Health Care for Women International
ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20
Gender differences in knowing about hypertension: The black experience Mary Ann Hautman RN, PhD & Perri Bomar RN, PhD To cite this article: Mary Ann Hautman RN, PhD & Perri Bomar RN, PhD (1992) Gender differences in knowing about hypertension: The black experience, Health Care for Women International, 13:1, 57-65, DOI: 10.1080/07399339209515978 To link to this article: http://dx.doi.org/10.1080/07399339209515978
Published online: 14 Aug 2009.
Submit your article to this journal
Article views: 4
View related articles
Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=uhcw20 Download by: [York University Libraries]
Date: 08 November 2015, At: 07:47
GENDER DIFFERENCES IN KNOWING ABOUT HYPERTENSION: THE BLACK EXPERIENCE Mary Ann Hautman, RN, PhD, and Perri Bomar, RN, PhD
Downloaded by [York University Libraries] at 07:47 08 November 2015
School of Nursing, University of San Diego, California
This descriptive exploratory study was undertaken in an attempt to describe how hypertension as a disease and illness is conceptualized from the point of view and experience of black couples. Twenty-one black couples were interviewed and the data content was analyzed. Explanatory models constructed from the taped interviews revealed that the differences in knowing about hypertension were primarily due to gender. Differences were identified in the structure and content of the explanatory models. Content differences between women and men were primarily in the areas of stress and diet. The significance of this research is that it identified gender differences in ways of learning about illness that need further exploration.
Our purpose in writing this paper is to describe gender differences in descriptions of hypertension by black couples of whom one partner has hypertension. In spite of the vast amount of research on hypertension and adherence to therapeutic regimens, major gaps in knowledge related to gender, ethnicity, and how clients conceptualize their problem remain. Hypertension rates among blacks are considerably higher than among whites (National High Blood Pressure Education Program, 1988). White males receive the greatest attention in the hypertension literature, followed by black males (Clark & Harrell, 1982), white females, and, last, black females (Johnson, Beard, Valdez, Mott, Hugher, & Fomby, 1986; Smyth, Call, Hansel!, Sparacino, & Stodtbeck, 1978). No studies were found that examine hypertension from the perspective of black couples. Gender and Health Promotion Gender is documented as a significant variable in health promotion studies. Women are (a) more interested in health issues; (b) more likely Health Care for Women International, 13:57-65, 1992 Copyright S 1992 by Hemisphere Publishing Corporation
57
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M. A. Hautman and P. Bomar
to engage in and influence family members' health behaviors (Gottlieb & Green, 1984; Hibbard & Pope, 1987); and (c) use diet as a form of health promotion more often than exercise (Woods, 1987). Men are (a) more likely to engage in routine exercise (Verbrugge, 1982); (b) more likely to take risks (Gottlieb & Green, 1984); and (c) more likely to communicate more equally with physicians (Korsch & Negrete, 1972). Numerous scholars have documented gender as a variable in hypertension morbidity and mortality whereas only one study was found that describes the role of gender in lay explanations of hypertension (Blumhagen, 1982). A few qualitative studies document how hypertension is conceptualized (Baumann & Leventhal, 1985; Meyer, Leventhal, & Gutmann, 1985). Explanatory Models of Hypertension Studies of lay accounts of illness/disease reveal that the biomédical model is integrated as a "popular model" into a person's explanation (Blumhagen, 1982; Hautman, 1987). Lay models of hypertension evolve over time and influence treatment behaviors. Individuals may monitor symptoms or obtain blood pressure readings to try to connect the abstract concept of hypertension with concrete empirical referents (Keller, Ward, & Baumann, 1989). METHOD An exploratory descriptive method was chosen because it is useful when little data are available (Field & Morse, 1985) and when the researcher wishes to grasp an emic or people-centered viewpoint (Leininger, 1990). Twenty-one black couples, nine male and twelve female hypertensives and their spouses, were volunteer participants in a large city in the western United States. Each person signed an approved human consent form. Participants were selected based on one of the spouses' having self-reported hypertension for at least 6 months. Reliance on self-report rather than physician referral was based on the consideration that nontraditional health care providers may be the source of care. Participants were interviewed in their homes by the investigators or by research assistants. The investigators critiqued taped interviews conducted by the assistants prior to and during data collection. Questions were based on Kleinman's (1980) explanatory model framework. Examples of open-ended questions asked of each respondent ranged from "What do you think caused your (your spouse's) hypertension?" and
