onset of their symptoms until the time they sought medical assistance.

Sociodemographic information and medical background form: We also collected information about age, socioeconomic status, marital status, and relevant medical background variables (see Table 2).

Table 2.

Sociodemographic and medical background characteristics of the sample.

Variable	N	%
Age (years)
30–50	4	33.3
51–70	5	41.7
71–90	3	25
Marital status
Single	0	0
Married/partnered	5	41.7
Divorced/widowed	7	58.3
^aEconomic status
Below average	4	33.3
Average income	3	25
Above average	5	41.7
Medical background
History of cardiac Illness	5	41.7
^bRisk factors	10	83.3
Family history of cardiac illnesses	8	66.7

Based on the Central Bureau of Statistics, Israel 2013 (household mean outcome in Israel in 2019 = 14,600 New Israeli Shekel per month).

Reflects the number of participants answering “yes” to one or more risk factors for heart disease (e.g. hypertension, high cholesterol, obesity, and diabetes).

Data analysis

Qualitative data were subjected to thematic analysis using a narrative methodology, from a realistic point of view.⁶⁰ In the first stage, all interview data were coded for content, line by line. As part of this coding process, stylistic aspects, such as silences, contradictions within the text, and nonverbal emotional expressions were noted as well. The coding process was carried out by two judges (Authors 1 and 2), and each wrote a list with all categories relating to all considerations that arose from the text. Cross-coding agreement was 90.2% and discrepancies in coding were resolved through discussion until a consensus was reached. These initial codes were classified under categories with joint meanings, for each interview separately. In the next stage, categories that were the most prevalent and had the richest data were marked and labeled. Data from all interviews were included in the analysis. In the third stage, categories were organized under main themes and subthemes, with an examination of each theme’s relevance to the research questions. The themes that emerged repeated themselves, and data analysis was carried out until saturation was reached. Being transparent and explicit about the methodological procedure ensured the reliability of the study, enabling future replication.

Ethical considerations

Human subject approval was obtained from the Institutional Review Board of the Hadassah Medical Organization, and the study conformed to the principles outlined in the Declaration of Helsinki. All participants in the study provided written informed consent for the collection of demographic and follow-up data, and for the recorded interview (Study # HMO-0332-17). Confidentiality was ensured by the use of pseudonyms within the dataset. As the interviews were conducted within only a few days after the MI, they were done so with the utmost sensitivity, empathy, and consideration of the participants’ physical and emotional circumstances.

Results

Patient characteristics

The average time of symptom onset to call as measured by a direct question in the interview was 4 h and 55 min (SD = 6.4; Median = 1.75 h). Only 3 out of the 12 participants did not delay at all in seeking medical assistance. They called for medical assistance few minutes after the cardiac symptoms had begun and received medical assistance within the 60-min recommended timeframe.⁶¹ The time of symptom onset to call ranged up to 20 h.

Overall, three major themes emerged from the thematic analysis. Two themes were found to be barriers to seeking medical help: “the use of denial as a defense mechanism” in response to the threatening experience, and “the need for control.” The latter theme consisted of two subthemes: (a) self-perceived competence, and (b) experiencing control over the cardiac event. By contrast, “fear of death” was detected as a theme that enhanced seeking help.

Barriers to seeking help: (1) the use of denial as a defense mechanism

The majority of participants (n = 9) described a process of denial, of varying levels of intensity, during the time they experienced cardiac symptoms, both in the early stages and in the midst of the MI. The use of denial as a defense mechanism contributed consistently to their delay in seeking help.

Lydia (Participants’ names are pseudonyms) (symptom onset to call time = 1.5 h, age = 45 years, married) shared that she had experienced heart-related (prodromal symptoms) symptoms for 2 weeks. In her words:

There are some people like me who don’t look at the reality. Anything that has to do with themselves they’re kind of blind about. A lot of it has to do with the medical stuff, it’s kind of like sweeping away everything you’re being told, deny. . . It’s a kind of “Rapunzel”—sleeping in a tower and not waking up. All of a sudden you wake up one day, for some it happens earlier and for some later on and you understand that you’re missing something.

Throughout the interview, she described the process she went through and how she tried to find alternative explanations for the symptoms she was experiencing. When she experienced the full-blown MI, she happened to be talking to her sister, who sent her an article describing heart attack symptoms among women. She was asked by the interviewer whether she understood the urgency of her condition after reading the article, to which she responded:

No, no. . . I just said—this heart attack isn’t mine. Even after the emergency room, where I sat for a whole day, I was still sure I had an ulcer! That I didn’t have anything with my heart! No way! Me—I have something with my heart? When they told me that they were going to do a catheterization, I was sure they were doing it just for the sake of it! Listen to how much I was in denial!

Jennifer (symptom onset to call time = 12 h, age = 58 years, divorced) described her feelings of, on one hand, “knowing” it was a heart attack, but on the other hand, not knowing. Her description of how she had received the diagnosis at the hospital indicated a high level of denial:

Your “control panel” is external in these cases, and then you’re free of emotion and free of stress and hysteria. I knew that something bad was happening; there was no issue there of a lack of awareness because I was aware. I’ve had cardiac events before, so I know. There’s no doubt that I knew that I needed to act quickly because I was aware of the significance of time. . . I knew in my head, but I didn’t feel it.

There was a substantial discrepancy between her described thoughts of “knowing” and the emotion she experienced when she was diagnosed with an MI:

There was a cute guy who took me to where the serious patients go. I said to him – “You’re putting me with the serious cases? It’s nothing.” And he said to me: “Ma’am, you’re having a heart attack, just like the men have.” Oh, so I was having a heart attack, oh my! (loudly), because until then I thought it was nonsense. I almost passed out, even though I knew. I couldn’t be having a heart attack, it sounded so manly or something. . .I said, okay I’m in good company like the men, everything will be okay.

The use of a denial served as a barrier in the women’s decisions to ask for medical assistance but in different ways. Some minimized the severity or urgency of the condition, trying to find another explanation for their symptoms; some denied the emotional component; and some denied any information that was too threatening to handle. In some cases, the participants were able to conceptualize the process of denial they experienced; with others, the use of denial was interpreted by the interviewer and not by the participant herself.

Barriers to seeking help: (2) the need for control

Self-perceived competence

Most participants (n = 8) described themselves as being strong, competent, and autonomous. Asking for help was perceived by them as a sign of weakness. They reiterated how they viewed themselves as women who had full control over their lives. Some emphasized the feeling that they had lost control during the MI, and they feared becoming a burden on their family members, a feeling that evoked shame and undermined their perception of a strong self. Holding onto this self-perception delayed the time it took to seek help.

Jennifer talked about the difficulty of accepting help from her daughter and her inability to let go of control. There was a conflict between her self-perceived competence, which she emphasized strongly, and her experience of feeling shame:

I’m always very much in control in these cases. It’s not the first time, I’ve experienced a lot of emergencies with my heart and stuff. . . I spoke to my daughter on the phone and she said: “Okay I’m sending you an ambulance.” I was so angry with her. Worst case, I’ll take myself. Worst case. A mess, all the neighbors will also see the ambulance. She tried to convince me but I screamed like a madwoman. When I make a decision, no one gets me to budge, it’s a plus and a minus in my case. For my whole life I was called “the man,” in everything I did. Look at this crazy thinking of mine, I need someone to convince me (to seek medical assistance). And I’m not that kind of woman, weak and. . .it’s the opposite.

Alisa (symptom onset to call time = 2 h, age = 70 years, divorced) emphasized the experience of losing control during the cardiac event as marking the loss of her autonomy:

I lost control. The medical team even had to lift me, things that don’t happen to me, because I’ve been in control my whole life (silence). I’m a person that is always in control. It’s a difficult feeling and suddenly I lost it all. . . It was a terrible feeling, terrible. Even before the catheterization and bypass surgery that I had undergone in the past, it didn’t happen, I was in control then. . . Now I almost lost everything—meaning I needed total help from others. It’s not good (giggles). I’m not used to it; I want to be in control until the very end of my life. I like making the decisions, as I’ve always done, my whole life. I don’t want to be a burden to anyone, ever; I want to be completely independent until the end. It really scares me.