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59
"What difficulties has this condition caused for you (your spouse)?" to "How has your (your spouse's) diet changed?" Two interviewers visited each home and the taped interviews lasted from 45 to 60 min. Tapes were transcribed and data were analyzed using content analysis as described by Berelson (1952) and George (1959). George (1959) notes that qualitative approaches in content analysis allow for preliminary readings and examination of inferred contextual meanings, as well as for manifest content and hypothesis formation, whereas strict quantitative approaches provide rigid guidelines, hypothesis testing, and frequency counts based solely on manifest content. Lincoln and Guba (1985) suggest criteria to determine the trustworthiness of qualitative studies. Our strategies for ensuring trustworthiness are as follows. Credibility was established by methodological triangulation with the use of both a quantitative measure reported elsewhere (Bomar & Hautman, 1990) and detailed personal interviews with persons from varying backgrounds. Transferability is addressed by the inclusion of descriptive examples that support the analysis in the text. Data checks of transcribed and coded interviews made by persons knowledgeable in content analysis provided some level of dependability and confirmability. FINDINGS AND DISCUSSION The major finding of this study is that there are gender differences in the conceptualization of hypertension. Data will be presented pertaining to the structure and content of the explanatory models after a brief description of the demographic data. The demographic data are as follows: mean years with hypertension, 9 years (range 1-20); mean age, 46.5 years (range 20-65); mean income, $46,000; mean years married, 19; and 75% of those included in the study had attended college. Explanatory Models of Hypertension Females with hypertension identified a few more concepts than did the males with hypertension. Both female and male normotensive spouses on an average mentioned slightly fewer concepts. Figure 1 is an example of the conceptual map of a female hypertensive and Figure 2 is that of a male hypertensive. Categories were determined by examining both intended meanings and manifest content. Arrows show the links between concepts: the thicker the line, the more frequent the connection. The spouses with diagnosed hypertension usually identified the most concepts related to their disease. Blumhagen's (1982) study of hyperten-
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M- A. Hautman and P. Bomar
KIDNEY DAMAGE OVERLOAD HEART
HEADACHE
1 V 1
TOO TENSE
CAPILLARY DAMAGE
HEART DAMAGE
Downloaded by [York University Libraries] at 07:47 08 November 2015
SALT
|-jpjvj
.HEART ATTACK NO BLOOD TO BRAIN
FATS HIGH
PREGNANCY
STROKE
CHOLESTEROL VESSELS CONSTRICT HEREDITY
Figure 1. Female explanatory model of hypertension. sion concepts, primarily among hypertensive males, shows conceptual maps depicting connecting nodes similar to those of the males in this study. His assumption that the belief systems of women would be more elaborate than those of men was not confirmed. Gender, Conceptual Bonding, and Hypertension Gender was the dominant factor in determining the structure of each model. Female respondents used what was termed single conceptual bonding, in which one concept was bonded or related to one other concept as cause or effect. Males formed multiple conceptual bonds in which two or more concepts were bonded together. For example, hypertensive males discussed how fatty foods were bonded in a pathway to high cholesterol, clogged arteries, increased resistance in the blood vessels, and then to stroke. Figures 1 and 2 illustrate the conceptual bonds identified for females and males, respectively. The decision tree approach to clinical problems structures a branching of events, tying one concept to another (Weinstein & Fineberg, 1980). Such an approach is used in teaching decision-making to clinicians. Other studies show that physicians talk down to women and ignore their need for information whereas male patients receive complete descriptions; this may be more closely patterned after the clinical model (Belenky, Clinchy, Goldberger, & Tarule, 1986; Wallen, Waitzkin, & Stoeckle, 1979). The differing construction of the models might also occur because men are assumed to be complex, objective thinkers
61