Experiencing control over the cardiac event

The vast majority of the women (n = 10) emphasized the feeling that they were able to manage the cardiac event themselves without depending on others. For them, this was the way to maintain their sense of having a competent self, even if this sense came at the expense of receiving the medical care they needed.

The experience of needing to have control over the cardiac event was very noticeable with Lora (symptom onset to call time = 20 h, age = 65 years, widowed), who shared that she tried to “survive” the MI and to prove to herself that she could remain strong in the face of it: “I felt like it was totally an emergency, but I said it’ll be okay. . . I also told myself that I was really managing nicely and I was proud, I said wow I’m holding on so well.”

Jessica (symptom onset to call time = 5 h, age = 34 years, married) had her cardiac event at a bus stop and proceeded to call her husband to pick up the children who were with her at the time. She shared how she knew exactly what she was supposed to do and objected to her husband’s suggestions:

He said, Let’s call an ambulance. I told him no, let’s call a taxi to the family doctor. . . He tried to convince me, but no! I deal with things, and I’m also actually successful at it. I knew that’s what I needed to do, I had no doubt about it. . . I can handle the pain, and look, I really did. Because I managed it by myself, I didn’t ask for help.

Thus, it seems that the need for control, over oneself and over the cardiac situation, served as a barrier to seeking appropriate medical help. In some cases, even in retrospect, these women still thought that they had managed the situation well, putting them at great risk in the event of a recurrence.

Facilitator of seeking help: fear of death

The third theme detected was related to the motivational factor that enhanced the seeking of medical care. The factor that was described by most of the women (n = 8) as the one that pushed them to seek help was the moment when they realized they might die, and the heightened intensity of fear that followed.

Gail (symptom onset to call time = 5 min, age = 74 years, divorced) highlighted the fact that it was the meaning of the pain that made her seek help:

I was really scared, that maybe I would die from it. I said, this is a heart attack. It hurts so much in my chest, please help me, help me, God help me stop this pain. It was serious pain but I had already experienced a lot of serious pain in my life. Like childbirth, that was immense pain. But it wasn’t the pain, it was knowing that it was a heart attack, and that’s why I say it was the meaning of the pain that got me—the meaning that I could die.

Alisa (symptom onset to call time = 2 h, age = 70 years, divorced) described the moment when she felt that she might die and compared this experience to previous cardiac events she had been through:

Then came the screams—Oh my god! Oh my god! It had never happened to me before. I had felt pressure in my chest, shoulder, and arms before (in a previous MI event) but I had never reached a point where I couldn’t really breathe like now. I thought that’s it. Here it is. This is it.

Shelly (symptom onset to call time = 12 h, age = 82 years, widowed) shared:

The only thing that really made me nervous was the fact that I felt so bad, to the point that I said I needed immediate help now. . . And that was the moment I said to myself: “Shelly! Ambulance!

Thus, the turning point for these women, the factor that pushed them to seek medical care, was the fear that they might die. For some, this moment came sooner; for others, it came after a long period of time.

Discussion

Main findings

Delay time in seeking medical help after an MI is a significant risk factor for extensive cardiac damage, especially among women as they tend to delay longer than do men. This study focused on the subjective experience of 12 Israeli women who experienced an MI. The majority of women in the study (n = 9) had a delayed symptom onset to call time, and the study focused on the psychological factors that might have contributed to these women’s help-seeking behavior. The main findings were that “the use of denial as a defense mechanism” and the “need for control” contributed to a delay in seeking help, whereas “fear of death” was the main motivating factor for seeking help.