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whereas women are assumed to be subjective, contextual thinkers (Belenky, Clinchy, Goldberger, & Tarule, 1986). Use of mechanical terminology, such as describing hypertension in terms of plumbing, was more common in men than women. A 64-yearold male hypertensive related that "blood pressure is something like plumbing . . . it's like when the hot water lines get rusty and it gets clogged up and the blood goes in smaller streams and don't get through." The medical model has masculinized thought depicting the body as a machine. Clinicians contacted by the investigators report that they use the machine analogy, thus providing some support for our findings. Gender and Stress Stress was perceived as a key cause of hypertension. Female hypertensives discussed the need to talk and said that keeping things bottled up inside produced symptoms such as tightness in the chest and headaches. Female nonhypertensives voiced concern that their hypertensive spouses were hesitant to share personal Stressors, as evidenced by the following typical response: My husband is not a big complainer. You really don't get too much out of him to talk about sickness or anything like that. . . . I always asked questions, but it seems he wanted to spare me and not tell me what was really bothering him.
HIGH CHOLESTEROL
HEART WORKS HARDER
FATTY FOOD SALT
^ \ ^
HIGH VESSEL PRESSURE
\ CLOG ARTERIES '
"\>
^ r
INCREASED WEIGHT HEREDITY
'
/
HPN
- ^^"^JOB
\ STRESS,« ~- PRESSURE MUSCLES TIGHTEN
/
yC^INCREASED RESISTANCE \
\
\ \ ^
f nr*nTATTACK C^V^DEATH \
\
\ ^ ^ ^
STROKE
N
\
KIDNEY DAMAGE \ HEADACHE
Figure 2. Male explanatory model of hypertension.
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M. A. Hautman and P. Bomar
Male respondents discussed stress as job or family pressures that needed to be dealt with through action, not discussion. Actions taken to deal with stress included exercise or "washing the car" or "working in the yard." However, a few hypertensive men attempted to deal with stress through relaxation. A 31-year-old man said: "If I feel I'm stressful . . . I sit on my bed and close my eyes and just start repeating number one and just relax my body from my feet up to the top of my head and it works. . . . " Stress as a causative factor in hypertension is well documented in the literature (Clark & Harrell, 1982; Johnson et al., 1986). However, Blumhagen's (1982) study of explanatory models of hypertension suggests that "hypertension" in the lay idiom should be written "hyper-tension." Our data supported this as respondents spoke of themselves or of their spouses as being too tense or being subjected to too much tension. Normotensive women wanted their hypertensive husbands to talk to them about their stresses. Most of the men felt that they had to deal with their stress alone. These findings support Staples' (1982) belief that black men hesitate to express their feelings or seek support because they see this as a sign of weakness. Studies of the stress and life-styles of black men are distressingly underreported in the literature. Gender and the Concept of Diet Female hypertensives used the term diet to connote the nutritive quality of food and described food in terms of nutrition, that is, low in salt or fat. They also listed more food types such as red meat, ham, fish, vegetables, and spices, and used food preparation terms such as frying, broiling, baking, and barbecuing. Dieting was an action to improve one's health rather than to lose weight. Nearly all females perceived themselves in the role of dietary manager/shopper for the home. Males, on the other hand, used the term diet as in "going on a diet" for the primary purpose of weight loss. Nonhypertensive males identified diet in terms of weight, which they perceived was the cause of their spouses' hypertension. Both men and women stated that fatty foods, foods with high salt content, red meat, and pork were "bad foods" whereas "veggies," fish, and salt-free cooking were good for them. The female partner was in charge of the household diet as evidenced by these responses from two representative hypertensive males: "She knows about my condition . . . and knows not to put salt on my food, not cook lots of greasy food . . . or red meat," and, "She knows that I love ice cream and she says that she won't be getting it anymore." Gender differences in the use of the term diet by women and men can be explained by studies showing that women are more involved in se-
Gender Differences in Hypertension Knowledge
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lecting and preparing food than are men and have a greater awareness of the nutritional value of food than do men (Cope & Hall, 1987; Walker, Volkan, Sechrist, & Pender, 1988). Men's focus on diet as weight loss is surprising given that a review of research on food-related behavior by Axelson (1986) demonstrates that women are more conscious of caloric considerations. Marriage Dyad and Explanations of Hypertension The content of couples' models were similar. The degree of similarity between partners could be attributed in a few instances to situations in which hypertensive spouses shared their concerns about their hypertension. However, couples who complained of lack of communication also had similar models. What differed was how each partner defined and interpreted or contextualized these concepts. Whether this is due to the communication style between couples is not known because these data were not collected. CONCLUSION Our findings demonstrate that gender is an important consideration in how hypertension is conceptualized and discussed. One of the assumptions underlying the participants' discussion of the models is that neither sex is better than the other. Women's models should not be discounted because they do not coincide with the Cartesian male model or decisiontree approach to viewing the world. Health care providers need to address gender issues such as ways of knowing about illness as well as issues related to biopsychosocial and cultural parameters. Providers who address women's conceptions and understand their cognitive and emotional makeup can help them to better address their own health care. Further research needs to be undertaken to compare ethnic differences in ways of knowing about illness and to determine if the structure of the illness account correlates with outcome variables such as self-care practices and measures of illness and disease management. REFERENCES Axelson, M. L. (1986). The impact of culture on food-related behavior. Annual Review of Nutrition, 6, 345-363. Baumann, L. J., & Leventhal, H. (1985). "I can tell when my blood pressure is up, can't I?" Health Psychology, 4, 203-218.
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Belenky, M. F., Clinchy, B. M., Goldberger, N. R., & Tarule, J. M. (1986). Women's ways of knowing. New York: Basic Books. Berelson, B. (1952). Content analysis in communication research. Glencoe, IL: Free Press. Blumhagen, D. (1982). Speaking of illness: Popular conceptions of hypertension in American culture. Unpublished doctoral dissertation, University of Washington (University Microfilm No. 8218202, 43, 854A). Bomar, P. J., & Hautman, M. A. (1990). Gender differences in health practices of black couples with hypertension. Journal of Human Hypertension, 4(4), 100-102. Clark, V. R., & Harrell, J. P. (1982). The relationship among type A behavior, styles used in coping with racism, and blood pressure. Journal of Black Psychology, 8(2), 89-99. Cope, N. R., & Hall, H. R. (1987). Risk factors associated with the health status of black women in the United States. In W. Jones, Jr., & M. F. Rice (Eds.), Health care issues in black America (pp. 43-56). New York: Greenwood Press. Field, P. A., & Morse, J. M. (1985). Nursing research: The application of qualitative approaches. Rockville, MD: Aspen. George, A. L. (1959). Qualitative and quantitative approaches to content analysis. In I. D. S. Pool (Ed.), Trends in content analysis (pp. 7-32). Urbana, IL: University of Illinois Press. Gottlieb, N., & Green, L. W. (1984). Life events, social network, life-style, and health: An analysis of the 1979 national survey on personal health practices and consequences. Health Education Quarterly, 11, 91-106. Hautman, M. A. (1987). Self-care responses to respiratory illness among Vietnamese. Western Journal of Nursing Research, 9(2), 223-243. Hibbard, J. H., & Pope, C. R. (1987). Women's roles, interest in health, and health behavior. Women & Health, 12(2), 67-84. Johnson, M. N., Beard, M. T., Valdez, R., Mott, J. A., Hugher, O., and Fomby, B. (1986). Psychological stress and blood pressure levels in black women. Journal of the National Black Nurses Association, 1(2), 41-54. Keller, M. L., Ward, S., & Baumann, L. J. (1989). Processes of self-care: Monitoring sensations and symptoms. Advances in Nursing Science, 12(1), 54-66. Kleinman, A. (1980). Patients and healers in the context of culture. Berkeley: University of California Press. Korsch, B. M., & Negrete, V. F. (1972). Doctor-patient communication. Scientific American, 227, 66-74. Leininger, M. (Ed.). (1990). Ethnomethods: The philosophic and epistemic bases to explicate transcultural nursing knowledge. Journal of Transcultural Nursing, 1(2), 40-49. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills: Sage. Meyer, D., Leventhal, H., & Gutmann, M. (1985). Common-sense models of illness: The example of hypertension. Health Psychology, 4(2), 115-135. National High Blood Pressure Education Program. (1988, May). The 1988 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, MD: U.S. Department of Health and Human Services (NIH publication No. 88-1008).