Consistent with the psychoanalytic literature,^30,62,63 this study found that denial was associated with a delay in seeking help during an MI. Most women in the study described this process of denial: ignoring the cardiac symptoms for a long time, minimizing the severity of their medical conditions, rejecting their vulnerability, and denying the emotional component. Several studies that included a female minority found a relationship between the use of denial and a longer delay in seeking help among both genders.^29,30,63,64 As such, our findings strengthen the understanding that the use of denial serves as a barrier to seeking medical help, also among women. Pursuant to this finding, interventions must focus on effective ways to cope with the tendency to deny any indication of an emerging cardiac event, including those with past events.

Moreover, during the interviews, participants reported that they had felt cardiac symptoms for days or even weeks before having the MI itself while ignoring and denying their existence, or their meaning. It is plausible to suggest that the denial mechanism was activated even before the heart attack occurred and barred these women from seeking medical help when an MI could potentially have been prevented. This finding suggests that interventions that target help-seeking should raise awareness, identification, and recognition of symptoms before they worsen.

Our second main finding was that “the need for control” has also emerged as a dominant cause of delays in seeking help among women. The descriptions that most of the women provided of themselves were consistent with what would be termed, professionally, as having an internal LOC, and they emphasized the feeling that they could “manage” the cardiac event they had experienced. Some women also emphasized the difficulty they had in relying on others, as such reliance evokes feelings of shame and the fear of becoming a burden. Often this strategy of self-reliance can be effective but relying solely on oneself during a heart attack is clearly counterproductive, as it prevents the seeking of appropriate medical assistance.

Interestingly, this finding is inconsistent with previous studies which found that an internal LOC contributes to seeking help in the time recommended after an MI, and that an external LOC causes a delay in seeking help.^23,29 This discrepancy may be the result of the fact that previous studies were conducted mostly among men, and it can be assumed that some of the cognitive, psychological, and social obstacles that men face differ from those faced by women. It is possible that in terms of the need for control, there is a unique aspect to women’s coping. For example, in a qualitative meta-synthesis conducted on the experiences of women with an existing diagnosis of heart disease, women needed to be empowered when dealing with the healthcare system and disease management.⁶⁵ More specifically, it was found that giving these women a sense of agency over the change in their lives contributed to their better management of the disease. These women said that they viewed themselves as inferior to men within the healthcare system, a gap reinforced by social and gender-based messages.⁶⁵ In a society like Israel, where women have to exert significant effort to achieve a sense of ownership and control over their lives,^66,67 they may understandably be reluctant to relinquish these hard-earned aspects. However, holding on to one’s need for control may be hazardous to one’s life in the context of an MI.

Finally, in a study investigating the delay in help-seeking behavior, Nymark et al.⁶⁴ identified “symptom appraisal” as the primary factor influencing the duration of delay, with “autonomy preservation” not found to be a significant contributor. Our findings diverge from theirs, as our study reveals that the factor akin to “autonomy preservation,” specifically the “need for control,” plays a significant role in delaying help-seeking. This discrepancy could be attributed to the predominantly male composition (74%) of the sample in the aforementioned study, whereas our investigation exclusively focused on women. Consequently, we propose that a gender-specific factor may underlie the delay in seeking help in this context, necessitating further exploration in larger and more diverse samples.

The current study also identified the moment that tipped the scale, and which served as the motivator for seeking help; that is, the moment when participants experienced the “fear of death.” According to existentialist theories, the fear of death is always present and powerful, and therefore we invest a great deal of mental activity in the denial of death.⁶⁸ These two opposing forces (e.g. fear of death and its denial) are represented in the current study, one as a barrier to seeking help and the other as a motivator. Only when the cardiac symptoms intensified were the women’s defense mechanisms shattered, bringing into consciousness the fear of death and leading these women to seek urgent medical care. This finding corresponds with a recent work showing that the combination of both physical and stress related symptoms was associated with higher odds of calling an ambulance.⁶⁹

Study limitations

Participant recruitment and personal interviews were conducted quite close to the time of the cardiac event, perhaps leading to the refusal of some patients to participate in the study (e.g. saying they were tired, too anxious, etc.). At the same time, the recruitment of participants so close to the event adds to this study’s authenticity. That is, it was conducted before the women repeated their narratives multiple times, and before other interpretations might have been attributed to their stories. In addition, although the number of participants was relatively small (N = 12), the study was successful in recruiting 50% of all the women hospitalized during the recruitment period, who were found eligible for the study (see Figure 1), and also, themes saturation has been reached. It is important to note that only three of the research participants did not delay seeking medical assistance; thus, there is a need for further investigation of the motivational factors that enhance help-seeking among women. Finally, the current study focused on women who, despite delaying, were able to reach out for medical assistant in time and survived the event. Unfortunately, we could not trace the insights of women who did not survive the MI.