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Smyth, K., Call, J., Hanseil, S., Sparacino, J., & Stodtbeck, F. L. (1978). Type A behavior pattern and hypertension among inner-city black women. Nursing Research, 27, 30-35. Staples, R. (1982). Black masculinity. San Francisco: Black Scholar Press. Verbrugge, L. M. (1982). Sex differentials in health. Public Health Reports, 97, 417419. Walker, S. N., Volkan, K., Sechrist, K. R., & Pender, N. J. (1988). Health-promoting life styles of older adults: Comparisons with young and old middle-aged adults, correlates and patterns. Advances in Nursing Science, 11(1), 76-90. Wallen, J., Waitzkin, H., & Stoeckle, J. (1979). Physician stereotypes about female health and illness: A study of patient's sex and the informative process during medical interviews. Women & Health, 4, 135-146. Weinstein, M. C , & Fineberg, I. V. (1980). Clinical decision analysis. Philadelphia: W. B. Saunders. Woods, N. F. (1987). Women's lives: Pressure and pleasure, conflict and support. Health Care for Women International, 8(2-3), 109-119.
ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20
Gender differences in knowing about hypertension: The black experience Mary Ann Hautman RN, PhD & Perri Bomar RN, PhD To cite this article: Mary Ann Hautman RN, PhD & Perri Bomar RN, PhD (1992) Gender differences in knowing about hypertension: The black experience, Health Care for Women International, 13:1, 57-65, DOI: 10.1080/07399339209515978 To link to this article: http://dx.doi.org/10.1080/07399339209515978
Published online: 14 Aug 2009.
Submit your article to this journal
Article views: 4
View related articles
Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=uhcw20 Download by: [York University Libraries]
Date: 08 November 2015, At: 07:47
GENDER DIFFERENCES IN KNOWING ABOUT HYPERTENSION: THE BLACK EXPERIENCE Mary Ann Hautman, RN, PhD, and Perri Bomar, RN, PhD
Downloaded by [York University Libraries] at 07:47 08 November 2015
School of Nursing, University of San Diego, California
This descriptive exploratory study was undertaken in an attempt to describe how hypertension as a disease and illness is conceptualized from the point of view and experience of black couples. Twenty-one black couples were interviewed and the data content was analyzed. Explanatory models constructed from the taped interviews revealed that the differences in knowing about hypertension were primarily due to gender. Differences were identified in the structure and content of the explanatory models. Content differences between women and men were primarily in the areas of stress and diet. The significance of this research is that it identified gender differences in ways of learning about illness that need further exploration.