Future research in the field should aim to examine gender differences with a research population consisting of both women and men, while emphasizing that the need for control and the use of denial as a defense mechanism are factors that may cause a delay in seeking help. These studies may shed further light on the gap between genders in seeking medical help and may lead to the development of appropriate interventions that are sensitive to the unique needs of each gender.

Conclusion

The conclusions of the study can help in planning health-promoting interventions and policy changes at the community level. These in turn can help reduce the symptom onset to call time, and thus hopefully prevent irreversible and life-threatening heart damage, especially in those with a history of heart disease. First, the identification of the denial mechanism is quite significant. Action must be taken to raise awareness that denial during a cardiac event is a widespread and normative, albeit dangerous, phenomenon. Its paralyzing effect on negative emotions, such as fear or anxiety, the existence of which enhance help-seeking after an MI, can result in delays in seeking help. Second, it is particularly important to enable women who have high levels of self-reliance and internal LOC to seek help while at the same time not threatening these fundamental characteristics, which are for the most part beneficial. Reframing the seeking of medical help as something positive for the maintenance of a healthy, competent, and autonomous self is crucial for these women, and may assist them in deciding to share their feelings and seek help. Understanding the unique barriers to seeking help among women will allow for more precise and effective campaigns and policies to facilitate timely and effective healthcare for women who are coping with MI, both physically and emotionally.

Supplemental Material

sj-docx-1-whe-10.1177_17455057241257761 – Supplemental material for Why do women with cardiac symptoms delay seeking medical help? Insights from a qualitative study among Jewish Israeli women

Supplemental material, sj-docx-1-whe-10.1177_17455057241257761 for Why do women with cardiac symptoms delay seeking medical help? Insights from a qualitative study among Jewish Israeli women by Maia Asher, Noa Vilchinsky, Rivka Tuval-Mashiach and Donna R Zwas in Women’s Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057241257761 – Supplemental material for Why do women with cardiac symptoms delay seeking medical help? Insights from a qualitative study among Jewish Israeli women

Supplemental material, sj-docx-2-whe-10.1177_17455057241257761 for Why do women with cardiac symptoms delay seeking medical help? Insights from a qualitative study among Jewish Israeli women by Maia Asher, Noa Vilchinsky, Rivka Tuval-Mashiach and Donna R Zwas in Women’s Health

Footnotes

Acknowledgements

This study is partially based on the first author’s thesis, supervised by the second author and submitted to Bar-Ilan University. The authors thank Lori Sloman and Hazel Vahav from Hadassah Medical Center for their invaluable assistance in the recruitment of participants for this study.

Declarations

ORCID iDs

Maia Asher

Donna R Zwas

Supplemental material

Supplemental material for this article is available online.

References

Mensah

Fuster

Murray

, et al. Global burden of cardiovascular diseases and risks, 1990-2022. J Am Cardiol 2023; 82(25): 2350–2473.

Falvo

Holland

BE.

Medical and psychosocial aspects of chronic illness and disability. Burlington, MA: Jones & Bartlett Learning, 2017.

Shiomi

Nakagawa

Morimoto

, et al. Association of onset to balloon and door to balloon time with long term clinical outcome in patients with ST elevation acute myocardial infarction having primary percutaneous coronary intervention: observational study. BMJ 2012; 344: e3257.

Weissler-Snir

Kornowski

Sagie

, et al. Gender differences in left ventricular function following percutaneous coronary intervention for first anterior wall ST-segment elevation myocardial infarction. Am J Cardiol 2014; 114(10): 1473–1478.