Our purpose in writing this paper is to describe gender differences in descriptions of hypertension by black couples of whom one partner has hypertension. In spite of the vast amount of research on hypertension and adherence to therapeutic regimens, major gaps in knowledge related to gender, ethnicity, and how clients conceptualize their problem remain. Hypertension rates among blacks are considerably higher than among whites (National High Blood Pressure Education Program, 1988). White males receive the greatest attention in the hypertension literature, followed by black males (Clark & Harrell, 1982), white females, and, last, black females (Johnson, Beard, Valdez, Mott, Hugher, & Fomby, 1986; Smyth, Call, Hansel!, Sparacino, & Stodtbeck, 1978). No studies were found that examine hypertension from the perspective of black couples. Gender and Health Promotion Gender is documented as a significant variable in health promotion studies. Women are (a) more interested in health issues; (b) more likely Health Care for Women International, 13:57-65, 1992 Copyright S 1992 by Hemisphere Publishing Corporation
57
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M. A. Hautman and P. Bomar
to engage in and influence family members' health behaviors (Gottlieb & Green, 1984; Hibbard & Pope, 1987); and (c) use diet as a form of health promotion more often than exercise (Woods, 1987). Men are (a) more likely to engage in routine exercise (Verbrugge, 1982); (b) more likely to take risks (Gottlieb & Green, 1984); and (c) more likely to communicate more equally with physicians (Korsch & Negrete, 1972). Numerous scholars have documented gender as a variable in hypertension morbidity and mortality whereas only one study was found that describes the role of gender in lay explanations of hypertension (Blumhagen, 1982). A few qualitative studies document how hypertension is conceptualized (Baumann & Leventhal, 1985; Meyer, Leventhal, & Gutmann, 1985). Explanatory Models of Hypertension Studies of lay accounts of illness/disease reveal that the biomédical model is integrated as a "popular model" into a person's explanation (Blumhagen, 1982; Hautman, 1987). Lay models of hypertension evolve over time and influence treatment behaviors. Individuals may monitor symptoms or obtain blood pressure readings to try to connect the abstract concept of hypertension with concrete empirical referents (Keller, Ward, & Baumann, 1989). METHOD An exploratory descriptive method was chosen because it is useful when little data are available (Field & Morse, 1985) and when the researcher wishes to grasp an emic or people-centered viewpoint (Leininger, 1990). Twenty-one black couples, nine male and twelve female hypertensives and their spouses, were volunteer participants in a large city in the western United States. Each person signed an approved human consent form. Participants were selected based on one of the spouses' having self-reported hypertension for at least 6 months. Reliance on self-report rather than physician referral was based on the consideration that nontraditional health care providers may be the source of care. Participants were interviewed in their homes by the investigators or by research assistants. The investigators critiqued taped interviews conducted by the assistants prior to and during data collection. Questions were based on Kleinman's (1980) explanatory model framework. Examples of open-ended questions asked of each respondent ranged from "What do you think caused your (your spouse's) hypertension?" and
Downloaded by [York University Libraries] at 07:47 08 November 2015
Gender Differences in Hypertension Knowledge
59
"What difficulties has this condition caused for you (your spouse)?" to "How has your (your spouse's) diet changed?" Two interviewers visited each home and the taped interviews lasted from 45 to 60 min. Tapes were transcribed and data were analyzed using content analysis as described by Berelson (1952) and George (1959). George (1959) notes that qualitative approaches in content analysis allow for preliminary readings and examination of inferred contextual meanings, as well as for manifest content and hypothesis formation, whereas strict quantitative approaches provide rigid guidelines, hypothesis testing, and frequency counts based solely on manifest content. Lincoln and Guba (1985) suggest criteria to determine the trustworthiness of qualitative studies. Our strategies for ensuring trustworthiness are as follows. Credibility was established by methodological triangulation with the use of both a quantitative measure reported elsewhere (Bomar & Hautman, 1990) and detailed personal interviews with persons from varying backgrounds. Transferability is addressed by the inclusion of descriptive examples that support the analysis in the text. Data checks of transcribed and coded interviews