Lawesson

Isaksson

Ericsson

, et al. Gender disparities in first medical contact and delay in ST-elevation myocardial infarction: a prospective multicentre Swedish survey study. BMJ Open 2018; 8(5): e020211.

McGinn

Rosamond

Goff

Jr , et al. Trends in prehospital delay time and use of emergency medical services for acute myocardial infarction: experience in 4 US communities from 1987-2000. Am Heart J 2005; 150(3): 392–400.

Moser

Kimble

Alberts

, et al. Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council. Circulation 2006; 114(2): 168–182.

Sheifer

Rathore

Gersh

, et al. Time to presentation with acute myocardial infarction in the elderly: associations with race, sex, and socioeconomic characteristics. Circulation 2000; 102(14): 1651–1656.

Kornowski

Orvin

Current status of cardiovascular medicine in Israel. Circulation 2020; 142(1): 17–19.

10.

Israel Ministry of Health. Transportation and evacuation by ambulance, 2023. https://www.health.gov.il/English/Services/Citizen_Services/Pages/ambulance.aspx

11.

White

Hunter

Holttum

How do women experience myocardial infarction? A qualitative exploration of illness perceptions, adjustment and coping. Psychol Health Med 2007; 12(3): 278–288.

12.

Maffei

Guiducci

Cugusi

, et al. Women-specific predictors of cardiovascular disease risk-new paradigms. Int J Cardiol 2019; 286: 190–197.

13.

ACSIS. Acute Coronary Syndrome Israeli Survey, March to April 2018, 2018. https://his-files.com/lifkoPDF/ACSIS_2018_pdf_v5.pdf

14.

Canto

Rogers

Goldberg

, et al. Association of age and sex with myocardial infarction symptom presentation and in-hospital mortality. JAMA 2012; 307(8): 813–822.

15.

Greenwood

Carnahan

Huang

Patient–physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci 2018; 115(34): 8569–8574.

16.

Izadnegahdar

Singer

Lee

, et al. Do younger women fare worse? Sex differences in acute myocardial infarction hospitalization and early mortality rates over ten years. J Womens Health 2014; 23(1): 10–17.

17.

Haider

Bengs

Luu

, et al. Sex and gender in cardiovascular medicine: presentation and outcomes of acute coronary syndrome. Eur Heart J 2020; 41(13): 1328–1336.

18.

King

McGuire

MA.

Symptom presentation and time to seek care in women and men with acute myocardial infarction. Heart Lung 2007; 36(4): 235–243.

19.

van Oosterhout

de Boer

Maas

, et al. Sex differences in symptom presentation in acute coronary syndromes: a systematic review and meta-analysis. J Am Heart Assoc 2020; 9(9): e014733.

20.

Garcia

Mulvagh

Bairey Merz

, et al. Cardiovascular disease in women: clinical perspectives. Circ Res 2016; 118(8): 1273–1293.

21.

Canto

Goldberg

RJ.

Time to standardize and broaden the criteria of acute coronary syndrome symptom presentations in women. Can J Cardiol 2014; 30(7): 721–728.

22.

Lichtman

Leifheit

Safdar

, et al. Sex differences in the presentation and perception of symptoms among young patients with myocardial infarction: evidence from the VIRGO study (variation in recovery: role of gender on outcomes of young AMI patients). Circulation 2018; 137(8): 781–790.

23.

Carney

Fitzsimons

Dempster

Why people experiencing acute myocardial infarction delay seeking medical assistance. Eur J Cardiovasc Nurs 2002; 1(4): 237–242.

24.

Breznitz

(ed.). The denial of stress. New York: International Universities Press Inc, 1983.

25.

Kreitler

Defense mechanisms and physical health. Adv Psychol 2004; 136: 477–519.

26.

Livneh

. Denial of chronic illness and disability: part I. Theoretical, functional, and dynamic perspectives. Rehabil Couns Bull 2009; 52(4): 225–236.