made by persons knowledgeable in content analysis provided some level of dependability and confirmability. FINDINGS AND DISCUSSION The major finding of this study is that there are gender differences in the conceptualization of hypertension. Data will be presented pertaining to the structure and content of the explanatory models after a brief description of the demographic data. The demographic data are as follows: mean years with hypertension, 9 years (range 1-20); mean age, 46.5 years (range 20-65); mean income, $46,000; mean years married, 19; and 75% of those included in the study had attended college. Explanatory Models of Hypertension Females with hypertension identified a few more concepts than did the males with hypertension. Both female and male normotensive spouses on an average mentioned slightly fewer concepts. Figure 1 is an example of the conceptual map of a female hypertensive and Figure 2 is that of a male hypertensive. Categories were determined by examining both intended meanings and manifest content. Arrows show the links between concepts: the thicker the line, the more frequent the connection. The spouses with diagnosed hypertension usually identified the most concepts related to their disease. Blumhagen's (1982) study of hyperten-
60
M- A. Hautman and P. Bomar
KIDNEY DAMAGE OVERLOAD HEART
HEADACHE
1 V 1
TOO TENSE
CAPILLARY DAMAGE
HEART DAMAGE
Downloaded by [York University Libraries] at 07:47 08 November 2015
SALT
|-jpjvj
.HEART ATTACK NO BLOOD TO BRAIN
FATS HIGH
PREGNANCY
STROKE
CHOLESTEROL VESSELS CONSTRICT HEREDITY
Figure 1. Female explanatory model of hypertension. sion concepts, primarily among hypertensive males, shows conceptual maps depicting connecting nodes similar to those of the males in this study. His assumption that the belief systems of women would be more elaborate than those of men was not confirmed. Gender, Conceptual Bonding, and Hypertension Gender was the dominant factor in determining the structure of each model. Female respondents used what was termed single conceptual bonding, in which one concept was bonded or related to one other concept as cause or effect. Males formed multiple conceptual bonds in which two or more concepts were bonded together. For example, hypertensive males discussed how fatty foods were bonded in a pathway to high cholesterol, clogged arteries, increased resistance in the blood vessels, and then to stroke. Figures 1 and 2 illustrate the conceptual bonds identified for females and males, respectively. The decision tree approach to clinical problems structures a branching of events, tying one concept to another (Weinstein & Fineberg, 1980). Such an approach is used in teaching decision-making to clinicians. Other studies show that physicians talk down to women and ignore their need for information whereas male patients receive complete descriptions; this may be more closely patterned after the clinical model (Belenky, Clinchy, Goldberger, & Tarule, 1986; Wallen, Waitzkin, & Stoeckle, 1979). The differing construction of the models might also occur because men are assumed to be complex, objective thinkers
61
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Gender Differences in Hypertension Knowledge
whereas women are assumed to be subjective, contextual thinkers (Belenky, Clinchy, Goldberger, & Tarule, 1986). Use of mechanical terminology, such as describing hypertension in terms of plumbing, was more common in men than women. A 64-yearold male hypertensive related that "blood pressure is something like plumbing . . . it's like when the hot water lines get rusty and it gets clogged up and the blood goes in smaller streams and don't get through." The medical model has masculinized thought depicting the body as a machine. Clinicians contacted by the investigators report that they use the machine analogy, thus providing some support for our findings. Gender and Stress Stress was perceived as a key cause of hypertension. Female hypertensives discussed the need to talk and said that keeping things bottled up inside produced symptoms such as tightness in the chest and headaches. Female nonhypertensives voiced concern that their hypertensive spouses were hesitant to share personal Stressors, as evidenced by the following typical response: My husband is not a big complainer. You really don't get too much out of him to talk about sickness or anything like that. . . . I always asked questions, but it seems he wanted to spare me and not tell me what was really bothering him.
HIGH CHOLESTEROL
HEART WORKS HARDER
FATTY FOOD SALT
^ \ ^
HIGH VESSEL PRESSURE
\ CLOG ARTERIES '
"\>
^ r
INCREASED WEIGHT HEREDITY
'
/
HPN
- ^^"^JOB
\ STRESS,« ~- PRESSURE MUSCLES TIGHTEN
/
yC^INCREASED RESISTANCE \
\
\ \ ^
f nr*nTATTACK C^V^DEATH \
\
\ ^ ^ ^
STROKE
N
\
KIDNEY DAMAGE \ HEADACHE
Figure 2. Male explanatory model of hypertension.
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M. A. Hautman and P. Bomar
Male respondents discussed stress as job or family pressures that needed to be dealt with through action, not discussion. Actions taken to deal with stress included exercise or "washing the car" or "working in the yard." However, a few hypertensive men attempted to deal with stress through relaxation. A 31-year-old man said: "If I feel I'm stressful . . . I sit on my bed and close my eyes and just start repeating number one and just relax my body from my feet up to the top of my head and it works. . . . " Stress as a causative factor in hypertension is well documented in the literature (Clark & Harrell, 1982; Johnson et al., 1986). However, Blumhagen's (1982) study of explanatory models of hypertension suggests that "hypertension" in the lay idiom should be written "hyper-tension." Our data supported this as respondents spoke of themselves or of their spouses as being too tense or being subjected to too much tension. Normotensive women wanted their hypertensive husbands to talk to them about their stresses. Most of the men felt that they had to deal with their stress alone. These findings support Staples' (1982) belief that black men hesitate to express their feelings or seek support because they see this as a sign of weakness. Studies of the stress and life-styles of black men are distressingly underreported in the literature. Gender and the Concept of Diet Female hypertensives used the term diet to connote the nutritive quality of food and described food in terms of nutrition, that is, low in salt or fat. They also listed more food types such as red meat, ham, fish, vegetables, and spices, and used food preparation terms such as frying, broiling, baking, and barbecuing. Dieting was an action to improve one's health rather than to lose weight. Nearly all females perceived themselves in the role of dietary manager/shopper for the home. Males, on the other hand, used the term diet as in "going on a diet" for the primary purpose of weight loss. Nonhypertensive males identified diet in terms of weight, which they perceived was the cause of their spouses' hypertension. Both men and women stated that fatty foods, foods with high salt content, red meat, and pork were "bad foods" whereas "veggies," fish, and salt-free cooking were good for them. The female partner was in charge of the household diet as evidenced by these responses from two representative hypertensive males: "She knows about my condition . . . and knows not to put salt on my food, not cook lots of greasy food . . . or red meat," and, "She knows that I love ice cream and she says that she won't be getting it anymore." Gender differences in the use of the term diet by women and men can be explained by studies showing that women are more involved in se-
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lecting and preparing food than are men and have a greater awareness of the nutritional value of food than do men (Cope & Hall, 1987; Walker, Volkan, Sechrist, & Pender, 1988). Men's focus on diet as weight loss is surprising given that a review of research on food-related behavior by Axelson (1986) demonstrates that women are more conscious of caloric considerations. Marriage Dyad and Explanations of Hypertension The content of couples' models were similar. The degree of similarity between partners could be attributed in a few instances to situations in which hypertensive spouses shared their concerns about their hypertension. However, couples who complained of lack of communication also had similar models. What differed was how each partner defined and interpreted or contextualized these concepts. Whether this is due to the communication style between couples is not known because these data were not collected. CONCLUSION Our findings demonstrate that gender is an important consideration in how hypertension is conceptualized and discussed. One of the assumptions underlying the participants' discussion of the models is that neither sex is better than the other. Women's models should not be discounted because they do not coincide with the Cartesian male model or decisiontree approach to viewing the world. Health care providers need to address gender issues such as ways of knowing about illness as well as issues related to biopsychosocial and cultural parameters. Providers who address women's conceptions and understand their cognitive and emotional makeup can help them to better address their own health care. Further research needs to be undertaken to compare ethnic differences in ways of knowing about illness and to determine if the structure of the illness account correlates with outcome variables such as self-care practices and measures of illness and disease management. REFERENCES Axelson, M. L. (1986). The impact of culture on food-related behavior. Annual Review of Nutrition, 6, 345-363. Baumann, L. J., & Leventhal, H. (1985). "I can tell when my blood pressure is up, can't I?" Health Psychology, 4, 203-218.
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