27.

Allan

Scheidt

SS.

Empirical basis for cardiac psychology. In: Allan

Scheidt

(eds) Heart & mind: the practice of cardiac psychology. Washington, DC: American Psychological Association, 1996, pp. 63–123.

28.

Fowers

BJ.

The cardiac denial of impact scale: a brief, self-report research measure. J Psychosom Res 1992; 36(5): 469–475.

29.

O’Carroll

Smith

Grubb

, et al. Psychological factors associated with delay in attending hospital following a myocardial infarction. J Psychosom Res 2001; 51(4): 611–614.

30.

Stenström

Nilsson

Stridh

, et al. Denial in patients with a first-time myocardial infarction: relations to pre-hospital delay and attendance to a cardiac rehabilitation programme. Eur J Cardiovasc Prev Rehabil 2005; 12(6): 568–571.

31.

Rotter

Generalised expectancies for internal versus external control of reinforcement. Psychol Monogr 1966; 80: 609.

32.

Lefcourt

. Recent developments in the study of locus of control. Prog Exp Pers Res 1972; 6: 1–39.

33.

Lazarus

Folkman

Stress, appraisal, and coping. In: Gellman Turner (eds) Encyclopedia of behavioral medicine. New York: Springer Publishing Company, 1984, pp. 1913–1915.

34.

Brecht

Dracup

Moser

, et al. The relationship of marital quality and psychosocial adjustment to heart disease. J Cardiovasc Nurs 1994; 9(1): 74–85.

35.

Thuresson

Jarlöv

Lindahl

, et al. Thoughts, actions, and factors associated with prehospital delay in patients with acute coronary syndrome. Heart Lung 2007; 36(6): 398–409.

36.

Poon

Goodman

Yan

, et al. Bridging the gender gap: insights from a contemporary analysis of sex-related differences in the treatment and outcomes of patients with acute coronary syndromes. Am Heart J 2012; 163(1): 66–73.

37.

Atzema

Austin

Huynh

, et al. Effect of marriage on duration of chest pain associated with acute myocardial infarction before seeking care. CMAJ 2011; 183(13): 1482–1491.

38.

Revenson

Griva

Luszczynska

, et al. Caregiving in the illness context. London: Springer, 2016.

39.

Schoenberg

Peters

Drew

EM.

Unraveling the mysteries of timing: women’s perceptions about time to treatment for cardiac symptoms. Soc Sci Med 2003; 56(2): 271–284.

40.

McSweeney

Lefler

Crowder

BF.

What’s wrong with me? Women’s coronary heart disease diagnostic experiences. Prog Cardiovasc Nurs 2005; 20(2): 48–57.

41.

Moser

McKinley

Dracup

, et al. Gender differences in reasons patients delay in seeking treatment for acute myocardial infarction symptoms. Patient Educ Couns 2005; 56(1): 45–54.

42.

Rosenfeld

Lindauer

Darney

BG.

Understanding treatment-seeking delay in women with acute myocardial infarction: descriptions of decision-making patterns. Am J Crit Care 2005; 14(4): 285–293.

43.

MacInnes

JD.

The illness perceptions of women following symptoms of acute myocardial infarction: a self-regulatory approach. Eur J Cardiovasc Nurs 2006; 5(4): 280–288.

44.

Sjöström-Strand

Fridlund

Women’s descriptions of symptoms and delay reasons in seeking medical care at the time of a first myocardial infarction: a qualitative study. Int J Nurs Stud 2008; 45(7): 1003–1010.

45.

Turris

Johnson

JL.

Maintaining integrity: women and treatment seeking for the symptoms of potential cardiac illness. Qual Health Res 2008; 18(11): 1461–1476.

46.

Turris

Finamore

Reducing delay for women seeking treatment in the emergency department for symptoms of potential cardiac illness. J Emerg Nurs 2008; 34(6): 509–515.

47.

Galdas

Johnson

Percy

, et al. Help seeking for cardiac symptoms: beyond the masculine–feminine binary. Soc Sci Med 2010; 71(1): 18–24.

48.

Gallagher

Marshall

Fisher

MJ.

Symptoms and treatment-seeking responses in women experiencing acute coronary syndrome for the first time. Heart Lung 2010; 39(6): 477–484.

49.

Herning

Hansen

Bygbjerg

, et al. Women’s experiences and behaviour at onset of symptoms of ST segment elevation acute myocardial infarction. Eur J Cardiovasc Nurs 2011; 10(4): 241–247.

50.

Davis

Mishel

Moser

, et al. Thoughts and behaviors of women with symptoms of acute coronary syndrome. Heart Lung 2013; 42(6): 428–435.

51.

Lichtman

Leifheit-Limson

Watanabe

, et al. Symptom recognition and healthcare experiences of young women with acute myocardial infarction. Circ Cardiovasc Qual Outcomes 2015; 8(2 Suppl. 1): S31–S38.

52.

Gyberg

Björck

Nielsen

, et al. Women’s help-seeking behaviour during a first acute myocardial infarction. Scand J Caring Sci 2016; 30(4): 670–677.

53.

Berg Gundersen

Sørlie

Bergvik

. Women with coronary heart disease–making sense of their symptoms and their experiences from interacting with their general practitioners. Health Psychol Behav Med 2017; 5(1): 29–40.

54.

Hadid

LAA

Al Barmawi

Al Hmaimat

NAA

, et al. Factors associated with prehospital delay among men and women newly experiencing acute coronary syndrome: a qualitative inquiry. Cardiol Res Pract 2020; 2020: 3916361.

55.

Liu

Qiu

, et al. ‘I’m still young. . . it doesn’t matter’–a qualitative study on the neglect of prodromal myocardial infarction symptoms among young-and middle-aged adults. J Adv Nurs 2023; 79(1): 332–342.

56.

Amsterdam

Wenger

Brindis

, et al. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 64(24): e139–228.

57.

Antman

Anbe

Armstrong

, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation 2004; 110(5): 588–636.

58.

Lieblich

Tuval-Mashiach

Zilber

Narrative research: reading, analysis, and interpretation. London: Sage, 1998.

59.

Josselson

Interviewing for qualitative inquiry: a relational approach. New York: Guilford Press, 2013.

60.

Clarke

Braun

Hayfield

Thematic analysis. In: Smith

(ed.) Qualitative psychology: a practical guide to research methods. London: Sage, 2015, pp. 222–248.

61.

Department of Health. National service framework for coronary heart disease. London: Stationery Office, 2000.

62.

Fang

Albarqouni

von Eisenhart Rothe

, et al. Is denial a maladaptive coping mechanism which prolongs pre-hospital delay in patients with ST-segment elevation myocardial infarction? J Psychosom Res 2016; 91: 68–74.

63.

Perkins-Porras

Whitehead

Strike

, et al. Causal beliefs, cardiac denial and pre-hospital delays following the onset of acute coronary syndromes. J Behav Med 2008; 31(6): 498–505.

64.

Nymark

Henriksson

Mattiasson

, et al. Influence of symptom appraisal and ability to act on patient delay when afflicted by an acute myocardial infarction. Eur Heart J 2017; 38(Suppl. 1): P2486.

65.

Galick

D’Arrigo-Patrick

Knudson-Martin

Can anyone hear me? Does anyone see me? A qualitative meta-analysis of women’s experiences of heart disease. Qual Health Res 2015; 25(8): 1123–1138.

66.

Lorber

Using gender to undo gender: a feminist degendering movement. Feminist Theory 2000; 1(1): 79–95.

67.

Lavee

Katz

The family in Israel: between tradition and modernity. Marriage & Family Review 2003; 35(1–2): 193–217.

68.

Yalom

ID.

Existential psychotherapy. London: Hachette UK, 2020.

69.

Davis

McCoy

Riegel

, et al. Association of symptoms and mode of transportation to emergency department in patients with acute coronary syndrome. Dimens Crit Care Nurs 2023; 42(2): 95–103.

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